Acute Confusion | CAM Assessment | HELP Protocol | Multimodal Intervention
DELIRIUM SUBTYPES
Critical Must-Knows
- Delirium is an acute confusional state with disturbance of consciousness and cognition developing over hours to days
- CAM (Confusion Assessment Method) requires: acute onset + inattention + EITHER disorganized thinking OR altered consciousness
- HELP (Hospital Elder Life Program) is evidence-based multimodal prevention protocol reducing delirium by 30-40%
- Hip fracture patients have highest risk (35-65% incidence) - early surgery within 48 hours reduces delirium
- Avoid high-risk medications: benzodiazepines, anticholinergics, meperidine (pethidine), first-generation antihistamines
Clinical Pearls
- "Delirium vs dementia: delirium is ACUTE with fluctuating course, dementia is CHRONIC with gradual decline
- "Hypoactive delirium is most common but often missed - actively screen all at-risk patients
- "3 Ds: Drugs, Disease, Environment - address all domains for prevention
- "Orthogeriatric co-management reduces delirium by ~19% (RR 0.81) in hip fracture patients
Critical Delirium Prevention Exam Points
Definition and Recognition
Delirium is acute brain dysfunction with disturbance of consciousness and cognition. DSM-5 requires: (1) disturbance of attention/awareness, (2) acute onset (hours-days), (3) fluctuating course, (4) additional cognitive disturbance. Use CAM or 4AT for screening.
Risk Factors
Predisposing vs Precipitating: Predisposing (age over 65, dementia, sensory impairment, comorbidities). Precipitating (surgery, pain, medications, infection, hypoxia, constipation, urinary retention). Hip fracture combines multiple risks.
HELP Protocol
Evidence-based multimodal intervention: Orientation, therapeutic activities, early mobilization, vision/hearing aids, sleep hygiene, nutrition/hydration, pain management, medication review. Reduces delirium by 30-40%.
Pharmacology
No role for prophylactic antipsychotics. Avoid deliriogenic drugs: benzodiazepines (paradoxical agitation in elderly), anticholinergics, meperidine. If treatment needed: haloperidol 0.5-1mg lowest effective dose. Investigate and treat underlying cause.
At a Glance
Delirium is an acute confusional state with disturbance of consciousness and cognition developing over hours to days, affecting 35-65% of hip fracture patients and increasing mortality 3-5×. The CAM (Confusion Assessment Method) requires acute onset + inattention + EITHER disorganized thinking OR altered consciousness for diagnosis. Hypoactive delirium (withdrawn, lethargic) is most common but frequently missed—actively screen all at-risk patients. The evidence-based HELP protocol reduces delirium by 30-40% through multimodal intervention: hydration, early mobilization, sensory aids, sleep hygiene, pain management, medication review, and orientation. Avoid deliriogenic medications: benzodiazepines (paradoxical agitation), anticholinergics, meperidine (neurotoxic metabolite), and first-generation antihistamines. No role for prophylactic antipsychotics; orthogeriatric co-management and early surgery (under 48h) reduce delirium incidence.
ACIDCAM Criteria for Delirium Diagnosis
| A | Acute onset and fluctuating course Develops over hours to days, waxes and wanes throughout the day |
| C | Confusion (inattention) Difficulty focusing, easily distracted, unable to follow conversation |
| I | Impaired thinking (disorganized) Rambling, irrelevant conversation, unclear flow of ideas, illogical thinking |
| D | Disturbed consciousness (altered level) Hyperalert, lethargic, stuporous, or comatose - altered from baseline |
| A | Acute onset and fluctuating course Develops over hours to days, waxes and wanes throughout the day | I | Impaired thinking (disorganized) Rambling, irrelevant conversation, unclear flow of ideas, illogical thinking |
| C | Confusion (inattention) Difficulty focusing, easily distracted, unable to follow conversation | D | Disturbed consciousness (altered level) Hyperalert, lethargic, stuporous, or comatose - altered from baseline |
Hook:ACID burns the brain acutely - delirium is an ACID test requiring A + C + (I or D) for diagnosis!
HELPS MEHELP Protocol Components
| H | Hydration and nutrition Oral intake encouraged, IV fluids if needed, avoid dehydration |
| E | Early mobilization Out of bed within 24 hours, walking assistance, minimize restraints |
| L | Listen (hearing aids) Ensure hearing aids in place, amplification devices, reduce sensory deprivation |
| P | Pain management Regular assessment, multimodal analgesia, avoid high-risk opioids |
| S | Sleep hygiene Minimize nighttime interruptions, warm milk, reduce noise, avoid sedatives |
| M | Medication review Stop deliriogenic drugs, rationalize polypharmacy, use Beers criteria |
| E | Environment and orientation Clock, calendar, familiar objects, natural light, family visits |
| H | Hydration and nutrition Oral intake encouraged, IV fluids if needed, avoid dehydration | P | Pain management Regular assessment, multimodal analgesia, avoid high-risk opioids | E | Environment and orientation Clock, calendar, familiar objects, natural light, family visits |
| E | Early mobilization Out of bed within 24 hours, walking assistance, minimize restraints | S | Sleep hygiene Minimize nighttime interruptions, warm milk, reduce noise, avoid sedatives | ||
| L | Listen (hearing aids) Ensure hearing aids in place, amplification devices, reduce sensory deprivation | M | Medication review Stop deliriogenic drugs, rationalize polypharmacy, use Beers criteria |
Hook:HELP protocol really HELPS ME prevent delirium in my orthopaedic patients!
BAD MEDSHigh-Risk Medications to Avoid
| B | Benzodiazepines Paradoxical agitation, respiratory depression, increased falls |
| A | Anticholinergics Antihistamines, tricyclics, antispasmodics - central anticholinergic syndrome |
| D | Diphenhydramine (Benadryl) First-generation antihistamine, strongly anticholinergic |
| M | Meperidine (Pethidine) Neurotoxic metabolite normeperidine, seizures in renal impairment |
| E | Excessive opioids High-dose opioids, especially in opioid-naive elderly |
| D | Drugs with long half-lives Diazepam, flurazepam - accumulate in elderly |
| S | Steroids (high-dose) Psychosis, mood changes, sleep disturbance |
| B | Benzodiazepines Paradoxical agitation, respiratory depression, increased falls | M | Meperidine (Pethidine) Neurotoxic metabolite normeperidine, seizures in renal impairment | S | Steroids (high-dose) Psychosis, mood changes, sleep disturbance |
| A | Anticholinergics Antihistamines, tricyclics, antispasmodics - central anticholinergic syndrome | E | Excessive opioids High-dose opioids, especially in opioid-naive elderly | ||
| D | Diphenhydramine (Benadryl) First-generation antihistamine, strongly anticholinergic | D | Drugs with long half-lives Diazepam, flurazepam - accumulate in elderly |
Hook:BAD MEDS cause delirium - avoid these in elderly orthopaedic patients!
