You are on page 1of 66

“Few ill health situations

are more degrading to
people of any age than
loss of reasoning,
faculties, and personhood.
These are the unpleasant
consequences of
delirium…”

Delirium in older people. Young J & Inouye S. BMJ 2007; 334:842-6

What do you want to know / get
out of this session?

What do I want you to get from
this session?
1. Recognise delirium (esp hypoactive)
2. Have a method for assessment and management
3. Be able to discuss delirium with patients & families
4. Take it seriously

Early Dx & Mx  better prognosis & outcomes

who is finding it difficult to provide care for her mother 88 yo lady from RACF. Usually independent mobility (4WF) and cognitively intact. Well throughout dinner. and decreased mobility 89 yo lady. . aggressive and noncooperative with ambulance. 90 yo lady home alone in retirement village.78 yo lady from home with dau. usually from home alone. Activated personal alarm at 3am. Confused. Presented to ED with large (15x15cm) haematoma on left leg. agitated. Admitted on Saturday with acute onset that morning of confusion. In ED found to be confused and mostly nonverbal. Referred by GP to hospital Recent decline in ability to perform activities of daily living Lives with her daughter. rambling speech. Out to dinner with son prev evening.

referral • Referred by GP to hospital • Recent decline in ability to perform activities of daily living • Lives with her daughter.Mrs S . who is finding it difficult to provide care for her mother • What do you think? .

Mrs S .history • History from daughter who states her mother has been confused for three days • Mrs S’ urinary incontinence has worsened over the past two days – she seems unable to locate the toilet • Mrs S is eating poorly and restless at night .

Mrs S .diagnosis • What is the most likely Dx? • What are the DDx? Dementia with BPSD (behavioural and psychological symptoms of dementia) • Depression • Other neurological conditions • Other psychiatric conditions • What else do you need to know to establish a diagnosis? .

What is delirium? • A clinical syndrome • Acute confusional state • Characterised by disturbance in: • Consciousness • Cognition (esp attention) • Perception (delusions / hallucinations) • Acute onset (hours to days) • Fluctuating course • Generally triggered by acute precipitant(s) .

history • Daughter confirms that her mother has been less confused in the mornings and has had moments of clarity • Mrs S has spoken of people being in her room at night • There has been a definite decline in cognition over the past three days and Mrs S has tended to “drift off” during conversations .Mrs S .

Mrs S .assessment • How will you assess Mrs S? • On history (collateral) • Assume a diagnosis of delirium until proven otherwise • What tools can you use? .

CAM (Confusion Assessment Method) • Four features: 1. • Acute onset and fluctuating course Inattention Disorganised thinking Altered level of consciousness Scoring: The diagnosis of delirium requires the presence of: Features 1 AND 2. 2. 3. . 4. and either 3 OR 4 It is scored as either positive or negative.

4.assessment • Mrs S drifts to sleep during the interview • She has difficulty following instructions and appears to be distracted by things you cannot see • Manages only three digits in the digit span test • She tells you that her (long deceased) husband will come and sort you out for being so impertinent CAM = positive 1.Mrs S . 2. Acute onset and fluctuating course Inattention Disorganised thinking Altered level of consciousness . 3.

Recognise delirium ✓ .1.

very confused speech and decreased mobility • What are your thoughts? .Mrs B .history • 88 year old from RACF • Usually independent mobility with 4WF and cognitively intact • Admitted on a Saturday with acute onset that morning of confusion.

? UTI .Mrs B .history cont… Post-take ward round…. Impression: Delirium – unclear cause. Comments about confused and muddled speech –”not making sense” Difficult to examine..

Mrs B . During ward round on Monday morning noted to have marked expressive dysphasia + some receptive dysphasia + R facial.. R UL and R LL weakness Transient and all improved over 15 minutes while examining patient Recurred approx 1 hour later Repeat CTB ….history cont… And then……. Commenced Heparin infusion and transferred to stroke unit .

back to Mrs S • What now? .….

