Delirium: developing a clinical pathway for Scotland

1. Delirium: developing a clinical pathway for Scotland Alasdair MacLullich Professor of Geriatric Medicine Consultant in Geriatric Medicine University of Edinburgh

2. 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

3. 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

4. Draft pathway

5. Detection

6. Detection of delirium • “THINK DELIRIUM” • NICE GUIDELINES, 2010

7. 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

8. 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’

9. What method should be used for detection? Draft pathway states: local tools Most sites don’t have delirium screening implemented The 4AT being used in some sites: www.the4AT.com

10. Assessment

11. 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

12. 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)

13. 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)

14. 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.

15. Management

16. Treat causes Infections Drugs Other acute illnesses Pain Drug effects Drug and/or alcohol withdrawal Etc.

17. Treating agitation & distress • 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)

18. 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

19. Ongoing care

20. 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

21. Resources (eg. clinical pathways, patient information sheets) at: • www.scottishdeliriumassociation.com • __________________________________________________ • www.europeandeliriumassociation.com • 8th Annual Meeting • Leuven, Belgium, Sep 20-21, 2013