Delirium (or: It's not a bloody UTI)

1. Graeme Hoyle Consultant Geriatrician Delirium(or: It's not a bloody UTI)

2. Overview • What is delirium? • Why is it important? • How to recognise it • How to manage it

3. Case History

4. OOH GP admission to medicine • Thanks for seeing Jeannie, 85, who's normally independent. • Neighbours concerned as she was wandering the Sheltered Housing complex confused and partially dressed. • When I attended, house a mess, struggling to get out of bed, doubly incontinent. • Drugs: Aspirin, frusemide 40mg, ramipril 2.5mg, codydramol, amitriptyline 10mg, oxybutynin, ferrous sulphate • Dx: Not coping at home. • ?UTI

5. 3 Major Errors • 1. Nobody is independent • This only seems to be a problem for old people • 2. Everyone is admitted to hospital because they're not coping at home • We only point this out for old people • 3. It's usually not a UTI • It's never just a UTI

7. Delirium

8. Delirium • ‘Acute confusional state’ • Known about for a long time • Why does a UTI make you confused?

9. Why is delirium important? • Delirium: • Is very common (1/3 of elderly admissions) • Has a high mortality (10-26%) • Has high rates of morbidity (LoS, instit.) • Despite this, delirium: • Is under-recognised • Is under-diagnosed • Is poorly managed

10. Pathology • Poorly understood • Neurotransmitters • ACh, Dopa • Inflammatory process • High levels of inflam cytokines • Hypothalamic-pituitary-adrenal axis • Overactivity with hypercortisolism • Leads to inflammatory process

11. Aetiology • Predisposing vs. Precipitating factors • A highly susceptible person only needs a minor insult to develop delirium • A fit person requires a major insult to develop delirium (eg pneumonia – CURB)

12. Predisposing factors • Old age • Frailty • Dementia • Past history of delirium • Visual/hearing impairment • Malnutrition • Polypharmacy • Comorbidity (esp. renal/hepatic impairment)

13. Precipitating factors • Infection • Dehydration • Constipation • Pain • Immobility • Medication use/withdrawal • Sleep deprivation • Catheterisation • Use of physical restraints

14. Clinical features • Altered level of consciousness • Cognitive deficit or perceptual disturbance • Acute onset, fluctuating course • Evidence of cause (also frequently altered sleep-wake cycle, emotional lability)

15. Forms of delirium • Hyperactive • Vigilant, agitated, wandering • Hypoactive • Drowsy, apathetic, frequently missed • More common, higher morbidity • Mixed

16. Management - overview • Assessment and screening • Prevention • Treatment • Complications • Discharge • Follow up

17. 1) Assessment and screening • At admission: • Identify those with delirium • Identify those at risk of developing delirium • Screening tests: • AMT • Delirium or dementia? • HISTORY IS KEY • SQiD

18. SQiD • 'Do you think …….. has been more confused lately?'

19. Assessment (cont’d) – identification of those at risk • Old age • Frailty • Dementia • Past history of delirium • Visual/hearing impairment • Malnutrition • Polypharmacy • Comorbidity (esp. renal/hepatic impairment)

20. 2) Prevention • Identify those at risk • Avoid/rapidly treat precipitating factors • Review drugs • Stop anticholinergic medication (eg TCAD) • Reduce or stop benzodiazepines • Management as per established delirium

21. Precipitating factors • Infection • Dehydration • Constipation • Pain • Immobility • Medication use/withdrawal • Sleep deprivation • Catheterisation • Use of physical restraints

22. 3) Treatment of delirium • Identify and treat precipitating factors • Full HISTORY and examination (inc PR) • FBC, U&E’s, LFT’s, Ca, CRP, TFTs, Glc • ECG • CXR • Non - pharmacological management • Pharmacological management

23. = being nice to your granny Non-pharmacological management

24. Preventing & managing delirium • Reorient patients to environment and time • Encourage early mobility and self-care (early involvement of multidisciplinary team) • Maintain fluid intake and nutrition • Correction of sensory impairment (spectacles and hearing aids) • Avoid constipation

25. Preventing & managing delirium • Normalise sleep-wake cycle • discourage daytime naps • ensure undisturbed night-time rest in a quiet room with low-level lighting • Ensure continuity of care • avoid frequent ward or room transfers • Avoid urinary catheterisation • Avoid physical restraint

26. Management of the agitated patient • Talk to the patient before reaching for the needle • Reorientate and reassure • Adopt a non-confrontational approach: • do not argue • tactfully disagree with abnormal beliefs • change the subject of conversation • acknowledge patient’s feelings whilst ignoring the content of their speech • Involve family / carers

27. Pharmacological management • Sedation/antipsychotics should only be used as second-line measures in the following situations: • To allow essential investigation or treatment • To prevent patient endangering themselves or others • Relief of distress in an agitated or hallucinating patient

28. What drug to use? • Haloperidol has greatest evidence-base • Small doses, titrated as needed - 0.5-1mg orally, 1mg im/iv, Max 5mg/24h • Avoid benzodiazepines unless • Alcohol withdrawal • Sensitivity to antipsychotics (PD, LBD – even then, consider quetiapine) • ALWAYS document in notes • Consider Adults with Incapacity Form

29. 4) Complications • Complications in delirium result from: • Immobility (e.g. pressure sores, nosocomial infection, DVT/PE) • Instability (falls) • Iatrogenic disease (over-sedation) • Malnutrition and dehydration • Screening, early recognition and early management (using multidisciplinary team) is essential

30. 5) Discharge • Delirium is a risk factor for dementia • ?delirium uncovering latent dementia • ?brain damage caused by delirium • Adequate functional assessment and discharge planning essential following resolution of delirium • May retain unpleasant memories of delirium • support, counselling and information for patient and family

31. 6) Follow up • May be persistent delirium for up to 1 year • Follow up assessment of cognitive function important - ?dementia • ? Formal psych review • Document Dx of delirium on discharge letter – high risk of further delirium

32. OOH GP admission to medicine • Thanks for seeing Jeannie, 85, who's normally independent. • Neighbours concerned as she was wandering the Sheltered Housing complex confused and partially dressed. • When I attended, house a mess, struggling to get out of bed, doubly incontinent. • Drugs: Aspirin, frusemide 40mg, ramipril 2.5mg, codydramol, amitriptyline 10mg, oxybutynin, ferrous sulphate • Dx: Not coping at home. • ?UTI

33. In AMAU • Not making much sense: tells you she has to get home as she's going to the shops tomorrow • Febrile, smells of urine, dry • AMT 5/10

34. What do you do next?

35. History! • Mildly forgetful • No care • Recent fall and hurt knee • PR exam: faecal impaction • Urine dipstick: blood/prot/nitrites/pus

36. Hb 138 MCV 88 Plt 385 WCC 15.2 Neut 13.2 Bloods • Na 132 • K 3.8 • Urea 13 • Creat 83 • CRP 86

37. What's your Diagnosis?

38. Delirium, secondary to: • Constipation • Dehydration • UTI • Drugs • Probable background cognitive impairment

39. What's your management?

40. Management • Stop drugs • Frusemide, codydramol, amitriptyline, oxybutynin, iron • Rehydrate • Laxatives • Empirical antibiotics for UTI • Early MDT assessment • Early mobilisation • Aim for early discharge

41. What do you do? Agitated and wandering at night

42. What's your advice to GP? 2 days later, much better