10 slides on…Delirium in older people with CKD

Dr Miles D WithamUniversity of Dundee

What is delirium?

• An acute, reversible, global disturbance of brain function• Can be thought of as ‘acute brain failure’• Different from dementia• Affects all of brain, not just a single area (so its not a TIA or

stroke)• Old terms (e.g. acute confusion) lack precision

Why is delirium important?

• Double the death rate in patients with delirium• Permanent reduction in cognition• Increases length of stay• Makes readmission more likely• Frightening to patients• Challenging for staff• Distressing for relatives

And why in kidney disease?

• Commoner in old age• Commoner with lots of comorbid disease• Commoner with lots of medications• Commoner when medications are not excreted• Uraemia is itself a cause• Common in hospitalised patients

• …so overall, likely to be very common in patients with kidney disease

So how do I detect it?

• Use the 4AT tool:

• www.the4at.com

Don’t you have to be agitated and hallucinating?

• No!• Some patients are agitated, but between a third and a half are

drowsy• This hypoactive delirium has an even worse prognosis – and is

easily missed• Hallucinations may be present, but often are not – and the

diagnosis doesn’t rely on hallucinations• The key features are: Acute onset, fluctuating course,

inattention, and a change in alertness – either hyperalert / agitated, or drowsy.

So how can I treat delirium?• Find the underlying causes – there are often several• Common causes in CKD patients are:- Unfamiliar environment (e.g. hospital)- Sensory deprivation (e.g. no glasses or hearing aid)- Drugs- Uraemia (esp if AKI)- Dehydration, electrolyte disturbance (esp sodium and glucose)- Hypoxia, fever, pain- Constipation, urinary retention- MI, Stroke- Infection (e.g. pneumonia, UTI)

Not everyone with delirium has a UTI ! Look for multiple causes

Support the patient

• Environmental and supportive factors• “Continuity of staff”• Quiet and calm environment• Low night lighting• Clearly visible clocks and calendars• Correct sensory deficits (glasses, hearing aid)• Familiar people• Put the bed as low as possible• Don’t routinely use bed rails• Try and restore normal sleep pattern• Explain to patient and to relatives

Drugs to treat delirium

• Only use as a last resort (if patient a danger to themselves or others)

• Drugs prolong delirium – they don’t treat it• Use haloperidol (0.5mg orally) as first choice• Avoid benzodiazepines unless alcohol withdrawal or

parkinsonian• Don’t use drugs just because someone is wandering around

Can delirium be prevented?

• Yes!• Hospital Elder Life Program [click here] – multicomponent

intervention that reduced delirium rates• Avoid drugs likely to precipitate delirium (esp those with

anticholinergic effects and those that accumulate in CKD)• Don’t move older people around hospitals