Manage the symptoms 1. Pharmacological 3. Provide appropriate D/C planning and follow-up . Support and educate patient & family/carers 5. Non-pharmacological – providing a supportive environment (psychological. Prevent complications 4. physical and sensory support) 2. Identify and address any precipitants 2.Assessment and management GOALS OF MANAGEMENT 1.

bladder & bowel dysfunction • Surgery / Anaesthetics • Environmental factors . electrolyte & fluid disturbance. seizure.change in environment. tubing…) . NGT. medical interventions (IDC. O2. interactions. side-effects.Precipitating factors REMEMBER – there may be multiple possible precipitants • Medications –prescription and OTC . IV lines.withdrawal (or intoxication) • Neurological conditions .effects. pain. infection • Medical conditions .infection.stroke. organ failure. toxicity • Drug / Alcohol . bleed. sleep deprivation.

nurses. resi care staff) • Review of systems • Review medications . GP. Identify and address any precipitants HISTORY EXAMINATION • HOPC (esp timeline) INVESTIGATIONS • From Pt if possible • PLUS collateral Hx (family.1.

Mrs S – further history • Mrs S’ daughter tells you that her mother was commenced on amitriptyline for her incontinence and ‘to help her sleep’ a week ago .

zoster). wounds. Identify and address any precipitants EXAMINATION • Thorough physical examination including: • • • • • • Vital signs CVS (inc volume status) Respiratory system Abdo exam (inc palpable bladder) Neuro exam (esp looking for new signs) Skin (esp for rashes (H. patches) • NB: To do this you need to take down all dressings .1.

other obs unremarkable • Dry mucous membranes.Mrs S – on examination • T° 382. JVP 0cm • Lower abdo tenderness .

1. Identify and address any precipitants

INVESTIGATIONS
• “A delirium screen”?????

• There is no such thing
• B12, folate, TFTs are not useful in the work-up
for delirium –they are part of a dementia workup as possibly reversible contributors to
cognitive impairment

1. Identify and address any precipitants

INVESTIGATIONS

• Baseline Ix:
• Pathology: FBE, EUC, LFT, Ca, CRP
• FWTU (and MSU if positive for leuk or nit)
• Other: BSL, ECG (plus CK and Trop if ischaemic changes or
chest pain), Post void residual bladder volume (PVRvol)
• Other Ix should be considered based on clinical scenario
• CXR, AXR, CTbrain, blood cultures, drug levels, TFTs,
CK & Trop, ammonia, LP, EEG, ……

Mrs S – investigations
• Urea 17, Creatinine 135 (baseline 75)
• WCC 14
• FWTU nitrites ++, leukocytes +++
• PVRvol = 840mL
• What is the cause for Mrs S’ delirium?
Multifactorial
• Amitriptyline
• Urinary retention
• UTI
• Dehydration
• AKI

Have a method for assessment✓ and management .2.

• Presented to ED with large haematoma on left leg. usually from home alone. • 15 x 15cm haematoma • In ED found to be confused and mostly non-verbal .Mrs C – History • 89 year old lady.

Mrs C – History cont… • 4/52 of decline in function (with son staying with her) • 1/52 of decline in cognition • At times not recognising family members • Non-verbal in ED and on ward Previous cognition: MMSE 2 months prior: 20/30 .

5mg d • HT • IHD • TIA GTN patch 50mg d • Multiple skin cancers Telmisartan 80mg d • PMR (on Pred) Aspirin 100mg d • Osteoporosis Warfarin • Bilateral cataract surgery (with IOL) Digoxin 62.PMHx What now? PMHx MEDS • Ramipril 10mg d AF Amlodipine 2.5mcg d Atenolol 50mg d Rosuvastatin 10mg d Prednisolone 1mg d Caltrate 600mg d Cholecalciferol 1000units d .

Mrs C – History cont… FBE: 118 / 6.7 / 270 (MCV 91) EUC: 142 / 4.6 / 132 Digoxin 1.2 INR: 8.6 / 12.5 FWTU –NAD .

.

.

Provide appropriate D/C planning and follow-up .Assessment and management GOALS OF MANAGEMENT 1. Pharmacological 3. Prevent complications 4. Manage the symptoms 1. Identify and address any precipitants 2. physical and sensory support) 2. Support and educate patient & family/carers 5. Non-pharmacological – providing a supportive environment (psychological.

Mrs S – management • What would prompt you to use medications for her delirium? • Which agent(s) would you choose? .

