DELIRIUM DR S A R A H A B D E L A T I S A S DR H I L A R Y W O L F E N D A L E S T 4

DELIRIUM DR S A R A H A B D E L A T I S A S DR H I L A R Y W O L F E N D A L E S T 4

AIMS Define delirium Identify: Different types of delirium Risk factors Preventable causes Screening tools Management

Can you define delirium?

How many types of delirium are there? Can you name them? Which of these do we see commonly in hospital?

Who is most at risk?

What is the prevalence of delirium? Medical patients? Surgical patients? Patients in long term care?

Can delirium be prevented? If so, can you think of any ways?

How do we screen for delirium? Can you think of any screening tools?

How does delirium affect patients and carers? Morbidity? Mortality? Complications?

NICE Guidelines Prevention Diagnosis and Management

Definition Acute confusional state common clinical syndrome Disturbance in consciousness, cognitive function and perception Acute onset Fluctuating course Preventable and treatable Assocc. with poor outcome

Prevalence On medical wards 20-30% Surgical patients 10-50% In long term care <20% Poor awareness and under reporting

Indicators Recent (hours/days) changes or fluctuation in behaviour Reported by patient, carer or relative If indicators present a competent HP should carry out a screening test

Indicators Cognitive function - reduced concentration, slow responses & confusion Perception - visual /auditory hallucinations Physical function - reduced mobility, slow movements, change in appetite, sleep disturbance, restlessness agitation Social behaviour - lack of cooperation, withdrawn, alteration in communication, mood and attitude

Types Hyperactive heightened arousal, restlessness, agitation and aggression Hypoactive withdrawn, quiet, drowsy Mixed combination of both Delirium in Dementia difficult to recognise

Risk Factors Older age > 65yrs Cognitive impairment Past or present Severe illness any condition at risk of deteriorating Hip fracture

Outcomes Longer hospital stay Increased risk of ICU admission Increased risk of hospital acquired complications falls and pressure sores i.e Increased need for long term care Increased risk of death

Diagnosis If indicators for delirium identified: Assess using Diagnositic and Statistical Manual of Mental Disorders (DSM-IV) criteria or short Confusion Assessment Method (CAM) In ICU or recovery room post-op CAM-ICU

Diagnosis If unclear whether delirium, dementia or delirium superimposed on dementia treat as delirium first Assessment to be carried out by trained competent HP Diagnosis of Delirium should be documented in both hospital and primary care health records.

Prevention For those at risk Provided by a team of HCP familiar with the patient Provide Multicomponent Intervention Package (MCIP) Assess patient within 24hrs of admission for clinical risk factors Tailor the MCIP to individual need

Prevention 1- Avoid room/ward changes unless absolutely necessary 2- Cognitive Impairment/disorientation- provide: Good lighting Clear Signage 24hr clock Calendar Re-orientation informing patient who they are, where they are and what you role is Facilitate visits from family and friends

Prevention 3- Dehydration prevent and treat, encourage oral intake and supplement with S/C and IV fluids 4- Constipation prevent and treat 5-Hypoxia assess and treat 6-Address infections investigate and treat avoid unnecessary catheterisation implement infection control procedure

Prevention 7- Immobility encourage to mobilise provide necessary aids early mobilisation post-op in bedbound pts encourage active range of motion exercises 8-Pain assess for non verbal signs in learning difficulties, dementia, ventilated and trachy. patients Medication review and analgesia 9-Nutrition assess status and check dentures

Prevention 10- Sensory impairment Resolving reversible causes ensuring visual and hearing aids available and in good working order 11- Good sleep pattern and hygiene avoid nursing/medical procedures during sleep hours schedule medication rounds to avoid sleep disturbance reduce noise

Treatment Identify and manage the underlying cause Effective communication, re-orientation and reassurance Involve family, friends and carers Provide a suitable environment

Treatment Distressed patients at risk to self and others verbal and non verbal de-escalation techniques short term use of anti-psychotics Haloperidol and Olanzepine at lowest doses titrate according to response ( less than 1 week) Anti-psychotics should be used with caution in patients with Parkinson Ds and Lewi-Body Dementia

Treatment If delirium does not resolve Re-evaluate the underlying cause(s) Follow up and assess for dementia

Diagnostic algorithm for Delirium

References NICE guidelines Trust guidelines Dec 2017 http://lthtrdocuments/current/p809.pdf

Mrs P 82 yo lady BG of IHD, OA, CVA 2015 Lives in sheltered accommodation Admitted with a fall Found on floor by grandson Brought to ED > MAU >Med ward

Referral ATSP day 3 of admission Confusion Poor oral intake Poor mobility Poorly communicative Is this her new baseline? Collateral history from Grandson

Investigations Bloods: Raised CK and AKI 1 Mildly raised WCC and CRP CXR some basal atelectasis CTB cerebral atrophy, established (old) lacunar infarct ECG sinus rhythm, 86bpm L&S BP no significant postural drop

On examination A- MOA B- Good AE, sats 95% RA, RR 17 C- HS regular I+II+0, calves SNT, BP 114/76, catheter draining clear urine D- Abdo firm, non-tender, BS normal, BM 5.8 AVPU Poorly attentive, disorientated to TPP, Appeared low in mood

Charts Catheterised- good UO Poor oral intake BNO? not documented Not mobilising Waterlow score >10

Medications Amitriptyline Regular co-codamol Bendroflumethiazide Clopidogrel Ramipril Bisoprolol Solifenacin Hypromellose eye drops PRN Tramadol

Screening CAM 4AT

Diagnosis?

Diagnosis? Delirium- Hypoactive Dementia Depression

Risk factors

Risk factors Age Comorbidities

Causes of delirium?

Causes of delirium? 3 different transfers during stay Sensory impairment glasses, hearing aid Nutrition dentures Hydration Catheterised Constipated Polypharmacy Immobility walking stick

Management 3 different transfers during stay Avoid transfers/sleepouts Sensory impairment Ensure glasses, hearing aids, dentures available in reach and working Nutrition SLT, Dietician, regular mouthcare Hydration Assess and treat, avoid lines where possible

Management Catheterised TWOC asap Constipated Avoid constipating drugs, prescribe laxatives, PR exams- enemas Polypharmacy Reduce Immobility Early mobilisation, provide aids, PT/OT input

Management Daily assessment CAM Ongoing management of preventable causes If no improvement, re-review preventable causes +/ diagnosis Document to GP episode of delirium

Can you define delirium? Disturbance in consciousness, cognitive function or perception Acute onset over hours to days Fluctuating course Serious condition associated with poor outcomes Preventable and treatable

How many types of delirium are there? Hyperactive- heightened arousal, restless, agitated, aggressive Hypoactive- withdrawn, quiet, sleepy Mixed

Who is most at risk? Older people (>65 yo) People with cognitive impairment (past or present) and/or dementia Severe illness Current hip fracture

Prevalence Medical wards 20-30% Surgical patients 10-50% In long term care <20% Poor awareness and under reporting

Can delirium be prevented? YES Identify those at risk Number of modifiable risk factors Preventing delirium should improve outcomes for people at risk and have cost savings for service providers

How do we screen for delirium? CAM CAM-ICU DSM IV criteria 4AT

How does delirium affect patients and carers? More likely to: Have longer hospital stay Have dementia at 3 year f/u Have more hospital-acquired complications eg. falls and pressure sores Have to go into long term care on discharge Die