Delirium

(or: It's not a bloody UTI)

Graeme HoyleConsultant Geriatrician

Overview

• What is delirium?• Why is it important?• How to recognise it• How to manage it

Case History

OOH GP admission to medicine• Thanks for seeing Jeannie, 85, who's normally

independent.• Neighbours concerned as she was wandering

the Sheltered Housing complex confused and partially dressed.

• When I attended, house a mess, struggling to get out of bed, doubly incontinent.

• Drugs: Aspirin, frusemide 40mg, ramipril 2.5mg, codydramol, amitriptyline 10mg, oxybutynin, ferrous sulphate

• Dx: Not coping at home. – ?UTI

3 Major Errors

1. Nobody is independent– This only seems to be a problem for old

people

2. Everyone is admitted to hospital because they're not coping at home– We only point this out for old people

3. It's usually not a UTI– It's never just a UTI

Delirium

Delirium

• ‘Acute confusional state’• Known about for a long time• Why does a UTI make you confused?

Why is delirium important?

• Delirium:– Is very common (1/3 of elderly admissions)– Has a high mortality (10-26%)– Has high rates of morbidity (LoS, instit.)

• Despite this, delirium:– Is under-recognised– Is under-diagnosed– Is poorly managed

Pathology

• Poorly understood• Neurotransmitters

– ACh, Dopa• Inflammatory process

– High levels of inflam cytokines• Hypothalamic-pituitary-adrenal axis

– Overactivity with hypercortisolism– Leads to inflammatory process

Aetiology

• Predisposing vs. Precipitating factors• A highly susceptible person only needs

a minor insult to develop delirium• A fit person requires a major insult to

develop delirium (eg pneumonia – CURB)

Predisposing factors

• Old age• Frailty• Dementia• Past history of delirium• Visual/hearing impairment• Malnutrition• Polypharmacy• Comorbidity (esp. renal/hepatic impairment)

Precipitating factors

• Infection• Dehydration• Constipation• Pain• Immobility• Medication use/withdrawal• Sleep deprivation• Catheterisation• Use of physical restraints

Clinical features

1) Altered level of consciousness2) Cognitive deficit or perceptual disturbance3) Acute onset, fluctuating course4) Evidence of cause

(also frequently altered sleep-wake cycle, emotional lability)

Forms of delirium

• Hyperactive– Vigilant, agitated, wandering

• Hypoactive– Drowsy, apathetic, frequently missed– More common, higher morbidity

• Mixed

Management - overview

1) Assessment and screening2) Prevention3) Treatment4) Complications5) Discharge6) Follow up

1) Assessment and screening

• At admission:– Identify those with delirium– Identify those at risk of developing delirium

• Screening tests:– AMT

• Delirium or dementia?– HISTORY IS KEY– SQiD

SQiD

'Do you think …….. has been more confused lately?'

Assessment (cont’d) – identification of those at risk

• Old age• Frailty• Dementia• Past history of delirium• Visual/hearing impairment• Malnutrition• Polypharmacy• Comorbidity (esp. renal/hepatic impairment)

2) Prevention

• Identify those at risk• Avoid/rapidly treat precipitating factors• Review drugs

– Stop anticholinergic medication (eg TCAD)– Reduce or stop benzodiazepines

• Management as per established delirium

Precipitating factors

• Infection• Dehydration• Constipation• Pain• Immobility• Medication use/withdrawal• Sleep deprivation• Catheterisation• Use of physical restraints

3) Treatment of delirium

• Identify and treat precipitating factors– Full HISTORY and examination (inc PR)– FBC, U&E’s, LFT’s, Ca, CRP, TFTs, Glc– ECG– CXR

• Non - pharmacological management• Pharmacological management

Non-pharmacological management

= being nice to your granny

Preventing & managing delirium

• Reorient patients to environment and time • Encourage early mobility and self-care (early

involvement of multidisciplinary team) • Maintain fluid intake and nutrition • Correction of sensory impairment (spectacles

and hearing aids) • Avoid constipation

Preventing & managing delirium

• Normalise sleep-wake cycle– discourage daytime naps – ensure undisturbed night-time rest in a quiet room

with low-level lighting• Ensure continuity of care

– avoid frequent ward or room transfers• Avoid urinary catheterisation• Avoid physical restraint

Management of the agitated patient

• Talk to the patient before reaching for the needle

• Reorientate and reassure • Adopt a non-confrontational approach:

– do not argue – tactfully disagree with abnormal beliefs – change the subject of conversation – acknowledge patient’s feelings whilst ignoring the

content of their speech• Involve family / carers

Pharmacological management

• Sedation/antipsychotics should only be used as second-line measures in the following situations:– To allow essential investigation or

treatment – To prevent patient endangering themselves

or others – Relief of distress in an agitated or

hallucinating patient

What drug to use?• Haloperidol has greatest evidence-base• Small doses, titrated as needed - 0.5-1mg orally, 1mg im/iv, Max 5mg/24h• Avoid benzodiazepines unless

– Alcohol withdrawal– Sensitivity to antipsychotics (PD, LBD – even then,

consider quetiapine)• ALWAYS document in notes• Consider Adults with Incapacity Form

4) Complications

• Complications in delirium result from:– Immobility (e.g. pressure sores, nosocomial

infection, DVT/PE) – Instability (falls) – Iatrogenic disease (over-sedation) – Malnutrition and dehydration

• Screening, early recognition and early management (using multidisciplinary team) is essential

5) Discharge

• Delirium is a risk factor for dementia– ?delirium uncovering latent dementia– ?brain damage caused by delirium

• Adequate functional assessment and discharge planning essential following resolution of delirium

• May retain unpleasant memories of delirium– support, counselling and information for patient

and family

6) Follow up

• May be persistent delirium for up to 1 year

• Follow up assessment of cognitive function important - ?dementia

• ? Formal psych review• Document Dx of delirium on discharge

letter – high risk of further delirium

OOH GP admission to medicine• Thanks for seeing Jeannie, 85, who's normally

independent.• Neighbours concerned as she was wandering

the Sheltered Housing complex confused and partially dressed.

• When I attended, house a mess, struggling to get out of bed, doubly incontinent.

• Drugs: Aspirin, frusemide 40mg, ramipril 2.5mg, codydramol, amitriptyline 10mg, oxybutynin, ferrous sulphate

• Dx: Not coping at home. – ?UTI

In AMAU

• Not making much sense: tells you she has to get home as she's going to the shops tomorrow

• Febrile, smells of urine, dry• AMT 5/10

What do you do next?

History!

• Mildly forgetful• No care• Recent fall and hurt knee

• PR exam: faecal impaction• Urine dipstick: blood/prot/nitrites/pus

Bloods

• Na 132• K 3.8• Urea 13• Creat 83

• CRP 86

• Hb 138• MCV 88• Plt 385• WCC 15.2 • Neut 13.2

What's your Diagnosis?

• Delirium, secondary to:• Constipation• Dehydration• UTI• Drugs• Probable background cognitive impairment

What's your management?

Management

• Stop drugs– Frusemide, codydramol, amitriptyline, oxybutynin, iron

• Rehydrate• Laxatives• Empirical antibiotics for UTI• Early MDT assessment• Early mobilisation• Aim for early discharge

Agitated and wandering at night

What do you do?

2 days later, much better

What's your advice to GP?