May 30, 2025 • 24 mins
⚕️ FREE MSRA PODCAST – Acute Confusional State (Delirium)
🎧 A high-yield breakdown of this acute mental status change – perfect for exam prep and real-life clinical practice.
🧠 Key Learning Points
📌 Definition
• Delirium is a sudden, fluctuating disturbance in attention, awareness, and cognition – often described as an acute confusional state.
📌 Causes & Risk Factors
• Infections (UTI, pneumonia, sepsis)
• Medications (anticholinergics, opioids, benzos)
• Metabolic issues (hyponatraemia, hypoxia)
• Surgery (especially emergency or major ops)
• Alcohol/drug intoxication or withdrawal
• Environmental changes (ICU, sensory deprivation)
• Risk ↑ in: age >65, dementia, frailty, polypharmacy
💡 Mnemonic: PINCHME – Pain, Infection, Nutrition, Constipation, Hydration, Medication, Electrolytes, Environment
📌 Pathophysiology
• Global brain dysfunction
• Reduced acetylcholine, neurotransmitter imbalance
• Neuroinflammation, oxidative stress
• Impaired interconnectivity between brain regions
📌 Symptoms
• Sudden, fluctuating confusion
• Impaired attention, disorientation
• Sleep-wake cycle disturbance (e.g. sundowning)
• Visual hallucinations, agitation (hyperactive) or lethargy (hypoactive)
💡 Mnemonic: DELIRIUM – Disturbed attention, Emotional changes, Language disturbed, Illusions/hallucinations, Reversal of sleep, Inattention, Unawareness, Mixed/hyper/hypoactive subtypes
📌 Differential Diagnosis
• Dementia (chronic and progressive)
• Depression, bipolar disorder
• Schizophrenia
• Metabolic encephalopathy
• Stroke, brain tumour
• Drug intoxication or withdrawal
• Non-convulsive status epilepticus
📌 Diagnosis
• Clinical – acute onset, fluctuating course, inattention, and disorganised thinking
• Cognitive test: 4AT
• Collateral history crucial
📌 Management
• Treat underlying cause (e.g. infection, dehydration, drug withdrawal)
• Optimize environment – calm, familiar, well-lit, sensory aids in place
• Supportive care: hydration, nutrition, mobilisation, sleep hygiene
• Antipsychotics (e.g. haloperidol) only if severely distressed
• Avoid benzodiazepines unless alcohol/benzo withdrawal
• Multidisciplinary approach essential
📌 Complications
• Falls and injuries
• Prolonged hospital stay
• Hospital-acquired infections
• Functional decline and loss of independence
• Increased risk of dementia
• Higher mortality rate
📌 Prognosis
• Variable – depends on cause and patient frailty
• Can resolve quickly if treated, but may persist or lead to long-term cognitive decline
📎 More MSRA Resources for Acute Confusional State (Delirium)
📝 Revision Notes: https://www.passthemsra.com/topic/acute-confusional-state-delirium-revision-notes/
🧠 Flashcards: https://www.passthemsra.com/topic/acute-confusional-state-delirium-flashcards/
💬 Accordion Q&A Notes: https://www.passthemsra.com/topic/acute-confusional-state-delirium-accordion-qa-notes/
🚀 Rapid Quiz: https://www.passthemsra.com/topic/acute-confusional-state-delirium-rapid-quiz/
🎓 Full Course: https://www.passthemsra.com/courses/neurology-for-the-msra/
#MSRA #MSRARevision #MSRATextbook #MSRAQuiz #MSRAQuestionBank #MSRAFlashcards #MSRAQ&A
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
OK, let's do this. You've brought us these revision
notes on a really, really important condition.
Often missed, actually. Yeah, absolutely.
Acute confusional state or delirium?
Delirium, right? And our mission today in this
deep dive is basically to unpackthese notes together, turn these
points into something clear, high yield, something you can
really use. It's all based on your sources.
(00:22):
Exactly. It's something healthcare
professionals see all the time, particularly with, you know,
vulnerable patients. Getting the core elements from
these notes down is just crucialfor spotting it and managing it.
So let's start right at the beginning.
What is delirium? How do these notes define it?
OK, so the definition gives us the basics.
It's described as a sudden and fluctuating change in mental
(00:44):
state. Key problems are with attention,
awareness and just general cognitive function.
Sudden and fluctuating. Those two words really jump out,
don't they? Why are they so key?
Because they're the hallmarks really.
They helped tell it apart from other things that acute onset,
like it wasn't there yesterday but it is today or it changed
really fast and the way symptomscan come and go, get better or
(01:06):
worse during the day. That's classic delirium.
Waxing and waning, they call. It and I see the notes mentioned
different ways it can look different.
Types the subtypes. There's hypoactive delirium.
That's where someone's quiet, withdrawn, maybe seems a bit
sleepy or apathetic. That sounds easy to miss.
Oh, it really is often missed because it's not disruptive, you
(01:27):
know, then you've got hyperactive delirium that's more
obvious, agitation, restlessness, sometimes
hallucinations or delusions even.
And then there's mixed where theperson sort of swings between
those two states. It definitely makes sense that
the quiet one is sneaky. It truly is, and the sources
make a really critical point early on.
Delirium is almost always causedby more than one thing.
(01:50):
It's multifactorial. Think of it like like a
vulnerable brain being tipped over the edge by different
insults. Common triggers flagged here are
things like acute infections, metabolic problems, issues
within the brain itself, or problems with medications or
substances. Medications you mentioned,
they're a big one. Huge.
Yeah, we'll definitely come backto that.
(02:12):
And just wrapping up the definition points from the
material, it stresses the acute onset, that fluctuating course,
the much higher risk in older adults and well this sobering
statistic on mortality, it's noted as up to 20%.
Wow, up to 20%, That's, that's significant.
It's definitely not just simple confusion.
(02:32):
No, not at all. And just for clarity, the
sources list some other names for it, synonyms.
Yeah, that's useful. Acute confusional state,
obviously also acute brain failure, which really gives you
a sense of the severity doesn't it?
It does. Acute organic reaction and even
post operative psychosis. They all point to the same
underlying syndrome. Got it.
So recognising any of those terms means thinking delirium.
