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THE
CONFUSED/AGITATED
PATIENT
Max Henderson
Session Objectives
By the end of this session you should be able to:
•
Give a working definition of confusion/agitation associated with illness
•
Describe the common pattern of symptoms associated with confusion/agitation
recognising their variability
•
Describe the conditions which are commonly associated with confusion/agitation in
general hospital patients
•
Outline the core steps involved in assessment, recognising the main medical, physical
and psychological causes of confusion/agitation
•
Give examples of general and pharmacological management that can be offered for
management of confusion/agitation, in addition to addressing reversible causes where
appropriate
•
Outline the legal considerations when managing a confused/agitated patient.
Key topics to be covered in the presentation
• Recognition of confusion/agitation – key
symptoms
• Common presentations of confusion/agitation
• Assessment of the confused/agitated patient
• Management of the confused/agitated patient
• Legal considerations (Mental Capacity
Act/Mental Health Act)
Agitation
•
Physical signs
Series of unintentional and purposeless motions
Often repetitive
•
Underlying mental state
Anxiety, fear, sadness ….etc
•
Feature of many disease states
Hypoxia, hypoglycaemia
Many psychiatric disorders
Adverse effect of a number of medications
BUT CAN ALSO BE COMPLETELY NORMAL!!!
Confusion
Loss of orientation
+/Memory impairment
Inability to focus attention
Abnormal conscious level
Range from mild to severe
Acute to chronic
Is a symptom not a diagnosis
May indicate underlying pathology
Delirium
Confusion
Behavioural
change
What is delirium?
• The most common neuropsychiatric complication of medical illness
• A (potential) medical emergency
• Aka:
Acute brain failure
Acute confusional state
Acute organic syndrome
Cerebral insufficiency
Encephalopathy
Post-operative psychosis
Toxic psychosis
Delirium Overview
• Indicators of delirium
• Characteristics
• Key features
• Types of delirium
• Why is delirium often missed?
Indicators of Delirium
Changes or fluctuations in:
Behaviour
Cognitive function
Perception
Physical function
Social behaviour
Not able to hold a conversation when usually able to do so
Characteristics
•Acute/abrupt onset
•Fluctuating course
•Worse at night
•Organic aetiology
•Frequently under-diagnosed!
Key Features
•Inattention
– in 97%
•Level of
inattention correlates with other cognitive impairment but NOT
non-cognitive aspects
•Disorientation least common
feature
•Psychosis in only 50%, florid in 20%
•No
association between psychosis and motoric state
Types of delirium
•Hyperactive (21%)
Agitation
Hallucinations
Behavioural disturbance
Irritability/anger
Laughing/swearing/ euphoria
Wandering
•Mixed (43%)
Alternates between hyperactive and
hypoactive states
•Hypoactive (29%)
↓ level of consciousness
Somnolence
Sparse or slow speech
Staring
Apathy
•Unclassified (7%)
Why is delirium so often missed?
•
Fail to appreciate there’s something wrong
•
Recognise something’s wrong but….
Too ready to accept confusion as “normal” or
“The CRP is normal it can’t be delirium!”
•
Wrong diagnosis
Its depression (scary.. Don’t want to go there)
Its dementia (incurable..whats the point)
Thus…
• You will only diagnose it if you consider it
• Systematic approach increases likelihood you
will think about it
• Using a tool increases the likelihood you will get
the diagnosis right
Diagnosis of Delirium
Detection of Delirium
• Obvious if agitated/floridly psychotic
• Up to half of cases missed though…..
• Need to compare with baseline status
Clinical diagnosis:
- Cognitive impairment-MMSE, AMTS
- Attention deficit- Digit span, months backwards, d-l-r-o-w
Assessment Tools
•
Confusion Assessment Method
•
Memorial delirium assessment scale
•
Delirium rating scale
•
Delirium symptom interview
•
Confusion rating scale
•
Clock drawing test
Differential Diagnosis
•Dementia (but remember that
dementia is a predisposing
factor for delirium!!)