Manage the symptoms Non-pharmacological Rx is ALWAYS 1st line (think about what it is your are treating) • Environmental strategies • • Appropriate lighting.2. quiet room. avoid room changes Clinical practice strategies • • • • • • Encourage family to be involved Maintain usual routine Regular orientation Minimise interventions Maintain function 1:1 nurse special .

2. if highly agitated or hallucinating) or if patient at risk of harm to self or others • Medications should NOT be used to sedate patients • Use lowest effective dose for shortest possible time –with regular review of efficacy and side-effects • Use oral route as first line • Use medications cautiously . Manage the symptoms PHARMACOLOGICAL Mx – important points • Medications DO NOT treat the delirium • Medications may help with SOME symptoms (mainly psychotic Sx) • NOT EFFECTIVE for wandering or calling out • Consider for distressing Sx (ie.

Except in patients with Parkinsons disease or Lewy Body Dementia where Quetiapine (12.25-0.2.If a patient with dementia is already prescribed an antipsychotic medication (ie.5mg oral or subcut –NOT IV) • Up to 3mg maximum in 24 hour period • Older patients are at higher risk of side-effects • Avoid multiple different types of medications (NB: Olanzapine has the most anticholinergic burden of the antipsychotics) . Manage the symptoms PHARMACOLOGICAL Mx • Haloperidol is 1st line drug of choice . Risperidone / Olanzapine) then best to use this • Use small doses (0.5mg) should be used carefully .

Temazepam) should generally only be used for specific causes of delirium • Alcohol or BZD withdrawal OR Seizures • However. if a patient is on long-term BZDs then do not cease them on admission to hospital (may precipitate delirium) • Occasionally do need to use BZDs for sedation – use as a last resort and realise the implications . Manage the symptoms PHARMACOLOGICAL Mx • NB: Benzodiazepines (incl.2.

Prevent complications • Functional decline • Malnutrition. dehydration • Pressure injuries • Falls (and assoc injuries) • Hospital acquired infections .3.

2. Have a method for assessment and management ✓ .

4. Support and educate patient & family/carers • What do you tell the family? .

vic.health.http://docs.gov.au/docs/doc/Delirium---Consumer-Brochure-(Color)--June-2007 .

Mrs S – progress • A week after treatment for her dehydration. urinary retention and withdrawal of the amitriptyline Mrs S improves. UTI. but is not back to her “usual self” • What will you tell Mrs S’ daughter? .

Outcomes of delirium Delirium doesn’t just stop when a patient leaves hospital • Median duration 7 days BUT • ~96% have NOT fully resolved at D/C • ~30% improve but relapse post D/C • May persist for weeks (~5% may last > 4 weeks) .

Outcomes of delirium • INCREASED MORBIDITY • • • • • • Length of stay Hospital acquired complications New admission to residential care Permanent decline in cognition Permanent decline in physical function Distress • INCREASED MORTALITY (indep risk factor) .

Provide appropriate D/C planning and follow-up .5.

Mrs S – continued… • Mrs S improves over two weeks and is discharged home with her daughter and additional supports • Six months later she falls and presents with a fractured pelvis • What might you say to her and her family on admission? .

3. Be able to discuss delirium with patients & families ✓ .

Cover shifts and ward rounds • Have a high index of suspicion for delirium – The “not quite right” or “bit off” patient – The patient with non-specific issue for review – The poor oral intake • If the family say the person is confused / not their normal self = delirium until proven otherwise • Don’t assume that all older people are confused – Get a COLLATERAL HISTORY about pre-morbid cognition .

Cover shifts and ward rounds • Check history and reason for admission • Check obs chart. bowel chart. food and fluid charts • Don’t just check regular meds • Look at stat and PRN orders • Regular PRN/stat orders for BZDs or antipsychotics at night should ring alarm bells .

.why should we?) .Cover shifts and ward rounds • Don’t just give phone orders • esp for BZDs • IVT • Think and ask before you prescribe medications • Why are you treating this patient? It shouldn’t just be because the nurses ask! • Remember it is OK not to treat and to Ix and monitor • A fever in someone who is not clinically unwell with no obvious source • A noisy patient overnight who is not at risk to self or others • A one-off high BP reading (a GP wouldn’t start treatment from one reading….