(02:52):
Exactly. OK, so we know what it is, key
features. Now where does it actually come
from? The causes, the aetiology,
looking at the material, it's a really, really long list.
It is long, yeah. And that just reflects the
multifactorial thing we talked about.
The key I think isn't memorisingevery single possibility, but
understanding the main categories to check off in your
head. Kind of like buckets, you need
(03:14):
to look into. Right, makes sense.
So what are those main buckets? Infections are massive,
especially in older or more vulnerable patients.
Think UTI's, pneumonia, sepsis, even meningitis or encephalitis.
A simple infection can absolutely trigger delirium.
OK. Infections and you flagged
medications as high yield. Critically high yield, these
(03:36):
notes say drugs are involved in nearly half of cases.
Half. Wow.
Yeah, common culprits include things you might not immediately
suspect. Certain painkillers, medications
with anticholinergic effects, You know, dry mouth,
Constipation, types of sedativeslike benzodiazepines.
Always always check the Med list.
OK, so infections meds. Surgery is a big one post
(03:56):
operative delirium. Any major surgery, especially
things like hip fracture repairsor emergency OPS, they carry a
high risk. Then there are toxic substances,
not just recreational drugs or withdrawal, but alcohol
intoxication or withdrawal or even environmental things like
carbon monoxide poisoning. So something like Co poisoning
could present as just confusion.Absolutely profound confusion,
(04:18):
vascular problems or another category, strokes, bleeds like
subdural hematomas, even heart failure if it impacts blood flow
to the brain and. Metabolic issues seem to crop up
everywhere in medicine. Massively important here and
often reversible if you catch them.
Think about the basics. Low oxygen hypoxia.
Electrolyte imbalances are critical.
Low sodium hypotremia, that's a really common trigger.
(04:41):
Higher low blood sugar. Poor kidney or liver function.
They can all seriously disrupt brain chemistry it.
Really sounds like the brain just needs everything to be
perfectly stable it. Really does.
Yeah. The notes also list specific
vitamin deficiencies, thiamine, B12, nicotinic acid, endocrine
problems like thyroid issues, head injury, the state after a
seizure, brain tumours and interestingly, even really
(05:03):
simple things like urinary retention or just being badly
constipated. That's one of those points,
Constipation or retention. Easy to overlook, but so
important in practise, right? Exactly.
Don't miss the simple reversiblestuff.
And sometimes you know, it's multiple things piling up or
unfortunately, despite looking hard, the cause isn't found.
OK, so given that huge list of potential triggers, who is
(05:27):
actually most likely to get delirium?
What are the key risk factors highlighted in these sources?
Right, this is about vulnerability.
The single biggest risk factor mentioned is age.
Being 65 or older significantly increases the risk.
And gender, is that a factor? Yes, male sex is listed as a
risk factor too. And really critically having any
(05:48):
pre-existing cognitive impairment, things like dementia
or history of stroke. And the worse the dementia, the
higher the risk of getting delirium on top of it.
So if the brains already a bit compromised, it's easier to tip
it over the edge. Precisely that.
Other big factors include havinglots of other medical problems,
comorbidities, or having had delirium before.
Once you've had an episode, you're more likely to have
(06:09):
another one. That's a key predictor.
We mentioned surgery as a cause,is it also a risk factor itself?
Definitely operative factors area major risk, especially
emergency surgery or high stressprocedures like fixing a hip
fracture. What about someone's general
health? If they're just very unwell,
yes. Being acutely I'll is a major
risk factor. Severe illness, burns, major
(06:31):
fractures, active infections, they all make you more
vulnerable. Things like low protein levels,
low albumin or being dehydrated also feature on the list.
And medications, they pop up again here as a risk.
Yep. Drug use, dependence and misuse
are risk factors. Link you right back to those
common culprits we talked about earlier.
Benzodiazepines get another mention here too.
Environment came up in the causes list.
(06:53):
Is that a risk factor as well? Absolutely.
Extremes of temperature, sensoryissues like not having your
glasses or hearing aids making it hard to orientate yourself,
poor mobility, being socially isolated, stress, being in a new
place like a hospital ward or ICU, or being terminally ill.
All these environmental and situational factors really
increase the risk, especially insomeone who's already
(07:13):
vulnerable. It really highlights how much
the patient's whole context matters, doesn't it?
Not just the medical chart it. Really does ICU admission itself
is flagged as a high risk environment and specific lab
results like abnormal kidney function tests, urea and
creatinine are listed too. Knowing this profile helps you
spot who needs closer watching and maybe some preventative
(07:35):
steps. OK, so we've got what it is,
what causes it, who gets it? But what's actually going on
inside the brain when someone's delirious?
What does the pathophysiology section tell us?
Yeah, this is fascinating. Although, you know, the exact
mechanisms are still pretty complex and not perfectly
understood. What the material highlights is
a state of sort of widespread brain dysfunction.
(07:57):
It seems to involve imbalances in brain chemicals,
neurotransmitters plus inflammation, increased
oxidative stress and disruption,and how different brain areas
talk to each other so. It's not like 1 switches off,
it's more like the whole networkis noisy or scrambled.
That's a good way to put it, yeah.
And these disruptions directly cause the symptoms you see, the
attention problems, the foggy thinking, the reduced awareness,
(08:19):
the perceptual changes. One specific neurotransmitter
gets called out is particularly relevant.
Reduced acetylcholine activity. Acetylcholine often linked to
memory and attention, right? Exactly a deficit there seems to
be a key finding in many cases. Other things mentioned are the
release of pro inflammatory cytokines.
These are like chemical messengers from the immune
(08:41):
system that can mess with brain function and that impaired
communication between brain regions.
It's essentially as one of the synonyms suggested and acute
brain failure state triggered byproblems elsewhere in the body
or directly in the brain. Given those changes in mental
state, it must get confused withother conditions sometimes.
What's on the differential diagnosis list?
What else could it be? Yeah.
(09:01):
This is super important because mistaking delirium for something
else means you might delay finding and treating the actual
cause. The notes list several common
look alikes. Well, the biggest one.
The most important distinction often is with dementia.
Both involve cognitive changes, right?
But dementia is typically chronic, progressive, a slow
(09:22):
decline over time. Delirium is acute, sudden onset
and fluctuating. That's the key difference.
