Delirium (or: It's not a bloody UTI)
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Delirium
(or: It's not a bloody UTI)
Graeme HoyleConsultant Geriatrician
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Overview
• What is delirium?• Why is it important?• How to recognise it• How to manage it
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Case History
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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
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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
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Delirium
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Delirium
• ‘Acute confusional state’• Known about for a long time• Why does a UTI make you confused?
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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
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Pathology
• Poorly understood• Neurotransmitters
– ACh, Dopa• Inflammatory process
– High levels of inflam cytokines• Hypothalamic-pituitary-adrenal axis
– Overactivity with hypercortisolism– Leads to inflammatory process
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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)
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Predisposing factors
• Old age• Frailty• Dementia• Past history of delirium• Visual/hearing impairment• Malnutrition• Polypharmacy• Comorbidity (esp. renal/hepatic impairment)
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Precipitating factors
• Infection• Dehydration• Constipation• Pain• Immobility• Medication use/withdrawal• Sleep deprivation• Catheterisation• Use of physical restraints
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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)
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Forms of delirium
• Hyperactive– Vigilant, agitated, wandering
• Hypoactive– Drowsy, apathetic, frequently missed– More common, higher morbidity
• Mixed
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Management - overview
1) Assessment and screening2) Prevention3) Treatment4) Complications5) Discharge6) Follow up
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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
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SQiD
'Do you think …….. has been more confused lately?'
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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)
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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
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Precipitating factors
• Infection• Dehydration• Constipation• Pain• Immobility• Medication use/withdrawal• Sleep deprivation• Catheterisation• Use of physical restraints
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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
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Non-pharmacological management
= being nice to your granny
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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What do you do next?
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History!
• Mildly forgetful• No care• Recent fall and hurt knee
• PR exam: faecal impaction• Urine dipstick: blood/prot/nitrites/pus
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Bloods
• Na 132• K 3.8• Urea 13• Creat 83
• CRP 86
• Hb 138• MCV 88• Plt 385• WCC 15.2 • Neut 13.2
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What's your Diagnosis?
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• Delirium, secondary to:• Constipation• Dehydration• UTI• Drugs• Probable background cognitive impairment
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What's your management?
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Management
• Stop drugs– Frusemide, codydramol, amitriptyline, oxybutynin, iron
• Rehydrate• Laxatives• Empirical antibiotics for UTI• Early MDT assessment• Early mobilisation• Aim for early discharge
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Agitated and wandering at night
What do you do?
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2 days later, much better
What's your advice to GP?