I WATCH DEATHPrecipitating Factors Assessment
| I | Infection UTI, pneumonia, surgical site infection |
| W | Withdrawal Alcohol, benzodiazepines, opioids |
| A | Acute metabolic Hyponatremia, hypoglycemia, hypercalcemia, acidosis |
| T | Trauma/surgery Hip fracture, major surgery, anaesthesia |
| C | CNS pathology Stroke, subdural, seizure, meningitis |
| H | Hypoxia Respiratory failure, PE, anaemia, cardiac failure |
| D | Drugs See BAD MEDS mnemonic |
| E | Environmental ICU, sensory deprivation, restraints, sleep disruption |
| A | Acute vascular MI, stroke, shock, hypertensive emergency |
| T | Toxins/poisons Carbon monoxide, heavy metals |
| H | Heavy drinking (alcohol) Intoxication or withdrawal |
| I | Infection UTI, pneumonia, surgical site infection | T | Trauma/surgery Hip fracture, major surgery, anaesthesia | D | Drugs See BAD MEDS mnemonic | T | Toxins/poisons Carbon monoxide, heavy metals |
| W | Withdrawal Alcohol, benzodiazepines, opioids | C | CNS pathology Stroke, subdural, seizure, meningitis | E | Environmental ICU, sensory deprivation, restraints, sleep disruption | H | Heavy drinking (alcohol) Intoxication or withdrawal |
| A | Acute metabolic Hyponatremia, hypoglycemia, hypercalcemia, acidosis | H | Hypoxia Respiratory failure, PE, anaemia, cardiac failure | A | Acute vascular MI, stroke, shock, hypertensive emergency |
Hook:I WATCH DEATH approach when investigating precipitating causes of delirium!
Overview and Epidemiology
Delirium is an acute disturbance in attention, awareness, and cognition that develops over a short period (hours to days) and fluctuates in severity throughout the day. It represents acute brain dysfunction and is a medical emergency requiring immediate investigation and intervention.
Definition and Diagnostic Criteria
DSM-5 Criteria for Delirium:
- Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to environment)
- Acute onset (hours to days) and represents a change from baseline
- Fluctuating course during the day
- Additional cognitive disturbance (memory deficit, disorientation, language, visuospatial ability, perception)
- Not better explained by pre-existing dementia and does not occur in context of severely reduced level of arousal (coma)
Epidemiology in Orthopaedic Surgery
Incidence rates:
- Hip fracture patients: 35-65% (highest risk orthopaedic population)
- Elective hip/knee arthroplasty: 4-10%
- Spinal surgery: 10-15%
- General orthopaedic trauma: 15-25%
- ICU admission after trauma: 50-80%
Risk increases with:
- Age over 65 years (each decade doubles risk)
- Pre-existing cognitive impairment or dementia
- Multiple comorbidities
- Emergency surgery
- Prolonged anaesthesia
- Postoperative complications
Why Hip Fracture Patients?
Hip fracture patients have the perfect storm for delirium: advanced age, pre-existing cognitive impairment, surgical stress, pain, anaemia from blood loss, medications (opioids, anticholinergics), immobility, and medical comorbidities. This is why orthogeriatric co-management is so effective.
Impact on Outcomes
Mortality:
- 3-5 times higher mortality at 6 months
- 10-26% in-hospital mortality in delirium patients vs 5% in non-delirium
Functional decline:
- Increased risk of new nursing home placement (2-3 fold)
- Loss of independence in ADLs (activities of daily living)
- Delayed or incomplete functional recovery
Hospital complications:
- Mean length of stay increased by 2.5 days
- Increased falls and injuries
- Higher rate of postoperative complications
- Pressure ulcers, aspiration pneumonia
Long-term cognitive effects:
- Accelerated cognitive decline
- Increased risk of dementia development
- Persistent cognitive impairment in 30-40% at 6 months
Healthcare costs:
- Substantial attributable healthcare costs (driven by longer stay, complications and institutionalisation)
- Higher per-admission costs versus patients without delirium
Pathophysiology and Subtypes
Pathophysiological Mechanisms
The exact pathophysiology of delirium remains incompletely understood, but several mechanisms are implicated:
1. Neurotransmitter imbalance:
- Cholinergic deficiency: Reduced acetylcholine availability or increased anticholinergic burden
- Dopaminergic excess: Increased dopamine activity in mesolimbic pathways
- Other neurotransmitters: Serotonin, GABA, glutamate, norepinephrine dysregulation
2. Neuroinflammation:
- Systemic inflammation (surgery, infection) triggers cytokine release (IL-1, IL-6, TNF-alpha)
- Cytokines cross blood-brain barrier
- Microglial activation and neuroinflammation
- Disruption of neurotransmission
3. Oxidative stress:
- Increased reactive oxygen species
- Mitochondrial dysfunction
- Neuronal injury
4. Neuroendocrine dysfunction:
- HPA axis dysregulation
- Cortisol elevation
- Melatonin disruption (sleep-wake cycle)
5. Blood-brain barrier disruption:
- Increased permeability in critical illness
- Allows neurotoxic substances into CNS
Vulnerable Brain Hypothesis
Patients with pre-existing brain vulnerability (dementia, previous stroke, chronic disease) have reduced brain reserve and cognitive reserve, making them susceptible to delirium from even minor insults. This is why delirium often unmasks underlying cognitive impairment.
Clinical Subtypes
Delirium Subtypes - Clinical Features and Management
| Subtype | Frequency | Clinical Features | Management Challenges |
|---|---|---|---|
| Hyperactive | 15-20% | Agitated, restless, hypervigilant, hallucinations, delusions, combative | Safety risk, medication often requested, disruptive to care |
| Hypoactive | 25-30% | Withdrawn, lethargic, reduced alertness, quiet, apathetic, slow responses | Often MISSED - appears sedated or depressed, highest mortality |
| Mixed | 50-55% | Fluctuates between hyperactive and hypoactive states during same day | Most common pattern, unpredictable course |
Hypoactive Delirium is Dangerous
Hypoactive delirium is the most commonly MISSED subtype because patients appear calm and don't disrupt care. However, it carries the highest mortality risk because underlying medical problems (sepsis, stroke, metabolic derangement) go unrecognized. Always actively screen for delirium - don't assume quiet means well.
Delirium vs Dementia vs Depression
Differential Diagnosis of Confusion in Elderly
| Feature | Delirium | Dementia | Depression |
|---|---|---|---|
| Onset | Acute (hours-days) | Chronic (months-years) | Weeks to months |
| Course | Fluctuating throughout day | Stable, progressive | Persistent |
| Consciousness | Altered (hyper/hypoalert) | Normal until late stages | Normal |
| Attention | Impaired (cannot focus) | Normal early, impaired late | Distractible but can focus |
| Hallucinations | Common (especially visual) | Uncommon until late | Rare |
| Reversibility | Potentially reversible | Progressive, irreversible | Treatable |
Key distinction: Delirium is ACUTE and FLUCTUATING (worsens at night - "sundowning"), while dementia is CHRONIC and STABLE day-to-day. Delirium can occur superimposed on dementia (common in hip fracture patients).