However, some types of dementia like Lewy body dementia do have
fluctuations which can make it trickier, especially if someone
with dementia develops telluriumon top.
So spotting that new sudden change against their baseline is
crucial. Absolutely crucial.
(09:43):
Other things that can look like include depression, especially
severe depression or bipolar disorder during manic or
depressive episodes, certain functional psychosis like
schizophrenia, or medical conditions like severe thyroid
problems, hyper or hyperthyroidism.
Any less common things on the list to be aware of?
Yes, things like non convulsive status epilepticus that seizures
(10:04):
without the obvious shaking, just confusion.
Or Charles Bonnett syndrome, visual hallucinations in people
with bad eyesight but who are otherwise thinking clearly.
The list also includes metabolicencephalopathy, brain
dysfunction from severe metabolic issues, stroke, brain
tumours, meningitis and of course, acute intoxication or
withdrawal from alcohol or drugs.
(10:24):
It really hammers home the need for a proper medical workup when
someone suddenly becomes confused.
It really does always ask is this new and is it fluctuating?
That should scream delirium until proven otherwise.
OK. Before we get into how it looks
day-to-day and what we do about it, just how common is this
condition? The epidemiologist section gives
some perspective. It's way more common than most
(10:44):
people think, especially in certain settings.
Out in the general community it's pretty low, maybe 1-2
percent. But look at older adults over
85, it could be up to 14%. That's a big jump just with age.
It is, but then look at healthcare settings.
Long term care residents 1040% prevalence.
Hospitalised. Older adults, people 65 plus
admitted to hospital, the prevalence is around 50%.
(11:06):
Fifty. Percent.
Half that number is, well, it's staggering.
It is. Staggering.
And it highlights why it's so vital to be aware of it.
In emergency departments. About 30% of older adults
presenting might have delirium. It complicates a huge chunk of
major surgeries. The notes say 1761% and in ICU's
it occurs in the vast majority, 70% to 87% of admissions.
(11:29):
So. Basically, if you're elderly and
you end up in hospital or especially ICU, you are in a
very high risk situation for delirium.
Extremely. High risk.
The notes also mentioned its prevalence in palliative care
can be present in up to 88% of patients in their final weeks.
Often it's the hypoactive, quiettype there.
And importantly, it doesn't always just vanish when the
(11:50):
person leaves hospital. The sources say significant
numbers like around 1/3 at one month still have some delirium
symptoms weeks or even months after discharge.
I might. Have assumed it just clears up
once the cause is fixed. That persistence is a really
key. Take away it, really.
Is and it links directly to the long term consequences.
The epidemiology section clearlystates delirium is linked to
(12:10):
increased illness, longer hospital stays, higher health
care costs, and significantly increased mortality.
OK, so. We know it's common, especially
in these vulnerable settings andhas serious implications.
Let's talk about what it actually looks like clinically.
What are the features right the?Presentations.
Remember those core things. Acute onset, fluctuating course.
(12:31):
Clinically, this shows up as problems with attention.
They might be really distractible, can't follow a
conversation, can't focus, reduced awareness of their
surroundings and difficulties with thinking, memory problems,
language issues, disorganised thought.
What? Sort of symptoms might family or
staff observe well. Beyond just general confusion or
disorientation, you might see reduced alertness.
(12:52):
Maybe they're very sleepy, or the opposite.
Agitation, restlessness, pullingat lines.
Hallucinations are common, especially visual ones, and
delusions. Paranoid ideas perhaps
particularly in that hyperactivetype.
There's sleep. Wake cycle often gets completely
messed up. Awake and confused at night,
drowsy during the day, I've. Heard the term sundowning used
(13:13):
for that, yes. Sundowning, where symptoms seem
to get worse in the evening or overnight.
That's a very common pattern yousee with delirium.
You might also see physical signs linked to the underlying
cause, fever, abnormal vital signs, maybe tremors.
So how? Is it actually diagnosed?
Is there a test for it? The.
Diagnosis is primarily clinical.It's based on recognising that
(13:34):
pattern, the acute onset, the fluctuating course affecting
attention and cognition. There isn't like a single blood
test for delirium itself, but investigations are absolutely
essential to find the underlyingcause because managing delirium
hinges on fixing that cause. Got it.
Assessment involves taking a good history, talking to family
or carers is vital, doing a physical and neurological exam
(13:56):
and often using a structured cognitive assessment tool and
the. Material mentions a specific
tool for that. Yes, the four.
AT is mentioned, it's a commonlyused screening tool for
delirium. Quick, easy to use at the
bedside, designed to pick up those key features.
OK. So diagnosis is clinical, but
finding the cause is paramount. How do we investigate what's the
workup according to these notes,right?
(14:17):
Investigations are all about hunting for that underlying
cause or causes and to help remember the common, often
reversible things you need to look for.
The sources give a really helpful mnemi oh a mnemonic is.
Always good for revision it is. The mnemonic is PIN CHME.
Each letter prompts you to thinkabout a key area.
OK, let's. Break it down.
(14:37):
PP is for. Pain.
Is there untreated pain driving this I I is for infection,
always high on the list. N is for nutrition.
Are they malnourished, deficientin something?
C is for Constipation. Remember how important that can
be. Yeah.
H is for hydration. Dehydration is a common factor.
M is for medication. Review that drug chart and then.
(14:58):
The sources list E twice EE. Yes, E for electrolyte
disturbances, think low sodium, high calcium, etcetera.
And E for environment, look at their surroundings, sensory
input, recent moves. So pain, infection, nutrition,
Constipation, hydration, medication, electrolyte,
environment, pin CHEME. It's a great checklist to run
(15:21):
through that. Is fantastic a really practical
way to remember the high yield causes?
So what are the actual tests that usually make up that
initial confusion screen OK? Based on PIN CME, you'd order
tests to cover those bases. The standard screen usually
includes routine bloods, a full blood count, FBC, looking for
infection signs, anaemia, urea and electrolytes, U and ES,
(15:42):
kidney function, sodium, potassium, hydration status.
Then things like liver function tests, LFTS, thyroid function
tests, TFTS, maybe inflammatory markers like CRP or ESR and a
calcium level. Those cover a lot of the
infection, nutrition, hydration,electrolyte and metabolic
possibilities. So those.
Basic blood tests hit quite a few points on the mnemonic.
