Alasdair MacLullich

Professor of Geriatric Medicine

Consultant in Geriatric Medicine

University of Edinburgh

What is delirium?

Severe, acute neuropsychiatric syndrome

Cognitive impairments

Reduced or increased level of consciousness

Psychotic features are common

Resolves in 80%

Mainly affects older people in hospital

Delirium is common and serious

>120 patients per 1000-bedded hospital

1 in 5 dead in a month

New institutionalisation

Strong marker of dementia

Accelerates existing dementia; linked with new onset

dementia

Distressing

High healthcare and social costs

Yet …

Only 20-25% detected

Generally poorly managed

Draft

pathway

Detection

Detection of delirium

“THINK DELIRIUM”

NICE GUIDELINES, 2010

Core features

Acute onset/fluctuating course

Inattention

Additional features

Altered alertness (eg. drowsiness)

Other cognitive deficits, eg. in memory

Poor comprehension

Psychotic features

Sleep-wake cycle disturbance

Delirium: many formal and informal terms

Creates problems: imprecision

Delirium and dementia get mixed up

‘Delirium’ triggers specific actions

‘Cognitive impairment’, ‘confusion’ usually don’t

best to use the term ‘delirium’

Draft pathway states: local tools

Most sites don’t have delirium screening implemented

The 4AT being used in some sites: www.the4AT.com

What method should be used for detection?

Assessment

Looking for causes 1: acute, severe illness

If delirium suspected, treat as a medical emergency

(1 in 5 are dead in one month)

Nursing / medical input early

ABC

Pulse / BP / RR / saturations / temp / BM / check drugs

Looking for causes 2: general assessment

Standard history and examination, +

FBC, U&E, Ca, LFTs, glucose

CRP

TFTS

ECG/CXR

ABGs

Urinalysis/MSU

CT head / MRI (if head injury or focal neurological

signs or if persisting delirium after 5 days)

Looking for causes 3: drug review

Opioids

Benzodiazepines

Antipsychotics

Amitriptyline

Anti-spasmodics, eg. oxybutinin, buscopan

Anti-epileptics when not used for epilepsy, eg

carbamazepine

Anti-histamines eg cetirizine

Anti-hypertensives (when causing hypotension)

Informant history

Mental status change:

Onset, duration, fluctuating?, character

Helpful in detecting BPSD

Also to detect previously undiagnosed dementia

Drug/alcohol use

Activities of daily living

Personality, preferences, etc.

Management

Treat causes

Infections

Drugs

Other acute illnesses

Pain

Drug effects

Drug and/or alcohol withdrawal

Etc.

Non-pharmacological

look for acute cause (pain, thirst, hunger, urinary retention)

repeated orientation

reassurance

avoidance of confrontation

avoidance of physical contact (can be perceived as assault)

Pharmacological

haloperidol 0.5mg 20-30 min intervals

risperidone 0.25mg nocte

consider lorazepam 1mg, but SECOND LINE (PD, DLB, BDZ/EtOH

w/d)

Treating agitation & distress

General care

Provide calm environmental & personal orientation

Hearing aids, glasses

Oxygen, hydration, nutrition

Treat pain

Avoid constipation (treat if in doubt)

Do not catheterise unless necessary

Observe sleep pattern, correct if possible

Involve relatives & carers

Ongoing care

Specialist referral

In 5 days if delirium persisting, sooner if delirium is

severe

Liaison psychiatry or geriatric medicine

Assessment of possible dementia

Cognitive testing if delirium resolved

IQCODE

Follow-up by GP or specialist clinic

Resources (eg. clinical pathways, patient information sheets) at:

www.scottishdeliriumassociation.com

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www.europeandeliriumassociation.com

8th Annual MeetingLeuven, Belgium, Sep 20-21, 2013