Risk Factors and Assessment
Predisposing vs Precipitating Factors
The interaction between predisposing factors (patient vulnerability) and precipitating factors (acute insults) determines delirium risk. High vulnerability requires only minor precipitant; low vulnerability requires major precipitant.
Predisposing Factors (Baseline Vulnerability)
Non-modifiable:
- Age over 65 years (strongest predictor)
- Pre-existing dementia or cognitive impairment
- History of delirium
- Severe illness or comorbidity burden
- Stroke or neurological disease
Modifiable:
- Sensory impairment (vision, hearing)
- Malnutrition or dehydration
- Functional dependence
- Depression
- Alcohol use
Precipitating Factors (Acute Insults)
Surgical:
- Hip fracture surgery
- Emergency surgery
- Prolonged anaesthesia (over 3 hours)
- Significant blood loss
Medical:
- Infection (UTI, pneumonia)
- Hypoxia, hypotension
- Metabolic disturbance
- Severe pain
Iatrogenic:
- High-risk medications (see BAD MEDS)
- Physical restraints
- Urinary catheter
- Sleep deprivation
Delirium Risk Prediction Models
High-risk features (each increases risk 2-5 fold):
- Age over 70 years
- Cognitive impairment (MMSE less than 24)
- Severe illness (ASA III-IV)
- Sensory impairment (vision or hearing)
- Depression
- Dehydration or malnutrition
- Alcohol use disorder
Hip fracture specific risks:
- Fracture type (intertrochanteric higher than intracapsular)
- Delay to surgery (over 48 hours)
- Intraoperative hypotension
- Postoperative anaemia (Hb less than 90 g/L)
- Inadequate analgesia
Delirium Risk Stratification
| Risk Level | Predisposing Factors | Delirium Risk | Prevention Strategy |
|---|---|---|---|
| Low risk | 0-1 factors | 5-10% | Standard care, early mobilization |
| Moderate risk | 2-3 factors | 15-30% | Targeted interventions, daily screening |
| High risk | 4 or more factors | 40-65% | Intensive multimodal prevention (HELP), orthogeriatric comanagement |
Assessment Tools
Confusion Assessment Method (CAM)
The CAM is the most widely validated bedside tool for delirium diagnosis. Requires brief training and takes 5 minutes to administer.
Diagnostic Algorithm: Delirium is present if: (Feature 1 AND Feature 2) AND (Feature 3 OR Feature 4)
Feature 1: Acute onset and fluctuating course
- Is there evidence of acute change in mental status from baseline?
- Does the abnormal behavior fluctuate during the day?
Feature 2: Inattention
- Does the patient have difficulty focusing attention?
- Is the patient easily distracted or unable to keep track of conversation?
Feature 3: Disorganized thinking
- Is the patient's thinking disorganized or incoherent?
- Rambling, irrelevant conversation, unclear flow of ideas?
Feature 4: Altered level of consciousness
- Overall, how would you rate the patient's level of consciousness?
- Alert (normal), vigilant (hyperalert), lethargic, stupor, coma
- Any response other than "alert" is abnormal
Sensitivity: 94%, Specificity: 89% for delirium diagnosis.
CAM in Clinical Practice
In practice, Feature 1 (acute onset) and Feature 2 (inattention) are almost always present in delirium. The key is then identifying EITHER disorganized thinking (rambling speech, illogical) OR altered consciousness (drowsy, hyperalert). Inattention can be tested by asking patient to recite months backwards or spell WORLD backwards.
Prevention Strategies
Evidence-Based Prevention Approaches
Prevention is more effective than treatment. Approximately 30-50% of delirium cases are preventable with multicomponent interventions.
HELP Protocol (Hospital Elder Life Program)
The HELP protocol is the gold standard evidence-based intervention for delirium prevention. It targets key risk factors with non-pharmacological interventions delivered by trained volunteers and staff.
Cognitive Stimulation
Orientation:
- Communication board with date, schedule
- Orientation to person, place, time
- Familiar objects from home
Therapeutic activities:
- Structured activities 3x daily
- Reminiscence, word games
- Discussion of current events
Mobilization
Early mobilization protocol:
- Out of bed within 24 hours
- Walking or wheelchair 3x daily
- Range of motion exercises
Minimize restraints:
- Physical restraints increase delirium 2-fold
- Avoid urinary catheters (remove ASAP)
Sensory Optimization
Vision:
- Glasses available and clean
- Adequate lighting
- Large-print materials
Hearing:
- Hearing aids in place and working
- Amplification devices
- Minimize background noise
Sleep Hygiene
Non-pharmacological sleep:
- Minimize nighttime interruptions
- Warm milk or herbal tea
- Relaxation music
Environment:
- Reduce noise (unit-wide quiet time)
- Minimize lights at night
- Normal circadian rhythm
Hydration and Nutrition
Oral intake:
- Encourage fluids 1500-2000mL/day
- Assistance with feeding
- Nutritional supplements if needed
Avoid:
- Prolonged fasting
- Dehydration
- Electrolyte imbalance
Pain Management
Multimodal analgesia:
- Regular paracetamol
- Regional anaesthesia where possible
- Lowest effective opioid dose
Avoid:
- Meperidine (pethidine)
- Excessive opioids in opioid-naive
HELP Protocol Effectiveness:
- 30-40% reduction in delirium incidence
- Reduced delirium severity
- Shorter delirium duration
- Cost-effective in health-economic analyses (fewer delirium days and complications)
- Number needed to treat is favourable (multicomponent prevention RR 0.69, Cochrane PMID 26967259)
Medication Review and Optimization
Medication Management in Delirium Prevention
| Drug Class | Risk | Alternatives | Action |
|---|---|---|---|
| Benzodiazepines | HIGH - paradoxical agitation | Non-pharm for anxiety/sleep | AVOID unless alcohol withdrawal |
| Anticholinergics | HIGH - central anticholinergic syndrome | Alternative antiemetics, antispasmodics | STOP if possible |
| Meperidine (Pethidine) | HIGH - neurotoxic metabolite | Morphine, oxycodone, regional anaesthesia | NEVER use in elderly |
| First-gen antihistamines | HIGH - anticholinergic | Second-gen antihistamines (cetirizine) | AVOID |
| H2-blockers (high-dose) | MODERATE - CNS effects | PPIs if acid suppression needed | Use lowest dose |
| Corticosteroids | MODERATE - psychosis risk | Use only when indicated | Lowest effective dose |
| Opioids (excessive) | MODERATE - dose-dependent | Multimodal analgesia, regional blocks | Titrate to effect |
Beers Criteria for Elderly: The American Geriatrics Society Beers Criteria lists potentially inappropriate medications in older adults. Key deliriogenic medications to avoid:
- Benzodiazepines (especially long-acting: diazepam, flurazepam)
- Anticholinergics (diphenhydramine, hydroxyzine, promethazine)
- Tricyclic antidepressants (amitriptyline)
- First-generation antipsychotics in high doses
- Meperidine (pethidine)
- Pentazocine
Australian PBS and eTG Guidance
PBS (Pharmaceutical Benefits Scheme) lists restrictions on benzodiazepines in elderly. eTG (Therapeutic Guidelines) recommends avoiding benzodiazepines for sleep in elderly and using non-pharmacological approaches first. If sedation essential, consider low-dose melatonin (not PBS-subsidized) or quetiapine 12.5-25mg (off-label use).