Exactly. You'd also typically send blood
(16:05):
cultures if you suspect sepsis, do urinalysis and send a urine
sample. UTI's are super common triggers,
especially in older adults. And a chest X-ray to look for
pneumonia part of the infection screen.
When do? You need to start thinking about
imaging the brain, CT scans and so on.
Yeah. Cranial imaging like ACT head
isn't usually first line unless there's a specific reason it's
(16:27):
considered. If you actively suspect a
neurological cause like a stroke, a bleed, a tumour, or if
the delirium just isn't getting better despite treating what you
think is the cause. Or if your initial screen is
completely negative and you're still scratching your head so.
Rule out the common reversible stuff first, generally
precisely. Other investigations listed,
depending on the clinical picture, might include an EEG
(16:50):
that looks at brain electrical activity, or maybe a lumbar
puncture to check the spinal fluid if you're worried about
meningitis or encephalitis. OK.
We figured out how to look for the cause.
How do we actually manage delirium once we suspect it?
What's the approach in the material?
Management is definitely multifaceted, but the absolute
cornerstone, the number one priority is fine and treat the
(17:11):
underlying 'cause you have to fix what triggered it makes.
Total sense infection, treat it dehydrated, hydrate them, Med
causing it, stop it. Exactly.
That alongside treating the cause, providing really good
supportive care is vital. That means keeping the patient
safe, preventing falls, self harm if they're very agitated,
(17:32):
meeting basic needs, nutrition, hydration, helping with
toileting and trying to minimisethings that make confusion worse
like too much noise, too many changes, sensory overload or
deprivation and environment. Was a big factor in CHME.
Great. Huge.
Environmental measures are really important and often
underutilised. Things like modifying the room
for safety, making sure there's good lighting, especially at
(17:53):
night, reducing unnecessary noise, helping the mobilise if
safe and crucially, addressing sensory deficits, making sure
they have their glasses, their hearing aids and that they're
working, helping. Them figure out where they are
and what's going on, yes. Reorientation techniques, a
visible clock and calendar, familiar objects from home,
having family visit or consistent nursing staff if
(18:13):
possible, gently reminding them of the time, place, situation.
Trying to maintain a normal sleep wake cycle is key to
curtains open during the day, quiet and dark at night so.
Treat the cause, optimise the environment and basic care.
What about using medications forthe delirium symptoms
themselves? Like agitation, right?
(18:33):
So medical management, beyond treating the cause also involves
optimising all their other existing medical conditions.
And a major point again is reviewing all their medications.
Stop or reduce anything unnecessary, especially drugs
known to cause confusion like those with strong
anticholinergic effects. For managing symptoms like
severe agitation or aggression, the first step should always be
(18:54):
de escalation techniques, talking calmly, reassurance if
medication is absolutely necessary because of risk to
sell. For others, the notes mentioned
cautious use of antipsychotics like small doses of haloperidol
or sometimes benzodiazepines. But hang on.
I remember you saying avoid benzos in the elderly earlier.
Yes. And that's a crucial point
reinforced here. If you have to use medication
(19:14):
for agitation, use the lowest effective dose.
Monitor very closely. And importantly, avoid
benzodiazepines in older adults unless it's specifically for
managing alcohol or benzo withdrawal itself.
They often make confusion and sedation worse in this group,
increasing fall risk. Got it.
Antipsychotics cautiously if needed.
(19:35):
Benzos generally avoid in the elderly unless for withdrawal,
correct? Management really needs that
collaborative team approach. Doctors, nurses, pharmacists,
therapists involving the family too.
Everyone needs to be on the samepage.
The sources also briefly mentioned management after
discharge, noting that cognitiveissues can linger, so ongoing
support might be needed. So what?
(19:56):
Happens next. Then what's the typical
prognosis and what are the potential complications listed
in these notes? Well.
The prognosis really varies. It depends heavily on what
caused the delirium, the patient's underlying health, how
frail they were to begin with, and how quickly and effectively
it's all managed. If you find and treat the cause
early, the symptoms can often resolve completely.
That's the. Ideal outcome, right?
(20:17):
That's. The goal?
However, as the epidemiology hinted, delirium is strongly
associated with worse outcomes overall.
Increased illness, much longer hospital stays, a decline in
functional ability meaning they might struggle with daily tasks
they could do before, and unfortunately, higher mortality
rates, especially in older adults.
And you mentioned that long termcognitive risk earlier, yes?
(20:39):
That's a really key take away from the notes.
Having an episode of delirium increases the risk of developing
long term cognitive decline, andit's associated with an
increased risk of dementia lateron.
So even if the acute episode passes, it can leave a lasting
impact on the brain. Prompt intervention and that
multidisciplinary care definitely improve the outlook
though. Given how serious the outcomes
(21:00):
can be, is there anything that can be done to prevent delirium
from happening in the 1st place?Yes.
Prevention is a huge focus, especially in high risk places
like hospitals. The notes outline several
strategies. Firstly, just being aware of who
is high risk. Using those factors, we
discussed age, existing cognitive issues, severe
illness, sensory impairment. Close observation of these
(21:22):
patients is key and that. Team approach again, Absolutely.
Essential for prevention to prompt assessment if early signs
develop. But the most effective strategy
seemed to be these tailored multi component intervention
packages. These are like bundles of care,
focusing proactively on things like ensuring good hydration and
nutrition, promoting mobility and activity, managing pain
(21:44):
effectively, optimising sleep, making sure sensory aids are
used, providing regular orientation cues.
It sounds. Like a lot of those, basic
supportive care and environmental measures are both
treatment and prevention. Exactly.
Applying them proactively to high risk patients is the best
bet for prevention. The material also makes an
explicit point. Routine use of antipsychotic
(22:06):
medications is not supported forpreventing delirium.
Don't use them prophylactically.That's.
Important prevention is mainly non drug based.
What if, despite best efforts, complications still happen?
Unfortunately, complications arecommon and can be serious.
Functional decline is very frequent.
People losing independence. There is a high risk of falls
leading to injuries, fractures. Prolonged hospitalisation is
(22:29):
almost a given which increases cost and risk of other hospital
acquired problems like. Infections, yes.
Things like hospital acquired infections, C difficile MRSA are
mentioned and pressure sores from being immobile and the.
Mortality risk we mentioned increased.
