Identification of underlying problems
In every patient with new onset of delirium, exclude life-threatening conditions, check the vital signs (temperature, blood glucose, etc), and perform a clinical examination. After a fall, check for symptoms of intracranial bleeding (with a CT scan if in doubt).
- Is the patient in pain?
- Perform a pain assessment (eg, Verbal Rating Scale or Numeric Rating Scale) [Note: please refer to the Perioperative pain module]; look for indirect signs
- Are there symptoms of infection?
- Clinical examination, laboratory tests (eg, blood count, renal
parameters, C-reactive protein), samples (urine, blood cultures, possibly lumbar puncture), chest x-ray. Start early antibiotic therapy.
- Is the patient dehydrated?
- Heart rate, respiratory rate, clinical examination: inspect oral mucous membranes/ tongue for longitudinal furrows, tissue turgor/skin folds.
- Are there signs of bleeding?
- Heart rate, respiratory rate, look for drainages, look for hemoglobin/hematocrit
- Is there a possibility of a withdrawal syndrome?
(consider benzodiazepines and alcohol)
- Benzodiazepine withdrawal or
alcohol withdrawal: refer for advice
- Was there a recent medication change (started,
stopped, or dose adjusted)?
- Evaluate for benzodiazepine, tricyclic antidepressants (TCA), anticholinergic medications, and other psychoactive agents. Review medications with a geriatrician or psychiatrist.
- Does your patient have urinary retention?
- Check for recent opioid use. Bladder examination (ultrasound), insert catheter, look for UTI (and urine samples). If there is infection, start the patient on early antibiotic therapy.
- Is your patient constipated?
- Review the patient's chart. Examine
the bowel and give a laxative if required or requested.
- Did the patient sustain a (another) fall? (also ask the nurses)
- Look for bruises or marks from a recent fall; consider a CT scan of the head.
- Are there signs of an acute cardiac problems/pulmonary embolism?
- Give oxygen 2L, ECG, cardiac enzymes, arterial blood gas analysis; if positive, refer to a cardiologist.
- Are there electrolyte abnormalities?
- Test for hypo/hypernatremia, hypercalcemia
Other: If you cannot find a cause, also consider hypothyroidism (TSH), intoxication, eg, digoxin, theophylline, lithium; check blood levels of medications.
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