Delirium

With Dr Scott Murray, Geriatrician, Royal Prince Alfred Hospital, Sydney, Australia

Introduction

Delirium, sometimes called “acute confusional state”, is a common clinical syndrome. It’s characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1-2 days (1).

It is a common clinical problem and a challenge for junior doctors after hours. It is under-recognised with rates of approximately 20-30% in general medical wards, 50% on geriatric wards, and in orthopaedic patients it can approach 85%.

Hyperactive delirium manifesting as agitation, confusion and restlessness is often easy to recognise. On the other hand, hypoactive delirium manifesting as sedation, quietness and psychomotor retardation, is very easy to miss (2). Early intervention in hospitalised patients reduces the risk of delirium, the severity and the duration of symptoms. With inattention and fluctuation signifying the hallmarks of delirium, the CAM score is a rapid assessment tool for nursing and medical staff. The CAM score may help distinguish delirium from other conditions such as depression, dementia and acute psychosis (1).

Case

You are a junior doctor working after hours covering the acute medical ward. You are called to see Joan, a 78-year-old female who was admitted three days prior with community-acquired pneumonia and has been worrying the nurses this evening. She is crying out, moaning and, whilst attempting to get out bed, had a fall. The nurses are requesting an assessment and the prescription of a tranquiliser to limit future activities.