Confusion in the acute setting Dr Susan Shenkin
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1 Confusion in the acute setting Dr Susan Shenkin 4 th International Conference, Society for Acute Medicine, Edinburgh 7-8 October 2010
2 Summary Confusion is not a diagnosis Main differentials are delirium/dementia Think delirium! An approach to diagnosis and management Some practical tips
3 Common Delirium and dementia in acute hospitals Delirium 15% of acute general hospital patients 30% of acute geriatric inpatients 40-60% post hip-fracture surgery Dementia 20% of acute general hospital patients 30% of geriatric inpatients Inouye, NEJM 2006 Sampson, Br J Psych 2009
4 Serious Delirium and dementia in acute hospitals ~ 20% dead in 30 days ~ 40% dead in 1 year Hazard ratio of death ~5 at 6 months McCusker, et. al, Arch Int Med, 2002
5 Serious Delirium and dementia in acute hospitals Patients with delirium or dementia have Increased mortality Increased length of stay Increased rate of institutionalisation Increased risk of complications (falls, pressure sores) Increased patient and carer distress Increased risk of dementia or delirium
6 Delirium and dementia Underdiagnosed in acute hospitals ~50% of those with delirium not diagnosed ~50% of those with dementia not diagnosed Kiely, et. al, J Gerontol, 2007 Meagher, et. al., Br.J.Psych, 2007 Davis Age &Ageing 2009
7 Delirium and dementia Underdiagnosed in acute hospitals ~50% of those with delirium not diagnosed ~50% of those with dementia not diagnosed Practice point Think delirium! Kiely, et. al, J Gerontol, 2007 Meagher, et. al., Br.J.Psych, 2007 Davis Age &Ageing 2009
8 Confusion A bit knocked off Not themselves Non Compliant Muddled Variable Flat Poor historian Agitated Aggressive Drowsy Vague Wandering
9 Confusion A bit knocked off Not themselves Non Compliant Muddled Variable Flat Poor historian Agitated Aggressive Drowsy Vague Wandering Practice point If you hear/use these terms, think delirium (/dementia) Confusion is not a diagnosis
10 What is delirium? DSM- IV Disturbance of consciousness with reduced ability to focus, sustain, or shift attention A change in cognition or the development of a perceptual disturbance The disturbance develops over a short period of time and tends to fluctuate during the course of the day
11 In other words Altered arousal (and inattention) Cognitive impairment Acute onset/fluctuating course
12 A diagnostic approach 1. Assess arousal 2. Test cognition 3. Acute onset/fluctuating course? 4. Underlying cause
13 1. Assess arousal
14 1. Assess arousal Delirium Who will you get - hyperactive 20% called to see? - hypoactive 50% - mixed 30% Fong,. et al. Nat. Rev. Neurol. 2009
15 1. Assess arousal They both could... Practice point Altered arousal = brain dysfunction but who will you get called to see? Why is your patient sleepy in the day? Think delirium!
16 A diagnostic approach 1. Assess arousal 2. Test cognition 3. Acute onset/fluctuating course? 4. Underlying cause
17 2. Test cognition AMT, MMSE or something else? 4 question abbreviated AMT ( AMT4) How old are you? What is your DOB? Where are you? What year is it? 340 patients with MMSE <24 in A/E Cognitive impairment will be missed if you rely on clinical judgment alone AMT <8/10 76% AMT4 <4 80% Subjective assessment 50% The choice of instrument is less important than the fact that an objective test is done Schofield et al, Eu J Emerg Med 2009
18 2. Test cognition MMSE, AMT or something else? Practice point Routine cognitive assessment as part of routine exam Use an objective test Beware deaf/dysphasic Schofield et al 2009
19 Testing Attention MMSE: Serial 7 s, WORLD backwards Digit Span: Repeat these 5 numbers Days of Week, Months of Year backwards
20 A diagnostic approach 1. Assess arousal 2. Test cognition 3. Acute onset/fluctuating course? 4. Underlying cause
21 3. Acute onset/fluctuating course? Collateral History Old case notes Previous MMSE/AMT!