Orthogeriatric Co-Management
Proactive orthogeriatric care involves dedicated geriatricians working with orthopaedic teams to optimize perioperative medical management.
Components:
- Daily geriatrician review within 24 hours of admission
- Comprehensive geriatric assessment (CGA)
- Medication optimization
- Delirium screening and prevention protocols
- Management of comorbidities
- Discharge planning and rehabilitation coordination
Evidence:
- ~19% reduction in delirium incidence (RR 0.81, 95% CI 0.71-0.92; Van Heghe 2021 meta-analysis, PMID 34591127)
- Reduced length of stay (~1.55 days)
- Reduced in-hospital mortality (28% lower) and 1-year mortality (14% lower)
- Improved outcomes; broadly cost-effective
- Recommended in major hip fracture guidelines and registries internationally
Australian National Hip Fracture Registry (ANZHFR) recommendations:
- Orthogeriatric care within 24 hours
- Surgery within 48 hours of admission
- Standardized delirium screening
- Multimodal delirium prevention
Surgical Timing and Anaesthetic Considerations
Early Surgery for Hip Fracture
Early Surgery Within 48 Hours Reduces Mortality and Complications
- Surgery within 48h: 20% lower 12-month mortality (RR 0.80)
- Fewer perioperative complications (8% vs 17%)
- HIP ATTACK RCT did NOT show a mortality benefit for ultra-early (6h) surgery
Timing targets:
- Ideal: within 36 hours of admission
- Maximum: 48 hours (NICE, ANZHFR, BOA guidelines)
- Delays only acceptable for reversible medical optimization (e.g., severe heart failure, active MI)
Benefits of early surgery (meta-analysis, Klestil 2018, PMID 30224765):
- 20% lower 12-month mortality with surgery within 48 hours (RR 0.80, 95% CI 0.66-0.97)
- Fewer perioperative complications (8% vs 17% in adjusted data)
- Earlier mobilization and reduced pain
- Shorter hospital stay
- Reduced delirium is driven mainly by multicomponent and orthogeriatric care rather than by surgical timing alone
Reasons for delay (should be minimized):
- Medical optimization (cardiac, respiratory)
- Anticoagulation reversal
- Theatre availability (system failure)
- Out-of-hours staffing
Medical Optimization vs Delay
The evidence shows that delaying surgery for "medical optimization" often does more harm than good. Patients sitting in bed in pain with ongoing blood loss and immobility accumulate complications. Only delay for reversible acute issues (active MI, pulmonary oedema, severe electrolyte disturbance). Don't delay for "stable" chronic conditions like AF, CCF, COPD - optimize concurrently and proceed to surgery.
Anaesthetic Technique
Regional vs General Anaesthesia for Delirium Prevention
The evidence: Multiple meta-analyses have examined whether regional anaesthesia (spinal, epidural) reduces delirium compared to general anaesthesia. The results are conflicting:
Regional anaesthesia (spinal/epidural):
- Avoids volatile anaesthetics and deep sedation
- Allows patient to remain awake and oriented
- Better early cognitive function
- BUT: most high-quality RCTs show no difference in delirium rates
General anaesthesia:
- Complete control of airway
- Better haemodynamic control
- Patient not aware of surgery
- BUT: concern about volatile agents and cognitive effects
Current evidence (Cochrane review, 2021):
- No significant difference in postoperative delirium between regional and GA
- No difference in mortality, cognitive outcomes, or complications
- Choice should be based on patient factors, surgical factors, and anaesthetist preference
When regional may be preferred:
- Frail patient with multiple comorbidities
- Difficult airway
- Severe respiratory disease
- Continuation as postoperative epidural analgesia
When GA may be preferred:
- Patient preference or anxiety
- Coagulopathy or antiplatelet use
- Prolonged surgery expected
- Neuraxial contraindications
The key message: technique matters less than perioperative care (early surgery, pain control, mobilization, delirium prevention).
Classification
Delirium Subtypes
Hyperactive Delirium
Presentation:
- Agitation, restlessness
- Hallucinations
- Combative behavior
- Pulling at lines/tubes
Recognition:
- Obvious and disruptive
- Staff attention drawn quickly
- 25% of cases
Hypoactive Delirium
Presentation:
- Withdrawn, quiet
- Reduced consciousness
- Lethargy, apathy
- Poor oral intake
Recognition:
- Often MISSED
- Worse prognosis
- 50% of cases
Mixed Delirium
Presentation:
- Fluctuates between both
- Unpredictable episodes
- Variable consciousness
Recognition:
- Most common overall
- 25% of cases
- Monitor closely
Classification by Cause
| Category | Examples | Key Points |
|---|---|---|
| Drug-induced | Anticholinergics, benzodiazepines, opioids | Review medication list |
| Metabolic | Hypoglycemia, uremia, hyponatremia | Check basic bloods |
| Infectious | UTI, pneumonia, wound infection | Common in elderly |
| Surgical/trauma | Hypoxia, pain, blood loss | Post-operative common |
| Withdrawal | Alcohol, benzodiazepines | History critical |
Clinical Pearl
Exam Viva Point: "Which subtype of delirium has worse prognosis?" Answer: Hypoactive delirium - it is often missed, delays treatment of underlying cause, and is associated with higher mortality. Active screening is essential.
Recognizing all delirium subtypes ensures no cases are missed, especially hypoactive.
Clinical Assessment
Screening Tools
CAM (Confusion Assessment Method)
Gold standard for diagnosis:
Feature 1: Acute onset and fluctuation
- Is there an acute change in mental status?
- Does it fluctuate during the day?
Feature 2: Inattention
- Difficulty focusing or following conversation
- Months of year backwards test
Feature 3: Disorganized thinking
- Rambling, irrelevant speech
- Illogical flow of ideas
Feature 4: Altered consciousness
- Hyperalert, lethargic, stuporous
Diagnosis: Features 1 + 2 + (3 OR 4)
4AT Score
Rapid bedside assessment:
A - Alertness (0-4 points):
- Normal = 0
- Mild sleepiness less than 10 sec = 0
- Clearly abnormal = 4
M - AMT-4 (0-2 points):
- Age, DOB, place, year
- All correct = 0
- 1 error = 1
- 2+ errors = 2
A - Attention (0-2 points):
- Months backwards Dec-July
- No errors = 0, 1+ errors = 1-2
A - Acute change (0-4 points):
- Acute change or fluctuation = 4
Score: 4+ = possible delirium
Bedside Assessment
| Domain | What to Assess | Method |
|---|---|---|
| Alertness | Level of consciousness | AVPU or GCS, response to voice |
| Attention | Ability to focus | Months backwards, serial 7s |
| Orientation | Person, place, time | Direct questioning |
| Memory | Recent and remote | 3-word recall, recent events |
| Perception | Hallucinations | Ask directly, observe behavior |
Clinical Pearl
Exam Viva Point: "How do you diagnose delirium using CAM?" Answer: Requires acute onset + fluctuating course (Feature 1) PLUS inattention (Feature 2) PLUS EITHER disorganized thinking (Feature 3) OR altered level of consciousness (Feature 4).
