Developing people for health and healthcare

‘Doctor! The mafia are running this place’

Date 24th July

2014

The challenges of managing Delirium

Developing people for

health and healthcare

Developing people for

health and healthcare

What is delirium?

• A disturbance of consciousness

• Change in cognition

• Develops over a short period of time and fluctuates during the course of the day

• Evidence of direct cause by general medical condition

Developing people for

health and healthcare

What is confusion?

Use this term with care.

Confusion is obsolete

Is this delirium or dementia?

It is not pleasant to be confused

Developing people for

health and healthcare

How common is delirium ?

Acute Medical Unit 11-12% (Sampson

2009, 2013)

General medicine 21.4% (NICE 2010)

All emergency admissions 27% (Goldberg

2012)

ICU 70-87% (Pisani 2003)

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health and healthcare

Screening

MTS<8CAM score

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health and healthcare

Example of screening tool- short CAM

1. Acute onset and fluctuating course

a) Evidence of an acute change in mental status from the patient’s baselineb) The abnormal behaviour fluctuates during the day, comes and goes

2. Inattention

Difficulty focusing attention, easily distracted or difficulty keeping track of what is said.

3. Disorganised thinking

Thinking is disorganised or incoherent, such as rambling or irrelevant conversation, unclearor illogical flow of ideas, or unpredictable switching from subject to subject.

4. Altered level of consciousness

a) Vigilant (hyperalert) b) Lethargic (drowsy, easily aroused) c) Stupor (difficult to arouse) d) Coma (not able to be aroused)

A positive CAM score requires the patient to feature 1 and 2 and either 3 or 4

Developing people for

health and healthcare

What can cause delirium ?

Older age

Dementia

Infection

Dehydration

Malnutrition

Multiple medications

Surgery

Change of environment

Hip fracture

Severe illness

Sleep deprivation

Constipation

Bladder catheterisation

Visual or hearing impairment

Immobility

Alcohol abuse

Pain

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health and healthcare

“Delirogenic” environment

•Lack of exercise/movement

•Intermittent noise and light control

•Environmental manipulation

•Sleep deprivation/adjustment

•Controlled fear

•Disorientation

•Sensory deprivation (hearing and vision)

Developing people for

health and healthcare

Principles of management

• Screen• History from an informant• Identify underlying cause• Reassurance and clear information• Avoid moving• Consistency of care• Good lighting • Clear signage; visible clocks• Communication and activities• Encouraging regular visitors

• Prevention is better than cure

Developing people for

health and healthcare

Communication top tips

#hellomynameis……

I’m one of the doctors

Today is Monday

You’re at the X Hospital

You had X problem

Don’t confront/dispute – acknowledge the emotion

Developing people for

health and healthcare

Recognise

Re-orientate

Reassure

Respect