Delirium Case Presentation

1. Delirium Case Presentation

2. Case • 93 ♂ • PC • 4/7 Confusion, agitation + general deterioration • 3/7 poor urine output

3. PMH • BPH • Long term catheter in situ • MI

4. DH • Omeprazole 20mg po od • Betahistine 8mg po om • Aspirin 75mg po om • Calcichew D3 forte

5. SH • Lives with wife • No carers • Independent around house • Enjoys doing crosswords • Recent falls

6. O/A • Temp 35.8 • Dehydrated • GCS 13/15 • AMTS 7/10 • Urine • offensive odour • Dip +ve blood, leukocytes, nitrites

7. Bloods • WCC 14.1 • Neut 9.7 • Hb 12.0 • Na 126 • K 4.4 • Urea 3.8 • Creat 78 • CRP 10

8. Diagnosis • Acute confusion • UTI • Hyponatraemia • Ciprofloxacin 5/7 • Omeprazole + betahistine stopped

9. Day 2 • GCS 7/15 • CT Brain • Small vessel ischaemia • No evidence of space occupying lesion, intracranial haemorrhage or skull # • CRP 46

10. After 2/52 • GCS 15 • AMTS 10/10 • A/W discharge home • Prophylactic trimethoprim

11. Delirium • Derived from Latin ‘off the track’

12. Delirium • Transient global disorder of cognition • Medical emergency • Affects 20% patients on general wards • Affects 30% of elderly medical patients • Associated with increased mortality, increased nursing, failed rehab and delayed discharge

13. Presentation • Acute + relatively sudden onset (over hours to days) • Decline in attention-focus, perception and cognition • Change in cognition must not be one better accounted for by dementia • Fluctuating time course of delirium helps to differentiate

14. Characterised by: • Disorientation in time, place +/- person • Impaired concentration + attention • Altered cognitive state • Impaired ability to communicate • Wakefulness – insomnia + nocturnal agitation • Reduced cooperation • Overactive psychomotor activity – irritability + agression

15. Diagnosis • Cannot be made without knowledge of baseline cognitive function • Can be confused with • 1. dementia – irreversible, not assd with change in consciousness • 2. depression • 3. psychosis – may be overlap but usually consciousness + cognition not impaired

16. Differentiating features of delirium and dementia

17. Risk factors in elderly • Age >80 • Extreme physical frailty • Multiple medical problems • Infections (chest + urine) • Polypharmacy • Sensory impairment • Metabolic disturbance • Long-bone # • General anaesthesia

18. Risk factors • Dementia is one of the most consistent risk factors • Underlying dementia in 25-50% • Presence of dementia increases risk of delirium by 2-3 times

19. Causes • Severe physical or mental illness or any process interfering with normal metabolism or function of the brain

20. Causes mnemonic • Infections (pneumonia, UTI) • Withdrawl (alcohol, opiate) • Acute metabolic (acidosis, renal failure) • Trauma (acute severe pain) • CNS pathology (epilepsy, cerebral haemorrhage) • Hypoxia • Deficiencies (B12, thiamine) • Endocrine (thyroid, PTH, hypo/hyperglycaemia) • Acute vascular (stroke, MI, PE, heart failure) • Toxins/drugs (prescribed tramadol, dig toxicity, antidepressants, anticholinergics, corticosteroids) recreational) • Heavy metals

21. Pathophysiology • Not fully understood • Main theory = reversible impairment of cerebral oxidative metabolism + neurotransmitter abnormalities • Ach – anticholinergics = cause of acute confusional states + Pts with impaired cholinergic transmission (eg Alzheimers) are more susceptible • Dopamine – excess dopamine in delirium • Serotonin – increased in delirium • Inflammatory mechanism – cytokines eg interleukin-1 release from cells • Stress reaction + sleep deprivation • Disrupted BBB may cause delirium

22. NICE Guidelines

23. Management • 1. Identify + treat underlying cause (return to pre-morbid state can take up to 3 weeks) • 2. Complete lab tests + investigations eg. FBC, CRP, U+Es, BM, LFTs, TFTs, B12, MSU, CXR • 3. Rule out EtOH withdrawl • 4. Assume an underlying organic cause

24. Management • 5. Ensure adequate hydration + nutrition • 6. Use clear, straightforward communication • 7. Orientate the patient to environment + frequent reassurance • 8. Identify if environmental factors are contributing to confused state

25. Management • Disturbed, agitated or uncooperative patients often require additional nursing input • Medication should not be regarded as first line treatment • Consider medication if all other strategies fail but remember all psychotropic meds can increase delirium + confusion

26. Medications • Benzodiazepines • Lorazepam 0.5-1mg tds orally • Shorter half life than diazepam + effective at lower doses • S/E - Respiratory depression, increased risk of falls, hypotension • Not for long term use

27. Medications • Antipsychotics • Avoid in PD • Haloperidol 0.5-1mg • S/E – cardiac, avoid in patients with hypotension, tachycardia + arrhythmias, extrapyramidal • Recent evidence suggests not to use in patients with dementia or risk of CVD due to increased risk of cerebral ischaemia • 3X increase in risk of stroke when Risperidone used in older patients with dementia

28. Medications • Dementia with Lewy Bodies • Severe reactions to antipsychotic drugs that can lead to death • Due to extrapyramidal effects • Urgent psychiatric opinion

29. Medication • Review regime every 48h • Will not improve cognition • Can reduce behavioural disturbance • Start with lowest dose possible + increase gradually • Offer orally first • Use as ‘fixed dose’ regime

30. Complications • Malnutrition • Aspiration pneumonia • Pressure ulcers • Weakness, decreased mobility, decreased function • Falls, #s

31. Outpatient Care • Memories of delirium are variable • Educate patient, family + carers about future risk factors • Elderly patients can require at least 6-8 weeks for a full recovery • For some patients the cognitive effects may not resolve completely

32. RUH Algorithm for diagnosis + management of delirium in older adults