Regular screening with validated tools ensures early delirium recognition.
Investigations
First-Line Investigations
Bedside Tests
Immediate assessment:
- Vital signs (temperature, HR, BP, RR)
- Oxygen saturation
- Blood glucose level (finger-prick)
- Bladder scan (urinary retention)
- ECG (arrhythmia, ischemia)
Simple but critical:
- Can identify reversible causes rapidly
- Hypoxia, hypoglycemia, retention common
Blood Tests
Standard panel:
- FBC (infection, anemia)
- U&E (renal function, electrolytes)
- LFTs, calcium
- CRP (inflammation marker)
- Blood glucose (formal)
Additional if indicated:
- Blood cultures (fever)
- Thyroid function
- B12, folate (chronic confusion)
- Troponin (cardiac symptoms)
Imaging and Other Tests
| Investigation | Indication | Looking For |
|---|---|---|
| Chest X-ray | Respiratory symptoms, fever | Pneumonia, heart failure |
| Urinalysis | Suspected UTI, catheter | Infection, hematuria |
| CT head | Focal neurology, fall, anticoagulated | Stroke, SDH, tumor |
| Lumbar puncture | Fever with neck stiffness | Meningitis, encephalitis |
Clinical Pearl
Exam Viva Point: "When do you order a CT head in delirium?" Answer: Focal neurological signs, history of fall, anticoagulation, head trauma, unexplained neurological change. Not routine for all delirium - metabolic and infectious causes far more common.
Investigations should be targeted based on clinical assessment findings.
Management of Established Delirium

General Principles
Once delirium is identified, the approach is:
- Investigate and treat underlying cause (I WATCH DEATH mnemonic)
- Supportive care and safety
- Non-pharmacological management first
- Pharmacological management only if necessary (severe agitation, safety risk)
Investigation of Underlying Cause
Systematic workup:
Bedside:
- Vital signs (fever, hypoxia, hypotension, tachycardia)
- Oxygen saturation
- Blood glucose
- Bladder scan (retention)
- Abdominal examination (constipation, ileus)
Laboratory tests:
- FBC (infection, anaemia)
- U&E (renal function, sodium, potassium)
- LFTs, calcium
- CRP/ESR (inflammation)
- Blood cultures if febrile
- Urinalysis and culture (if symptoms or catheter)
- Thyroid function (if indicated)
- Vitamin B12, folate (if chronic confusion)
Imaging:
- CXR (pneumonia, heart failure)
- CT head (if focal neurology, fall, anticoagulated)
- CT chest/abdomen (if source of sepsis unclear)
Other:
- ECG (arrhythmia, silent MI)
- Medication review (identify deliriogenic drugs)
Always Investigate - Don't Just Sedate
The temptation when faced with an agitated delirious patient at 2am is to give sedation. Resist this. Delirium is a symptom, not a diagnosis. There is an underlying cause (infection, hypoxia, MI, stroke, drug effect) that needs identification and treatment. Sedating a delirious patient with undiagnosed pneumonia or MI can be fatal.
Non-Pharmacological Management
First-line approach for all delirium:
Reassurance and reorientation:
- Calm, reassuring manner
- Frequent reorientation (person, place, time)
- Explain procedures simply
- Familiar objects, photos, family presence
- Continuity of care (same nurses where possible)
Environmental modification:
- Well-lit room during day
- Natural light exposure
- Quiet environment at night
- Remove unnecessary equipment
- Clock and calendar visible
Mobilization:
- Early mobilization (even just sitting in chair)
- Physiotherapy
- Avoid bed rest
- Minimize restraints
Sensory aids:
- Glasses and hearing aids in place
- Minimize background noise
Sleep hygiene:
- Minimize nighttime interruptions
- Group care activities
- Avoid excessive daytime sleep
Family involvement:
- Family presence reduces agitation
- Familiar voices
- Provide information to family
Pharmacological Management
Indications for medication:
- Severe agitation endangering patient or staff
- Risk of harm (pulling lines, falling)
- Distressing hallucinations or delusions
- Non-pharmacological measures failed
Important principles:
- No medication has proven efficacy for delirium - they only manage symptoms
- No role for prophylactic antipsychotics (HOPE-ICU, MIND-USA trials showed no benefit)
- Use lowest effective dose for shortest duration
- Reassess need frequently
Antipsychotic Medications for Delirium
Haloperidol - most studied, first-line
- Typical (first-generation) antipsychotic
- Blocks D2 receptors
- Less sedating than atypicals
- Fewer anticholinergic effects than atypicals
Dosing:
- Start with 0.5mg PO/IM/IV in elderly
- Can repeat in 20-30 minutes if inadequate response
- Usual dose range 0.5-2mg
- Maximum 3-5mg per 24 hours in elderly
- Reduce dose in renal/hepatic impairment
Monitoring:
- ECG before starting (QTc prolongation risk)
- Risk of torsades de pointes (rare but serious)
- Extrapyramidal side effects (rare at low doses)
Atypical antipsychotics (alternatives):
- Quetiapine 12.5-50mg - more sedating, useful at night
- Risperidone 0.25-0.5mg - similar efficacy to haloperidol
- Olanzapine 2.5-5mg - more sedating, anticholinergic effects
Evidence:
- Multiple RCTs show antipsychotics reduce agitation symptoms but do not shorten delirium duration or improve outcomes
- No difference between typical and atypical antipsychotics
- Use for symptom control only, not to "treat" delirium
Australian context:
- PBS does not restrict antipsychotics for delirium
- eTG recommends haloperidol 0.5-1mg as first-line for severe agitation
- Document indication and review daily
Antipsychotic Cautions
Antipsychotics carry black box warning for increased mortality in elderly with dementia. Use only when necessary for safety. Risk vs benefit discussion. QTc prolongation risk - check baseline ECG, avoid in QTc over 500ms or in combination with other QT-prolonging drugs.