Mortality is a major complication.
Even if the delirium resolves, there can be lasting residual
psychiatric problems or cognitive impairment.
(22:50):
And the notes in the complications list of the Stark
reality that some severe cases can progress to stupor, coma and
ultimately death. Wow, that really does cover the
full spectrum of delirium or acute confusional state.
Drawing straight from your revision notes, we've gone from
the definition, the subtypes, through that huge list of causes
and who's most vulnerable. A glimpse at the brain changes
(23:13):
what else? It might be confused with how
incredibly common it is, particularly in hospital, then
how it looks, how we investigateusing things like PENSI a ME,
the management strategies, focusing on the cause and
support and finally the prognosis, prevention and those
serious potential complications.It really.
Is a condition that can seem complex because of all the
causes, but the core management principle is quite
(23:36):
straightforward. Find and fix the trigger while
supporting the patient and theirbrain.
Recognising it quickly is just so important and.
Perhaps a final thought for you,the listener, to consider based
on all this. Just think about how sometimes
seemingly minor things, maybe being a bit dehydrated or
constipated, or just the stress and disorientation of being
moved to a different room and hospital, can interact with
(23:58):
underlying vulnerabilities like older age or mild memory
problems and tip someone into this really profound state of
acute brain failure. It's often that combination,
that perfect storm. Yeah, it really highlights why
paying attention to the basics, hydration, bowels, pain,
environment, sensory aids, is soincredibly critical, especially
(24:21):
in frail older people. Absolutely.
Well, thank you for bringing these notes for this deep dive.
It's been incredibly useful. Very high yield.
My pleasure. Hope it helps and.
If you are revising and looking for more resources like this,
remember the sources mentioned pass the msray.com and
freemessray.com. Yeah, definitely.
Worth checking those out for further study.
OK, let's do this. You've brought us these revision
notes on a really, really important condition.
Often missed, actually. Yeah, absolutely.
Acute confusional state or delirium?
Delirium, right? And our mission today in this
deep dive is basically to unpackthese notes together, turn these
points into something clear, high yield, something you can
really use. It's all based on your sources.
(00:22):
Exactly. It's something healthcare
professionals see all the time, particularly with, you know,
vulnerable patients. Getting the core elements from
these notes down is just crucialfor spotting it and managing it.
So let's start right at the beginning.
What is delirium? How do these notes define it?
OK, so the definition gives us the basics.
It's described as a sudden and fluctuating change in mental
(00:44):
state. Key problems are with attention,
awareness and just general cognitive function.
Sudden and fluctuating. Those two words really jump out,
don't they? Why are they so key?
Because they're the hallmarks really.
They helped tell it apart from other things that acute onset,
like it wasn't there yesterday but it is today or it changed
really fast and the way symptomscan come and go, get better or
(01:06):
worse during the day. That's classic delirium.
Waxing and waning, they call. It and I see the notes mentioned
different ways it can look different.
Types the subtypes. There's hypoactive delirium.
That's where someone's quiet, withdrawn, maybe seems a bit
sleepy or apathetic. That sounds easy to miss.
Oh, it really is often missed because it's not disruptive, you
(01:27):
know, then you've got hyperactive delirium that's more
obvious, agitation, restlessness, sometimes
hallucinations or delusions even.
And then there's mixed where theperson sort of swings between
those two states. It definitely makes sense that
the quiet one is sneaky. It truly is, and the sources
make a really critical point early on.
Delirium is almost always causedby more than one thing.
(01:50):
It's multifactorial. Think of it like like a
vulnerable brain being tipped over the edge by different
insults. Common triggers flagged here are
things like acute infections, metabolic problems, issues
within the brain itself, or problems with medications or
substances. Medications you mentioned,
they're a big one. Huge.
Yeah, we'll definitely come backto that.
(02:12):
And just wrapping up the definition points from the
material, it stresses the acute onset, that fluctuating course,
the much higher risk in older adults and well this sobering
statistic on mortality, it's noted as up to 20%.
Wow, up to 20%, That's, that's significant.
It's definitely not just simple confusion.
(02:32):
No, not at all. And just for clarity, the
sources list some other names for it, synonyms.
Yeah, that's useful. Acute confusional state,
obviously also acute brain failure, which really gives you
a sense of the severity doesn't it?
It does. Acute organic reaction and even
post operative psychosis. They all point to the same
underlying syndrome. Got it.
So recognising any of those terms means thinking delirium.
(02:52):
Exactly. OK, so we know what it is, key
features. Now where does it actually come
from? The causes, the aetiology,
looking at the material, it's a really, really long list.
It is long, yeah. And that just reflects the
multifactorial thing we talked about.
The key I think isn't memorisingevery single possibility, but
understanding the main categories to check off in your
head. Kind of like buckets, you need
(03:14):
to look into. Right, makes sense.
So what are those main buckets? Infections are massive,
especially in older or more vulnerable patients.
Think UTI's, pneumonia, sepsis, even meningitis or encephalitis.
A simple infection can absolutely trigger delirium.
OK. Infections and you flagged
medications as high yield. Critically high yield, these
(03:36):
notes say drugs are involved in nearly half of cases.
Half. Wow.
Yeah, common culprits include things you might not immediately
suspect. Certain painkillers, medications
with anticholinergic effects, You know, dry mouth,
Constipation, types of sedativeslike benzodiazepines.
Always always check the Med list.
OK, so infections meds. Surgery is a big one post
(03:56):
operative delirium. Any major surgery, especially
things like hip fracture repairsor emergency OPS, they carry a
high risk. Then there are toxic substances,
not just recreational drugs or withdrawal, but alcohol
intoxication or withdrawal or even environmental things like
carbon monoxide poisoning. So something like Co poisoning
could present as just confusion.Absolutely profound confusion,
(04:18):
vascular problems or another category, strokes, bleeds like
subdural hematomas, even heart failure if it impacts blood flow
to the brain and. Metabolic issues seem to crop up
everywhere in medicine. Massively important here and
often reversible if you catch them.
Think about the basics. Low oxygen hypoxia.
Electrolyte imbalances are critical.
Low sodium hypotremia, that's a really common trigger.
(04:41):
Higher low blood sugar. Poor kidney or liver function.
They can all seriously disrupt brain chemistry it.
