Delirium Case Presentation
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Transcript of Delirium Case Presentation
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Delirium Case Presentation
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Case
93 ♂
PC 4/7 Confusion, agitation + general
deterioration 3/7 poor urine output
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PMH
BPH Long term catheter in situ MI
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DH
Omeprazole 20mg po od Betahistine 8mg po om Aspirin 75mg po om Calcichew D3 forte
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SH
Lives with wife No carers Independent around house Enjoys doing crosswords Recent falls
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O/A
Temp 35.8 Dehydrated GCS 13/15 AMTS 7/10 Urine
offensive odour Dip +ve blood, leukocytes, nitrites
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Bloods
WCC 14.1 Neut 9.7 Hb 12.0 Na 126 K 4.4 Urea 3.8 Creat 78 CRP 10
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Diagnosis
Acute confusion UTI Hyponatraemia
Ciprofloxacin 5/7 Omeprazole + betahistine stopped
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Day 2
GCS 7/15
CT Brain Small vessel ischaemia No evidence of space occupying lesion,
intracranial haemorrhage or skull #
CRP 46
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After 2/52
GCS 15 AMTS 10/10 A/W discharge home Prophylactic trimethoprim
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Delirium
Derived from Latin ‘off the track’
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Delirium
Transient global disorder of cognition
Medical emergency Affects 20% patients on general
wards Affects 30% of elderly medical
patients Associated with increased mortality,
increased nursing, failed rehab and delayed discharge
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Presentation
Acute + relatively sudden onset (over hours to days)
Decline in attention-focus, perception and cognition
Change in cognition must not be one better accounted for by dementia
Fluctuating time course of delirium helps to differentiate
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Characterised by:
Disorientation in time, place +/- person Impaired concentration + attention Altered cognitive state Impaired ability to communicate Wakefulness – insomnia + nocturnal
agitation Reduced cooperation Overactive psychomotor activity –
irritability + agression
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Diagnosis
Cannot be made without knowledge of baseline cognitive function
Can be confused with 1. dementia – irreversible, not assd with
change in consciousness 2. depression 3. psychosis – may be overlap but
usually consciousness + cognition not impaired
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Differentiating features of delirium and dementia
Features Delirium Dementia
Onset Acute Insidious
Course Fluctuating Progressive
Duration Days – weeks Months - years
Consciousness Altered Clear
Attention Impaired Normal (unless severe)
Psychomotor changes
Increased or decreased
Often normal
Reversibility Usually Rarely
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Risk factors in elderly
Age >80 Extreme physical frailty Multiple medical problems Infections (chest + urine) Polypharmacy Sensory impairment Metabolic disturbance Long-bone # General anaesthesia
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Risk factors
Dementia is one of the most consistent risk factors
Underlying dementia in 25-50% Presence of dementia increases risk
of delirium by 2-3 times
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Causes
Severe physical or mental illness or any process interfering with normal metabolism or function of the brain
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Causes mnemonic Infections (pneumonia, UTI) Withdrawl (alcohol, opiate) Acute metabolic (acidosis, renal failure) Trauma (acute severe pain) CNS pathology (epilepsy, cerebral haemorrhage) Hypoxia Deficiencies (B12, thiamine) Endocrine (thyroid, PTH, hypo/hyperglycaemia) Acute vascular (stroke, MI, PE, heart failure) Toxins/drugs (prescribed tramadol, dig toxicity,
antidepressants, anticholinergics, corticosteroids) recreational)
Heavy metals
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Pathophysiology
Not fully understood Main theory = reversible impairment of cerebral
oxidative metabolism + neurotransmitter abnormalities
Ach – anticholinergics = cause of acute confusional states + Pts with impaired cholinergic transmission (eg Alzheimers) are more susceptible
Dopamine – excess dopamine in delirium Serotonin – increased in delirium Inflammatory mechanism – cytokines eg
interleukin-1 release from cells Stress reaction + sleep deprivation Disrupted BBB may cause delirium
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NICE Guidelines
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Management
1. Identify + treat underlying cause (return to pre-morbid state can take up to 3 weeks)
2. Complete lab tests + investigations eg. FBC, CRP, U+Es, BM, LFTs, TFTs, B12, MSU, CXR
3. Rule out EtOH withdrawl 4. Assume an underlying organic
cause
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Management
5. Ensure adequate hydration + nutrition
6. Use clear, straightforward communication
7. Orientate the patient to environment + frequent reassurance
8. Identify if environmental factors are contributing to confused state
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Management
Disturbed, agitated or uncooperative patients often require additional nursing input
Medication should not be regarded as first line treatment
Consider medication if all other strategies fail but remember all psychotropic meds can increase delirium + confusion
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Medications
Benzodiazepines Lorazepam 0.5-1mg tds orally Shorter half life than diazepam +
effective at lower doses S/E - Respiratory depression, increased
risk of falls, hypotension Not for long term use
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Medications
Antipsychotics Avoid in PD Haloperidol 0.5-1mg S/E – cardiac, avoid in patients with
hypotension, tachycardia + arrhythmias, extrapyramidal
Recent evidence suggests not to use in patients with dementia or risk of CVD due to increased risk of cerebral ischaemia
3X increase in risk of stroke when Risperidone used in older patients with dementia
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Medications
Dementia with Lewy Bodies Severe reactions to antipsychotic drugs
that can lead to death Due to extrapyramidal effects
Urgent psychiatric opinion
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Medication
Review regime every 48h Will not improve cognition Can reduce behavioural disturbance Start with lowest dose possible +
increase gradually Offer orally first Use as ‘fixed dose’ regime
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Complications
Malnutrition Aspiration pneumonia Pressure ulcers Weakness, decreased mobility,
decreased function Falls, #s
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Outpatient Care
Memories of delirium are variable Educate patient, family + carers
about future risk factors Elderly patients can require at least
6-8 weeks for a full recovery For some patients the cognitive
effects may not resolve completely
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RUH Algorithm for diagnosis + management of delirium in older adults