Special Scenarios
Hypoactive delirium:
- Often no medication needed
- Treat underlying cause
- Mobilization and stimulation
- Family engagement
Hyperactive delirium with safety concerns:
- Try redirection, one-to-one observation first
- If medication needed: haloperidol 0.5mg
- Physical restraints only as absolute last resort (increase delirium and injury risk)
Delirium in ICU:
- Higher incidence (50-80%)
- Associated with mechanical ventilation, sedation, critical illness
- ABCDEF bundle (Awakening, Breathing, Coordination, Delirium monitoring, Early mobility, Family engagement)
- Light sedation targets
- Daily sedation interruption
Delirium in dementia:
- More challenging to diagnose (change from baseline)
- Higher risk
- More prone to medication side effects
- Family input essential for baseline function
Postoperative Care
Post-Operative Delirium Prevention
Immediate Recovery Period
First 24-48 hours:
- Reorient frequently (person, place, time)
- Pain assessment and control (avoid over-sedation)
- Early mobilization when safe
- Restore glasses/hearing aids ASAP
- Encourage oral intake
Avoid:
- Unnecessary catheterization
- Excessive fluid restriction
- Prolonged NPO status
Ward Care
Ongoing strategies:
- Consistent nursing staff
- Family involvement
- Sleep-wake cycle promotion
- Daily cognitive stimulation
- Monitor bowel and bladder function
Environment:
- Natural light during day
- Quiet at night
- Clock and calendar visible
- Familiar objects from home
Monitoring for Delirium
| Timing | Assessment | Action |
|---|---|---|
| Every shift | CAM or 4AT screen | Document in chart |
| If screen positive | Full CAM assessment | Investigate cause |
| Daily | Function, pain, sleep | Adjust care plan |
| High-risk patients | More frequent monitoring | Lower threshold for assessment |
Clinical Pearl
Exam Viva Point: "How do you monitor for delirium post-operatively?" Answer: Regular screening with CAM or 4AT every shift, especially in high-risk patients. Any acute change warrants full assessment and investigation for underlying cause.
Vigilant postoperative monitoring enables early detection and intervention.
Complications
Delirium Complications and Consequences
Acute complications:
- Falls and injuries (2-3× increased risk)
- Self-removal of lines, drains, catheters
- Aspiration pneumonia
- Pressure injuries from immobility
- Healthcare worker injuries from agitated patients
Medical complications:
- Prolonged hospitalization (mean 2.5 additional days)
- Increased nosocomial infections
- Venous thromboembolism from immobility
- Malnutrition and dehydration
- Medication-related adverse events
Long-term consequences:
- Increased 30-day mortality (3-5× higher)
- Persistent cognitive impairment (30-40% at 12 months)
- Accelerated functional decline
- Increased institutionalization rates
- Post-traumatic stress (patient and family)
- Increased healthcare costs
Delirium is Not Benign
Delirium is independently associated with:
- 30-40% of survivors have persistent cognitive impairment
- 3× mortality at 6 months
- Accelerated dementia progression in those with pre-existing cognitive impairment
- 75% of families report significant stress
Outcomes and Long-Term Effects
Impact on Clinical Outcomes
Outcomes Associated with Delirium in Orthopaedic Surgery
| Outcome Domain | Impact | Magnitude | Time Course |
|---|---|---|---|
| Mortality | In-hospital and 6-month mortality increased | 3-5 fold increase | Persistent at 1 year |
| Length of stay | Prolonged hospitalization | Mean 2.5 extra days | Immediate |
| Functional decline | Loss of independence in ADLs | 60% vs 30% in controls | 3-6 months |
| Institutionalization | New nursing home placement | 2-3 fold increase | At discharge and 6 months |
| Cognitive decline | Accelerated dementia trajectory | Doubles risk of dementia | Persistent at 1 year |
| Falls and fractures | Increased fall risk | 3-fold increase during admission | During delirium episode |
| Healthcare costs | Increased costs | Higher per-admission cost vs no delirium | Immediate and follow-up |
Mortality data:
- In-hospital mortality: 10-26% (vs 5% without delirium)
- 30-day mortality: 15-30%
- 6-month mortality: 25-40%
- 1-year mortality: 35-50%
Functional outcomes:
- 60% have decline in ADL function at discharge
- 40% have persistent functional impairment at 6 months
- Reduced likelihood of returning home
- Increased caregiver burden
Cognitive effects:
- Delirium accelerates cognitive decline in those with dementia
- Increases risk of developing dementia in those without (2-fold)
- Persistent cognitive deficits in 30-40% at 6 months
- May not return to baseline cognitive function
Long-Term Cognitive Impairment
Recent evidence suggests that delirium is not simply a transient, fully reversible condition. It may cause permanent brain injury.
Mechanisms of long-term harm:
- Neuroinflammation with neuronal apoptosis
- Disruption of blood-brain barrier
- Amyloid deposition (Alzheimer's pathology)
- White matter changes on MRI
- Hippocampal atrophy
Clinical implications:
- Some patients never return to baseline
- Delirium may unmask subclinical dementia
- Or delirium may directly cause dementia
- Prevention therefore even more critical
Delirium as Brain Injury
We now understand that delirium is not just "temporary confusion" but represents acute brain injury. It can have permanent consequences. This shifts the paradigm from "it will resolve" to aggressive prevention is essential. Think of delirium like stroke - a brain injury that we must prevent, not just an expected nuisance in elderly surgical patients.
HELP Protocol (Inouye 1999): Multicomponent Prevention Reduces Delirium
- Delirium 9.9% (intervention) vs 15.0% (usual care), OR 0.60
- Fewer delirium days (105 vs 161) and episodes (62 vs 90)
- No effect on severity or recurrence once delirium developed
Multicomponent Interventions Prevent Delirium (Cochrane)
- Multicomponent interventions: delirium RR 0.69 (0.59-0.81)
- No clear benefit from antipsychotics, cholinesterase inhibitors or melatonin
- BIS-guided anaesthesia reduces postoperative delirium (RR 0.71)
Antipsychotics Do Not Shorten Delirium (HOPE-ICU; MIND-USA)
- HOPE-ICU: haloperidol no effect on delirium/coma-free days (5 vs 6, p=0.53)
- MIND-USA: haloperidol and ziprasidone no better than placebo
- Reserve antipsychotics for severe agitation, not prevention
Regional vs General Anaesthesia - No Difference in Delirium (RAGA)
- Delirium 6.2% (regional) vs 5.1% (general), not significant
- No difference in severity, length of stay, or 30-day mortality
- Choose technique on patient factors and local expertise
Orthogeriatric Co-Management Reduces Delirium and Mortality
- 19% lower risk of delirium (RR 0.81)
- 28% lower in-hospital and 14% lower 1-year mortality
- Length of stay shortened by ~1.55 days
Evidence Base
Summary of Key Evidence
High-Quality Evidence (Level 1)
HELP Protocol:
- Original RCT: 30-40% reduction in delirium incidence
- NNT 6-8 patients to prevent one case
- Multiple replications across settings
- Cochrane review confirms benefit
Early Surgery:
- Multiple RCTs including HIP ATTACK
- Surgery within 48 hours reduces delirium, mortality
- NICE, BOA, ANZHFR guidelines aligned
Antipsychotic Prophylaxis:
- HOPE-ICU, MIND-USA trials: NO benefit
- Prophylactic haloperidol does NOT prevent delirium
- Reserve for severe agitation only
Moderate-Quality Evidence (Level 2-3)
Orthogeriatric Co-Management:
- Multiple cohort studies, observational data
- ~19% reduction in delirium (RR 0.81), reduced LOS and mortality
- Multiple registries and cohorts supportive
- Now standard of care
Fascia Iliaca Block:
- Multiple RCTs show reduced opioid use
- Trend toward reduced delirium (not always significant)
- Recommended in guidelines
Medication Review:
- Observational studies support avoiding anticholinergics
- Beers Criteria, STOPP/START criteria developed
- Limited RCT evidence for medication discontinuation alone
What the evidence clearly supports:
- Multicomponent non-pharmacological interventions (HELP protocol)
- Early surgery for hip fractures (within 48 hours)
- Orthogeriatric co-management
- Avoiding deliriogenic medications
- Fascia iliaca blocks for pain control
What the evidence does NOT support:
- Prophylactic antipsychotics
- Any specific anaesthetic technique (regional vs general equivalent)
- Routine melatonin supplementation (insufficient evidence)
- Single-component interventions (must be multimodal)
Clinical Pearl
Exam Viva Point: "What is the evidence for delirium prevention?" Key answer: HELP protocol (Level 1 evidence, 30-40% reduction) and early surgery within 48 hours are best supported. Prophylactic antipsychotics have NO benefit (HOPE-ICU, MIND-USA trials).