Really sounds like the brain just needs everything to be
perfectly stable it. Really does.
Yeah. The notes also list specific
vitamin deficiencies, thiamine, B12, nicotinic acid, endocrine
problems like thyroid issues, head injury, the state after a
seizure, brain tumours and interestingly, even really
(05:03):
simple things like urinary retention or just being badly
constipated. That's one of those points,
Constipation or retention. Easy to overlook, but so
important in practise, right? Exactly.
Don't miss the simple reversiblestuff.
And sometimes you know, it's multiple things piling up or
unfortunately, despite looking hard, the cause isn't found.
OK, so given that huge list of potential triggers, who is
(05:27):
actually most likely to get delirium?
What are the key risk factors highlighted in these sources?
Right, this is about vulnerability.
The single biggest risk factor mentioned is age.
Being 65 or older significantly increases the risk.
And gender, is that a factor? Yes, male sex is listed as a
risk factor too. And really critically having any
(05:48):
pre-existing cognitive impairment, things like dementia
or history of stroke. And the worse the dementia, the
higher the risk of getting delirium on top of it.
So if the brains already a bit compromised, it's easier to tip
it over the edge. Precisely that.
Other big factors include havinglots of other medical problems,
comorbidities, or having had delirium before.
Once you've had an episode, you're more likely to have
(06:09):
another one. That's a key predictor.
We mentioned surgery as a cause,is it also a risk factor itself?
Definitely operative factors area major risk, especially
emergency surgery or high stressprocedures like fixing a hip
fracture. What about someone's general
health? If they're just very unwell,
yes. Being acutely I'll is a major
risk factor. Severe illness, burns, major
(06:31):
fractures, active infections, they all make you more
vulnerable. Things like low protein levels,
low albumin or being dehydrated also feature on the list.
And medications, they pop up again here as a risk.
Yep. Drug use, dependence and misuse
are risk factors. Link you right back to those
common culprits we talked about earlier.
Benzodiazepines get another mention here too.
Environment came up in the causes list.
(06:53):
Is that a risk factor as well? Absolutely.
Extremes of temperature, sensoryissues like not having your
glasses or hearing aids making it hard to orientate yourself,
poor mobility, being socially isolated, stress, being in a new
place like a hospital ward or ICU, or being terminally ill.
All these environmental and situational factors really
increase the risk, especially insomeone who's already
(07:13):
vulnerable. It really highlights how much
the patient's whole context matters, doesn't it?
Not just the medical chart it. Really does ICU admission itself
is flagged as a high risk environment and specific lab
results like abnormal kidney function tests, urea and
creatinine are listed too. Knowing this profile helps you
spot who needs closer watching and maybe some preventative
(07:35):
steps. OK, so we've got what it is,
what causes it, who gets it? But what's actually going on
inside the brain when someone's delirious?
What does the pathophysiology section tell us?
Yeah, this is fascinating. Although, you know, the exact
mechanisms are still pretty complex and not perfectly
understood. What the material highlights is
a state of sort of widespread brain dysfunction.
(07:57):
It seems to involve imbalances in brain chemicals,
neurotransmitters plus inflammation, increased
oxidative stress and disruption,and how different brain areas
talk to each other so. It's not like 1 switches off,
it's more like the whole networkis noisy or scrambled.
That's a good way to put it, yeah.
And these disruptions directly cause the symptoms you see, the
attention problems, the foggy thinking, the reduced awareness,
(08:19):
the perceptual changes. One specific neurotransmitter
gets called out is particularly relevant.
Reduced acetylcholine activity. Acetylcholine often linked to
memory and attention, right? Exactly a deficit there seems to
be a key finding in many cases. Other things mentioned are the
release of pro inflammatory cytokines.
These are like chemical messengers from the immune
(08:41):
system that can mess with brain function and that impaired
communication between brain regions.
It's essentially as one of the synonyms suggested and acute
brain failure state triggered byproblems elsewhere in the body
or directly in the brain. Given those changes in mental
state, it must get confused withother conditions sometimes.
What's on the differential diagnosis list?
What else could it be? Yeah.
(09:01):
This is super important because mistaking delirium for something
else means you might delay finding and treating the actual
cause. The notes list several common
look alikes. Well, the biggest one.
The most important distinction often is with dementia.
Both involve cognitive changes, right?
But dementia is typically chronic, progressive, a slow
(09:22):
decline over time. Delirium is acute, sudden onset
and fluctuating. That's the key difference.
However, some types of dementia like Lewy body dementia do have
fluctuations which can make it trickier, especially if someone
with dementia develops telluriumon top.
So spotting that new sudden change against their baseline is
crucial. Absolutely crucial.
(09:43):
Other things that can look like include depression, especially
severe depression or bipolar disorder during manic or
depressive episodes, certain functional psychosis like
schizophrenia, or medical conditions like severe thyroid
problems, hyper or hyperthyroidism.
Any less common things on the list to be aware of?
Yes, things like non convulsive status epilepticus that seizures
(10:04):
without the obvious shaking, just confusion.
Or Charles Bonnett syndrome, visual hallucinations in people
with bad eyesight but who are otherwise thinking clearly.
The list also includes metabolicencephalopathy, brain
dysfunction from severe metabolic issues, stroke, brain
tumours, meningitis and of course, acute intoxication or
withdrawal from alcohol or drugs.
(10:24):
It really hammers home the need for a proper medical workup when
someone suddenly becomes confused.
It really does always ask is this new and is it fluctuating?
That should scream delirium until proven otherwise.
OK. Before we get into how it looks
day-to-day and what we do about it, just how common is this
condition? The epidemiologist section gives
some perspective. It's way more common than most
(10:44):
people think, especially in certain settings.
Out in the general community it's pretty low, maybe 1-2
percent. But look at older adults over
85, it could be up to 14%. That's a big jump just with age.
It is, but then look at healthcare settings.
Long term care residents 1040% prevalence.
Hospitalised. Older adults, people 65 plus
admitted to hospital, the prevalence is around 50%.
(11:06):
Fifty. Percent.
Half that number is, well, it's staggering.
It is. Staggering.
And it highlights why it's so vital to be aware of it.
In emergency departments. About 30% of older adults
presenting might have delirium. It complicates a huge chunk of
major surgeries. The notes say 1761% and in ICU's
it occurs in the vast majority, 70% to 87% of admissions.