22 3. Acute onset/fluctuating course? Collateral History Old case notes Previous MMSE/AMT! Practice point Collateral history is essential
23 Diagnosing delirium: Confusion Assessment Method (CAM) Feature 1: Feature 2: Feature 3: Feature 4: Acute change in mental status with a fluctuating course Inattention Disorganized thinking Altered level of consciousness Delirium = Features 1 and 2 and either 3 or 4 Inouye SK, Ann Int Med, 1990
24 Diagnosing delirium Practice point Ensure diagnosis documented in notes and discharge summary Inouye SK, Ann Int Med, 1990
25 A diagnostic approach 1. Assess arousal 2. Test cognition 3. Acute onset/fluctuating course? 4. Underlying cause
26 4. Seeking the cause(s) of delirium History Exam Ix Cardinal symptoms (pain, SOB, diarrhoea, vomit, constipation) Alcohol and medication use and withdrawal Fever, Sats, Hydration Focal neurological signs Focal infective signsjoints, biliary tract, prostheses, urine, chest, skin CXR, ECG U+E, FBC,CRP, Glucose, Blood cultures?ct?lp?eeg
27 4. Seeking the cause(s) of delirium History Exam Ix Cardinal symptoms (pain, SOB, diarrhoea, vomit, constipation) Alcohol and medication use and withdrawal Fever, Sats, Hydration Focal neurological signs Focal infective signsjoints, biliary tract, prostheses, urine, chest, skin CXR, ECG U+E, FBC,CRP, Glucose, Blood cultures?ct?lp Think beyond the dipstix?eeg
28 4. Seeking the cause(s) of delirium History Exam Ix Practice point Often multifactorial Search for ALL causes They may be hidden/rare Think beyond the dipstix
29 Treatment of delirium Seek and treat precipitants Non-pharmacological measures Drugs
30 Treatment of delirium Seek and treat precipitants Non-pharmacological measures Drugs Practice point Treatment and prevention involve excellent multidisciplinary care
31 Drug treatment of delirium Drug Dose Adverse Effect Comment Haloperidol 0.5mg to 1.0 mg po/im Extrapyramidal syndrome QT prolongation Avoid in PD/LBD RCTs show reduction in duration and severity Olanzapine 2.5-5mg daily In trials equal Quetiapine 25mg bd efficacy to Haloperidol Lorazepam 0.5-1mg po Sedation, respiratory depression, agitation Donepezil 5mg od po Nausea, vomiting diarrhoea No supportive trial evidence No RCTs Based on : Fong, T. G. et al. Nat. Rev. Neurol. 5, (2009)
32 Think delirium!
33 Suspected dementia in acute hospitals Dementia = chronic cognitive impairment + functional decline Document MMSE in notes Collateral History/IQCODE Consider depression Consider reversible causes Arrange follow-up
34 Summary Confusion is not a diagnosis Main differentials are delirium/dementia Think delirium! An approach to diagnosis and management Some practical tips
35 For more information Delirium: Fong TG et al: Nat. Rev. Neurol. 5, (2009) NICE guidelines: Dementia: Sampson EL et al: Br J Psych. 195, (2009) NICE guidelines: SIGN guidelines:
36 Distinguishing delirium from dementia attention mood Coherent thinking Level of Consciousness Altered mental status Motor activity Perception Executive functioning
37 Delirium : the mental status examination DEMENTIA DELIRIUM
38 Prevention is better than cure Recognise at risk >65 years Cognitive impairment Hip fracture Severe illness Familiar health care team Avoid moves Tailored multicomponent intervention package Communication If drugs necessary haloperidol/olanzapine (low&slow <1/52)
39 Multicomponent intervention Cognitive impairment Lighting, Clear signage, Clock and calendar, Regular reorientation, Family and friends, Cognitively stimulating activities (reminiscence) Address dehydration/constipation/nutrition Address hypoxia Address infection Address immobility/sensory impairment Address pain Medication review Good sleep patterns
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