The evidence strongly supports multicomponent non-pharmacological prevention bundles.
Viva Scenarios - Delirium Prevention
Use these scenarios to practise clinical reasoning and management decisions
Scenario 1: Hip Fracture Patient with Confusion
"You are the orthopaedic registrar on call. An 82-year-old woman is admitted with an intertrochanteric hip fracture. She has a history of mild dementia (lives independently with home help). The nursing staff call you at 2am because she is confused, trying to get out of bed, and pulled out her IV cannula. She is shouting and states she needs to go home to feed her cats. Her observations are: HR 95, BP 135/80, RR 18, SpO2 96% on room air, T 37.2�C. What is your approach?"
Scenario 2: Delirium Prevention Protocol
"You are developing a delirium prevention protocol for your hospital's orthopaedic ward, particularly targeting hip fracture patients who have a 50% delirium rate. The hospital executive has asked you to present an evidence-based protocol. What would you include?"
Scenario 3: Hypoactive Delirium Recognition
"You are doing ward rounds on Day 2 post-op following a total hip replacement in a 78-year-old woman for osteoarthritis. She had an uneventful spinal anaesthetic and surgery. The nurses report she has been 'very quiet and sleeping a lot.' Her family says 'she's not herself - she's usually chatty but barely responded when we visited.' Her observations are normal. The physiotherapist notes she was confused about the exercises and couldn't remember the session from yesterday. What is your concern and how would you assess and manage this?"
MCQ Practice Points
Clinical Pearl
Q: What is the most important modifiable risk factor for postoperative delirium in elderly hip fracture patients?
A: Time to surgery. Delayed surgery (over 24-48 hours) significantly increases delirium risk. Other modifiable factors include: untreated pain, polypharmacy (especially anticholinergics, benzodiazepines), sensory deprivation (missing glasses/hearing aids), sleep disruption, dehydration, constipation. Early surgery (within 36-48 hours) is recommended by all major guidelines.
Clinical Pearl
Q: What screening tool is recommended for postoperative delirium assessment in orthopaedic patients?
A: 4AT (4 A's Test) or CAM (Confusion Assessment Method). The 4AT is rapid (under 2 minutes) and assesses: Alertness, AMT4 (age, DOB, place, year), Attention (months backwards), Acute change/fluctuation. Score 4 or greater indicates delirium. CAM requires training but has high specificity. Both should be used twice daily in high-risk patients.
Clinical Pearl
Q: Which medications should be avoided or minimized in elderly patients to reduce delirium risk?
A: High-risk medications (STOPP criteria): benzodiazepines, anticholinergics (oxybutynin, antihistamines), opioids (especially pethidine/meperidine), tramadol (lowers seizure threshold, serotonergic). Use lowest effective opioid dose with regular paracetamol base. Regional anaesthesia may reduce delirium compared to general anaesthesia. Avoid abrupt cessation of regular medications (alcohol, benzodiazepines).
Clinical Pearl
Q: What is the recommended pharmacological management of hyperactive delirium in a postoperative orthopaedic patient?
A: First-line: Haloperidol 0.5-1mg PO/IM/IV (max 5mg/24hr in elderly). Use lowest effective dose for shortest duration. Second-line: risperidone 0.5mg BD or quetiapine 12.5-25mg nocte. Benzodiazepines are ONLY indicated for alcohol/benzodiazepine withdrawal delirium. Non-pharmacological measures (reorientation, family presence, sleep hygiene) are first priority.
Clinical Pearl
Q: What are the key non-pharmacological interventions in a delirium prevention bundle for hip fracture patients?
A: HELP (Hospital Elder Life Program) principles: (1) Orientation protocols (clock, calendar, family photos), (2) Early mobilization (day 1 post-op), (3) Sleep promotion (minimize night-time observations, no night-time medications), (4) Cognitive stimulation, (5) Sensory aids (glasses, hearing aids), (6) Adequate hydration/nutrition, (7) Avoid urinary catheters when possible. These reduce delirium incidence by 30-40%.
Guidelines, Registries & Global Practice
Global Epidemiology
Delirium is the most common acute neuropsychiatric complication of hospitalisation in older adults worldwide. Reported incidence varies by population: roughly 11-51% across postoperative cohorts, with hip fracture patients at the highest end (commonly 35-65%), elective hip/knee arthroplasty far lower (around 4-10%), and ICU/critically ill patients reaching 48% or more (MIND-USA cohort, PMID 30346242). Predisposing vulnerability (age, baseline cognitive impairment, sensory loss, frailty) and acute precipitants (surgery, sepsis, hypoxia, deliriogenic drugs) interact, so incidence reflects case-mix as much as care quality. Across settings, multicomponent prevention reduces incidence by roughly one-third (Cochrane RR 0.69, PMID 26967259).
Major Guidelines Side by Side
International Delirium / Hip Fracture Guidance
| Body (region) | Screening | Surgical timing | Prevention / treatment stance |
|---|---|---|---|
| NICE CG103 / NG157 (UK) | Assess at-risk; clinical diagnosis (DSM/short-CAM) | Hip fracture surgery within 36 hours (day of/after admission) | Multicomponent non-pharmacological prevention; antipsychotics only short-term for severe distress/risk |
| SIGN 157 / BOAST (UK) | 4AT on admission and to detect change | Surgery without delay once medically fit (within 36-48h) | Orthogeriatric co-management; avoid deliriogenic drugs |
| AGS (USA) | CAM as reference standard; routine screening of at-risk elders | Early surgery recommended | Multicomponent prevention; explicitly recommends AGAINST routine antipsychotic/cholinesterase-inhibitor prophylaxis |
| ERAS / fragility-fracture pathways | Embedded delirium screening | Surgery within 24-48h optimal | Bundled enhanced-recovery: regional analgesia, early mobilisation, opioid sparing |
| ANZHFR / ACSQHC (Aus & NZ) | Perioperative delirium screening for all | Surgery within 48h (ideally 36h); orthogeriatric review within 24h | Non-pharmacological bundle; haloperidol 0.5-1mg only for severe agitation |
Where guidelines genuinely diverge it is on the surgical-timing threshold (NICE/SIGN favour 36 hours, ANZHFR and most ERAS pathways 48 hours) and on the strength of the anti-antipsychotic recommendation (AGS states this most explicitly). All converge on multicomponent non-pharmacological prevention, validated screening, and avoidance of deliriogenic drugs.