Key points Delirium: • is common • is a clinical diagnosis • is associated with increased morbidity and mortality • is often missed You need to have a high index of suspicion and if you think or write confused / agitated / disoriented / wandering / …… then ASSUME DELIRIUM UNTIL PROVEN OTHERWISE .

3. Young J & Inouye S. BMJ 2007. These are the unpleasant consequences of delirium…” Delirium in older people. 334:842-6 . Take it seriously ✓ “Few ill health situations are more degrading to people of any age than loss of reasoning. and personhood. faculties.

Cases .

Confused.Mrs H . c/o dysuria & headache Ambulance called and non-cooperative with MAS staff – finally agreed to come to hospital.history 90 yo lady from home alone in retirement village. agitated. Activated her personal alarm at 3am and staff attended . Well throughout dinner and on return to home. Out to dinner with son previous evening. • Thoughts? .

history cont… In ambulance: T 381 HR: 103 BSL: 9.9 GCS 15 Headache 4/10 In ED: Drowsy –GCS 13 Febrile BP: 180/90 FWTU: leucs 3+ and blood 2+ .Mrs H .

Mrs H .history cont… On ward: • • • • • • Urinary frequency and new incontinence Urinary retention  IDC inserted Marked agitation (and appeared terrified) Ongoing high fevers (396) Hypoxic (SaO2 88% RA) Sinus tachycardia (HR 120) .

Mrs H – O/E O/E: -R basal crackles on chest auscultation -Abdo –NAD -Skin –NAD -No joint or spinal tenderness / no neck stiffness -Normal left fundus (unable to visualise right) MSU –WCC 60 CXR –possible minor bibasal changes WCC –normal CRP -30 CT brain –reported as NAD but impression of subtle oedema .

Mrs H – ???? DDx?? Working diagnosis: Severe community acquired pneumonia Ceftriaxone 1g BD + Azithromycin 500mg daily Next day on post-take ward round .concern about cerebral irritation and DDx of meningitis / encephalitis Aciclovir 500mg BD + Benzylpenicillin 1.8g QID .

Mrs H – ….3rd nerve palsy .facial droop ..worsening agitation . Over next 48 hours……. .deteriorating conscious state Blood cultures: 1st set: negative 2nd set (12 hrs later): Listeria monocytogenes .

Previously living alone at home but had moved in with daughter a few months prior as not managing being alone.Mrs L 90 year old lady with known diagnosis of vascular dementia admitted with delirium. Admitted with confusion. agitation and halllucinations that had come on over period of 1-2 days. .

Mrs L PMHx Medications Vascular dementia Aspirin 100mg dialy Type 2 DM (diet controlled) Candesartan 8mg daily AF (not on Warfarin due to frequent falls) Metoprolol 50mg bd Osteoporosis HT GORD Recurrent UTIs Urinary incontinence DVT (below knee in May 2010) Frusemide 40mg daily Digoxin 62.25mg nocte Paracetamol 1gram tds Refresh tears Coloxyl and senna PRN .5microg daily Pantoprazole 40mg daily Fentanyl patch 12microg/hour Risperidone 0.

Not unwell. disorientation and visual hallucinations .Increasing confusion.Mrs L Over past few months since living with daughter .Recurrent falls. agitation.Worsening nocturnal behaviours with some agitation Behaviours markedly changed 2 nights prior to admission: . most recent 1 week prior with headstrike .Bloods fairly unremarkable / FWTU NAD . no symptoms to suggest infection .Obs stable .

Prescribed by LMO to assist with BPSD New working diagnosis Delirium due to paradoxical reaction to Risperidone with background of dementia with BPSD Risperidone ceased – delirium settled and Pt D/C home with support and education for daughter around BPSD and its Mx .Mrs L Working diagnosis on admission: Delirium on background dementia –cause unclear Further history on post-take ward round Commenced Risperidone night prior to behaviours worsening.

334:842-6 .“Few ill health situations are more degrading to people of any age than loss of reasoning. BMJ 2007. faculties. Young J & Inouye S. and personhood. These are the unpleasant consequences of delirium…” Delirium in older people.