(11:29):
So. Basically, if you're elderly and
you end up in hospital or especially ICU, you are in a
very high risk situation for delirium.
Extremely. High risk.
The notes also mentioned its prevalence in palliative care
can be present in up to 88% of patients in their final weeks.
Often it's the hypoactive, quiettype there.
And importantly, it doesn't always just vanish when the
(11:50):
person leaves hospital. The sources say significant
numbers like around 1/3 at one month still have some delirium
symptoms weeks or even months after discharge.
I might. Have assumed it just clears up
once the cause is fixed. That persistence is a really
key. Take away it, really.
Is and it links directly to the long term consequences.
The epidemiology section clearlystates delirium is linked to
(12:10):
increased illness, longer hospital stays, higher health
care costs, and significantly increased mortality.
OK, so. We know it's common, especially
in these vulnerable settings andhas serious implications.
Let's talk about what it actually looks like clinically.
What are the features right the?Presentations.
Remember those core things. Acute onset, fluctuating course.
(12:31):
Clinically, this shows up as problems with attention.
They might be really distractible, can't follow a
conversation, can't focus, reduced awareness of their
surroundings and difficulties with thinking, memory problems,
language issues, disorganised thought.
What? Sort of symptoms might family or
staff observe well. Beyond just general confusion or
disorientation, you might see reduced alertness.
(12:52):
Maybe they're very sleepy, or the opposite.
Agitation, restlessness, pullingat lines.
Hallucinations are common, especially visual ones, and
delusions. Paranoid ideas perhaps
particularly in that hyperactivetype.
There's sleep. Wake cycle often gets completely
messed up. Awake and confused at night,
drowsy during the day, I've. Heard the term sundowning used
(13:13):
for that, yes. Sundowning, where symptoms seem
to get worse in the evening or overnight.
That's a very common pattern yousee with delirium.
You might also see physical signs linked to the underlying
cause, fever, abnormal vital signs, maybe tremors.
So how? Is it actually diagnosed?
Is there a test for it? The.
Diagnosis is primarily clinical.It's based on recognising that
(13:34):
pattern, the acute onset, the fluctuating course affecting
attention and cognition. There isn't like a single blood
test for delirium itself, but investigations are absolutely
essential to find the underlyingcause because managing delirium
hinges on fixing that cause. Got it.
Assessment involves taking a good history, talking to family
or carers is vital, doing a physical and neurological exam
(13:56):
and often using a structured cognitive assessment tool and
the. Material mentions a specific
tool for that. Yes, the four.
AT is mentioned, it's a commonlyused screening tool for
delirium. Quick, easy to use at the
bedside, designed to pick up those key features.
OK. So diagnosis is clinical, but
finding the cause is paramount. How do we investigate what's the
workup according to these notes,right?
(14:17):
Investigations are all about hunting for that underlying
cause or causes and to help remember the common, often
reversible things you need to look for.
The sources give a really helpful mnemi oh a mnemonic is.
Always good for revision it is. The mnemonic is PIN CHME.
Each letter prompts you to thinkabout a key area.
OK, let's. Break it down.
(14:37):
PP is for. Pain.
Is there untreated pain driving this I I is for infection,
always high on the list. N is for nutrition.
Are they malnourished, deficientin something?
C is for Constipation. Remember how important that can
be. Yeah.
H is for hydration. Dehydration is a common factor.
M is for medication. Review that drug chart and then.
(14:58):
The sources list E twice EE. Yes, E for electrolyte
disturbances, think low sodium, high calcium, etcetera.
And E for environment, look at their surroundings, sensory
input, recent moves. So pain, infection, nutrition,
Constipation, hydration, medication, electrolyte,
environment, pin CHEME. It's a great checklist to run
(15:21):
through that. Is fantastic a really practical
way to remember the high yield causes?
So what are the actual tests that usually make up that
initial confusion screen OK? Based on PIN CME, you'd order
tests to cover those bases. The standard screen usually
includes routine bloods, a full blood count, FBC, looking for
infection signs, anaemia, urea and electrolytes, U and ES,
(15:42):
kidney function, sodium, potassium, hydration status.
Then things like liver function tests, LFTS, thyroid function
tests, TFTS, maybe inflammatory markers like CRP or ESR and a
calcium level. Those cover a lot of the
infection, nutrition, hydration,electrolyte and metabolic
possibilities. So those.
Basic blood tests hit quite a few points on the mnemonic.
Exactly. You'd also typically send blood
(16:05):
cultures if you suspect sepsis, do urinalysis and send a urine
sample. UTI's are super common triggers,
especially in older adults. And a chest X-ray to look for
pneumonia part of the infection screen.
When do? You need to start thinking about
imaging the brain, CT scans and so on.
Yeah. Cranial imaging like ACT head
isn't usually first line unless there's a specific reason it's
(16:27):
considered. If you actively suspect a
neurological cause like a stroke, a bleed, a tumour, or if
the delirium just isn't getting better despite treating what you
think is the cause. Or if your initial screen is
completely negative and you're still scratching your head so.
Rule out the common reversible stuff first, generally
precisely. Other investigations listed,
depending on the clinical picture, might include an EEG
(16:50):
that looks at brain electrical activity, or maybe a lumbar
puncture to check the spinal fluid if you're worried about
meningitis or encephalitis. OK.
We figured out how to look for the cause.
How do we actually manage delirium once we suspect it?
What's the approach in the material?
Management is definitely multifaceted, but the absolute
cornerstone, the number one priority is fine and treat the
(17:11):
underlying 'cause you have to fix what triggered it makes.
Total sense infection, treat it dehydrated, hydrate them, Med
causing it, stop it. Exactly.
That alongside treating the cause, providing really good
supportive care is vital. That means keeping the patient
safe, preventing falls, self harm if they're very agitated,
(17:32):
meeting basic needs, nutrition, hydration, helping with
toileting and trying to minimisethings that make confusion worse
like too much noise, too many changes, sensory overload or
deprivation and environment. Was a big factor in CHME.
Great. Huge.