Clinical Pearl
Exam Viva Point: "How do international guidelines on delirium prevention differ?" Answer: They agree on multicomponent non-pharmacological prevention, validated screening (CAM/4AT) and avoiding deliriogenic drugs. They differ mainly on the surgical-timing target (NICE/SIGN 36h vs ANZHFR/ERAS 48h) and on how strongly they advise against prophylactic antipsychotics (AGS most explicit).
DELIRIUM PREVENTION
Clinical summary
Definition and Diagnosis
- •Delirium = acute disturbance in attention, awareness, cognition developing over hours-days with fluctuating course
- •CAM criteria: (Acute onset + Inattention) + (Disorganized thinking OR Altered consciousness)
- •4AT screening: Alertness, AMT4, Attention (months backwards), Acute change - score 4+ indicates delirium
- •Subtypes: Hyperactive (15-20%, agitated), Hypoactive (25-30%, withdrawn - OFTEN MISSED), Mixed (50-55%)
- •Delirium vs dementia: Delirium is ACUTE and FLUCTUATING, dementia is CHRONIC and STABLE
Epidemiology and Risk
- •Hip fracture patients: 35-65% incidence (highest risk orthopaedic population)
- •Elective arthroplasty: 4-10% incidence
- •Mortality: 3-5x higher in delirium patients
- •Predisposing factors: Age over 65, dementia, sensory impairment, comorbidities
- •Precipitating factors: Surgery, pain, medications, infection, hypoxia, immobility
HELP Protocol (Evidence-Based Prevention)
- •HELPS ME mnemonic: Hydration, Early mobilization, Listen (hearing aids), Pain, Sleep, Medication review, Environment
- •Reduces delirium incidence by 30-40%, NNT 6-8 patients
- •Orientation: clock, calendar, familiar objects, reorientation, family visits
- •Mobilization: out of bed within 24 hours, avoid restraints and catheters
- •Sleep: minimize nighttime interruptions, warm milk, quiet time, avoid sedatives
- •Vision/hearing: glasses and hearing aids in place, adequate lighting
- •Nutrition: encourage 1500-2000mL fluids daily, nutritional supplements
BAD MEDS to Avoid
- •Benzodiazepines - paradoxical agitation in elderly (except for alcohol/benzo withdrawal)
- •Anticholinergics - central anticholinergic syndrome (TCAs, antihistamines, antispasmodics)
- •Diphenhydramine (Benadryl) - strongly anticholinergic first-generation antihistamine
- •Meperidine (Pethidine) - neurotoxic metabolite normeperidine, NEVER in elderly
- •Excessive opioids - especially in opioid-naive, use multimodal analgesia
- •Drugs with long half-lives - diazepam, flurazepam accumulate
- •Steroids - high-dose can cause psychosis and sleep disturbance
Surgical and Anaesthetic Considerations
- •Early surgery within 48 hours (ideally 36 hours) reduces delirium and mortality
- •Regional vs GA: NO difference in delirium rates (multiple RCTs)
- •Maintain intraoperative MAP over 65 mmHg, avoid hypotension and hypoxia
- •Fascia iliaca block for hip fractures - excellent analgesia, reduces opioid use
- •Multimodal analgesia: paracetamol + regional blocks + lowest effective opioids
- •Transfuse if Hb less than 80 g/L (some advocate less than 90 g/L in elderly)
- •Orthogeriatric co-management reduces delirium by ~19% (RR 0.81) and lowers mortality
I WATCH DEATH (Precipitating Causes)
- •Infection - UTI, pneumonia, surgical site infection
- •Withdrawal - alcohol, benzodiazepines, opioids
- •Acute metabolic - hyponatremia, hypoglycemia, hypercalcemia
- •Trauma/surgery - hip fracture, major surgery, anaesthesia
- •CNS pathology - stroke, subdural, seizure
- •Hypoxia - respiratory failure, PE, anaemia
- •Drugs - benzodiazepines, anticholinergics, opioids, steroids
- •Environmental - ICU, sensory deprivation, restraints
- •Acute vascular - MI, stroke, shock
- •Toxins - carbon monoxide, heavy metals
- •Heavy drinking - alcohol intoxication or withdrawal
Management of Established Delirium
- •Investigate underlying cause systematically - bloods (FBC, UEC, CRP), urinalysis, CXR, ECG
- •Non-pharmacological first: reassurance, reorientation, mobilization, family presence, sensory aids
- •Avoid benzodiazepines (worsen delirium except in alcohol/benzo withdrawal)
- •Antipsychotics ONLY for severe agitation or safety risk: haloperidol 0.5-1mg lowest dose
- •No role for prophylactic antipsychotics (HOPE-ICU, MIND-USA trials - no benefit)
- •Hypoactive delirium: often no medication needed, focus on cause and mobilization
- •Always investigate before sedating - delirium is a symptom not a diagnosis
Outcomes and Prognosis
- •Mortality: 3-5x increased risk, 10-26% in-hospital mortality vs 5% without delirium
- •Length of stay: increased by mean 2.5 days
- •Functional decline: 60% lose independence in ADLs, 2-3x increased nursing home placement
- •Long-term cognitive: 30-40% have persistent impairment at 6 months, doubles dementia risk
- •Delirium is brain injury - may not be fully reversible, prevention critical
- •Hypoactive delirium has HIGHEST mortality - often missed, underlying problems unrecognized
Australian Context
- •ANZHFR (Australian National Hip Fracture Registry) recommends surgery within 48 hours
- •ANZHFR recommends orthogeriatric review within 24 hours of admission
- •eTG (Therapeutic Guidelines): avoid benzodiazepines for sleep in elderly, use non-pharm
- •eTG: haloperidol 0.5-1mg first-line for severe agitation in delirium
- •PBS: benzodiazepines have restrictions in elderly populations
- •Beers Criteria used to identify potentially inappropriate medications in elderly
Exam Pearls
- •50% of delirium is preventable with multimodal interventions
- •Hypoactive delirium most commonly missed - actively screen all at-risk patients
- •HELP protocol NNT 6-8 to prevent one case of delirium
- •Both inadequate pain AND excessive opioids increase delirium - multimodal analgesia key
- •Early surgery within 48 hours more important than choice of anaesthetic technique
- •Delirium in elderly is acute brain injury with potential permanent effects - aggressive prevention essential