Managing Acute Confusion in The Elderly

1. Managing Acute Confusion in The Elderly Dr Rachel Nockels OPALS Consultant

2. Why is this relevant? • GP curriculum statement 9 (care of older people) requires GPs to be able to manage the problems of older people, such as confusion, in the elderly

3. Causes of Acute confusion • Delirium • Worsening dementia • Depression • Alcohol withdrawal or substance misuse • Psychotic disorder • Thyroid disease • Mania • (Schizophrenia)

4. Delirium - definition • A common clinical syndrome characterised by disturbed consciousness, cognitive function or perception which has an acute onset and fluctuating course NICE delerium guideline

5. Definition DSM IV • disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. • a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. • the disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. • there is evidence from the history, physical examination, and laboratory findings that: (1) the disturbance is caused by the direct physiological consequences of a general medical condition, (2) the symptoms in criteria (a) and (b) developed during substance intoxication, or during or shortly after, a withdrawal syndrome, or (3) the delirium has more than one aetiology”.

6. Confusion Assessment Method • Acute onset and fluctuating course • Inattention • Disorganised thinking • Altered level of consciousness A positive CAM requires presence of 1 AND 2 plus either 3 or 4

7. European Delirium Association

8. Theories of delirium pathophysiology • Cholinergic deficiency • Aberrant stress response/ neuroinflammation

9. Delirium – sub types • Hyperactive • Hypoactive • Mixed • (Subsyndromal)

10. Prevalence • Medical wards – 20-30% • Post surgery – 10-50% • Long term care – just under 20% • Community- ? Up to 1%

11. Who Is At Risk? • Those aged 65 years and older • Hip fracture • Cognitive impairment • Severe illness • Sensory impairment • Previous episode of delirium

12. Precipitating factors • Drugs • Infection • Neurological • Cardiological • Respiratory • Electrolyte imbalance • Endocrine and metabolic • Constipation • Change in environment

13. Think Pinch Me • Pain • INfection • Constipation • Hydration • Medication • Environment

14. Consequences • Dementia/Cognitive impairment • Progression of dementia • Discharge to care home (for people who were in hospital) • Falls • Hospital admission (for people who were in long-term care) • Post discharge care

15. Consequences cont. • Post traumatic stress disorder • Pressure Ulcers • Mortality • Impact on carers • Length of stay • Quality of life for patients

16. Management

17. Best management is prevention • Reorientate • Nurse in familiar surroundings • Stop all unnecessary medications • Keep lighting appropriate • Put in hearing aids and wear glasses • Keep well hydrated • Monitor nutrition • Re-align sleep wake cycle

18. Treatment • Identify cause(s) • Ensure effective communication • Use verbal and non verbal techniques • Keep moves to a minimum • If a risk to themselves or others consider short term haloperidol or olanzapine • Continue to re evaluate

19. De Escalation Techniques • Approach in a calm manner • Give choices and maintain patient dignity • Speak in a low even tone • Do not maintain eye contact • Do not interrupt or argue • Allow space, do not touch patient • Empathise with their feelings • Don’t put yourself at risk

20. Sedation • Should be avoided • If necessary use low dose and gradually increase

21. Who Needs Admitting? • Live alone • Will be left unsupervised for any duration of time • If carers (or RH) are unprepared or unable to continue looking after the patient • If the cause does not become clear despite investigation or the patient fails to improve with treatment and/or • If the history and/or examination indicate a cause requiring acute hospital treatment

22. Conclusion • Acute confusion in the elderly is a common problem • Delirium is often missed especially hypoactive form • It can take months to resolve • The consequences can be devastating • Try not to use sedation if at all possible

23. Thank you Any questions?