Environmental measures are really important and often
underutilised. Things like modifying the room
for safety, making sure there's good lighting, especially at
(17:53):
night, reducing unnecessary noise, helping the mobilise if
safe and crucially, addressing sensory deficits, making sure
they have their glasses, their hearing aids and that they're
working, helping. Them figure out where they are
and what's going on, yes. Reorientation techniques, a
visible clock and calendar, familiar objects from home,
having family visit or consistent nursing staff if
(18:13):
possible, gently reminding them of the time, place, situation.
Trying to maintain a normal sleep wake cycle is key to
curtains open during the day, quiet and dark at night so.
Treat the cause, optimise the environment and basic care.
What about using medications forthe delirium symptoms
themselves? Like agitation, right?
(18:33):
So medical management, beyond treating the cause also involves
optimising all their other existing medical conditions.
And a major point again is reviewing all their medications.
Stop or reduce anything unnecessary, especially drugs
known to cause confusion like those with strong
anticholinergic effects. For managing symptoms like
severe agitation or aggression, the first step should always be
(18:54):
de escalation techniques, talking calmly, reassurance if
medication is absolutely necessary because of risk to
sell. For others, the notes mentioned
cautious use of antipsychotics like small doses of haloperidol
or sometimes benzodiazepines. But hang on.
I remember you saying avoid benzos in the elderly earlier.
Yes. And that's a crucial point
reinforced here. If you have to use medication
(19:14):
for agitation, use the lowest effective dose.
Monitor very closely. And importantly, avoid
benzodiazepines in older adults unless it's specifically for
managing alcohol or benzo withdrawal itself.
They often make confusion and sedation worse in this group,
increasing fall risk. Got it.
Antipsychotics cautiously if needed.
(19:35):
Benzos generally avoid in the elderly unless for withdrawal,
correct? Management really needs that
collaborative team approach. Doctors, nurses, pharmacists,
therapists involving the family too.
Everyone needs to be on the samepage.
The sources also briefly mentioned management after
discharge, noting that cognitiveissues can linger, so ongoing
support might be needed. So what?
(19:56):
Happens next. Then what's the typical
prognosis and what are the potential complications listed
in these notes? Well.
The prognosis really varies. It depends heavily on what
caused the delirium, the patient's underlying health, how
frail they were to begin with, and how quickly and effectively
it's all managed. If you find and treat the cause
early, the symptoms can often resolve completely.
That's the. Ideal outcome, right?
(20:17):
That's. The goal?
However, as the epidemiology hinted, delirium is strongly
associated with worse outcomes overall.
Increased illness, much longer hospital stays, a decline in
functional ability meaning they might struggle with daily tasks
they could do before, and unfortunately, higher mortality
rates, especially in older adults.
And you mentioned that long termcognitive risk earlier, yes?
(20:39):
That's a really key take away from the notes.
Having an episode of delirium increases the risk of developing
long term cognitive decline, andit's associated with an
increased risk of dementia lateron.
So even if the acute episode passes, it can leave a lasting
impact on the brain. Prompt intervention and that
multidisciplinary care definitely improve the outlook
though. Given how serious the outcomes
(21:00):
can be, is there anything that can be done to prevent delirium
from happening in the 1st place?Yes.
Prevention is a huge focus, especially in high risk places
like hospitals. The notes outline several
strategies. Firstly, just being aware of who
is high risk. Using those factors, we
discussed age, existing cognitive issues, severe
illness, sensory impairment. Close observation of these
(21:22):
patients is key and that. Team approach again, Absolutely.
Essential for prevention to prompt assessment if early signs
develop. But the most effective strategy
seemed to be these tailored multi component intervention
packages. These are like bundles of care,
focusing proactively on things like ensuring good hydration and
nutrition, promoting mobility and activity, managing pain
(21:44):
effectively, optimising sleep, making sure sensory aids are
used, providing regular orientation cues.
It sounds. Like a lot of those, basic
supportive care and environmental measures are both
treatment and prevention. Exactly.
Applying them proactively to high risk patients is the best
bet for prevention. The material also makes an
explicit point. Routine use of antipsychotic
(22:06):
medications is not supported forpreventing delirium.
Don't use them prophylactically.That's.
Important prevention is mainly non drug based.
What if, despite best efforts, complications still happen?
Unfortunately, complications arecommon and can be serious.
Functional decline is very frequent.
People losing independence. There is a high risk of falls
leading to injuries, fractures. Prolonged hospitalisation is
(22:29):
almost a given which increases cost and risk of other hospital
acquired problems like. Infections, yes.
Things like hospital acquired infections, C difficile MRSA are
mentioned and pressure sores from being immobile and the.
Mortality risk we mentioned increased.
Mortality is a major complication.
Even if the delirium resolves, there can be lasting residual
psychiatric problems or cognitive impairment.
(22:50):
And the notes in the complications list of the Stark
reality that some severe cases can progress to stupor, coma and
ultimately death. Wow, that really does cover the
full spectrum of delirium or acute confusional state.
Drawing straight from your revision notes, we've gone from
the definition, the subtypes, through that huge list of causes
and who's most vulnerable. A glimpse at the brain changes
(23:13):
what else? It might be confused with how
incredibly common it is, particularly in hospital, then
how it looks, how we investigateusing things like PENSI a ME,
the management strategies, focusing on the cause and
support and finally the prognosis, prevention and those
serious potential complications.It really.
Is a condition that can seem complex because of all the
causes, but the core management principle is quite
(23:36):
straightforward. Find and fix the trigger while
supporting the patient and theirbrain.
Recognising it quickly is just so important and.
Perhaps a final thought for you,the listener, to consider based
on all this. Just think about how sometimes
seemingly minor things, maybe being a bit dehydrated or
constipated, or just the stress and disorientation of being
moved to a different room and hospital, can interact with
(23:58):
underlying vulnerabilities like older age or mild memory
problems and tip someone into this really profound state of
acute brain failure. It's often that combination,
that perfect storm. Yeah, it really highlights why
paying attention to the basics, hydration, bowels, pain,
environment, sensory aids, is soincredibly critical, especially
(24:21):
in frail older people. Absolutely.
Well, thank you for bringing these notes for this deep dive.
It's been incredibly useful. Very high yield.
My pleasure. Hope it helps and.
If you are revising and looking for more resources like this,
remember the sources mentioned pass the msray.com and
freemessray.com. Yeah, definitely.
Worth checking those out for further study.
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