•Schizophrenia
•Hypomania
•Anxiety
•Depression
Delirium
Dementia
Diagnostic criteria
Diagnostic Criterium
• Which one?
ICD-10
DSM-IIIR
DSM-IV
ICD-11
DSM-V
Definitions
ICD 10 definition
•
Impairment in consciousness or
attention
DSM IV definition
•Disturbed consciousness
•Disturbed attention
•
Global cognitive impairment
•Disturbed cognition
•
Psychomotor disturbance
•Acute / subacute onset
•
Sleep-wake cycle disturbance
•
Emotional disturbance
•Fluctuating symptoms
ICD-10
(N=43)
17
25
13
1
8
42
DSM-III
(N=80)
7
DSM-IV
(N=106)
19
Pitkala 2003
DSM-III-R
(N=83)
Confusion about confusion
• 5-fold difference in prevalence rates
• Only 1:5 clinically diagnosed deliriums meet ‘caseness’
for both criteria
• Remember HYPOactive forms
• “But I know it when in see it…”?
Problems
• ICD-10 too limiting: must tick all boxes
• What is consciousness?
• What is clouding?
• Must they have BOTH altered attention AND clouding of consciousness?
• Is reduced attention evidence of impaired consciousness?
• What do we do about a problem like dementia?
Basic epidemiology
Epidemiology
General
population
0.4%
General
populatio
n (>55
yrs) 1.1%
General
hospital
admission
s 9-30%
Elderly
general
hospital
admission
s 5-55%
Elderly
A&E
attenders
17%
Advanced
cancer
patients
25-85%
Postoperative
patients
5-75%
Intensive
Care
Units 1250%
Nursing
home
residents
up to 60%
Delirium is common in advanced disease
• 25% - 85% in the literature
• 42% showed cognitive impairment on admission to
palliative care unit (Lawlor 2000)
• 31% < 8 on AMTS at St Christopher’s Hospice
Risk Factors
Predisposing
Precipitating
•Increased age
•Length of surgery
•Pre existing cognitive
impairment
•Increased urea:creatinine
•Severe illness (esp ↑ pain
↓ sleep)
•Drugs – withdrawal or
addition
•Infection
•Visual impairment
•New #
•Polypharmacy
•Metabolic derangement
Causes of delirium
Causes of delirium: Drugs
Opiates (especially if renal failure): dehydration and toxicity
Sedatives e.g. benzodiazepiness
GI drugs: cimetidine, ranitidine, metoclopramide
NSAIDS
Corticosteroids
Anticholinergics e.g. amitriptyline
Causes of deliruim
Metabolic causes (18%)
• Fluid imbalance
• Electrolyte imbalance e.g. hypercalcaemia
Trauma
Infection
• UTI, RTI
Poorly controlled pain
Hypoxia
Constipation
Poor glycaemic control
Never forget…
ALCOHOL
WITHDRAWAL
!!!!!!!!!
Delirium Tremens
• Associated with alcohol withdrawal
• MEDICAL EMERGENCY – untreated mortality up to
35%
• Typically appears 2-3 days after stopping drinking –
more than just “bad withdrawal”
• Delirium symptoms PLUS
Diarrhoea
Changes in BP
Prominent VISUAL hallucinations, also occasionally
TACTILE
Patient commonly terrified
Neuropathology of delirium
Neuropathology of delirium
• Several neurotransmitter systems implicated
Serotonergic
Noradrenergic
Opiatergic
Glutaminergic
Histaminergic
•
Inflammatory cascade
Macrophage / monocyte activity
Reduced oxygen carriage
Cytokine activity  altered BBB permeability
Why does delirium matter?
Delirium is associated with increased suffering
Patient
distress
Increased
mortality
Increased
length of stay
Increased use
of medication
Family distress
? Staff distress
Assessment
Before
you see
the patient
Whilst you
are seeing
the patient
After you
have seen
the patient
Before you see the patient
The problem:
• Is there a problem?
• What sort or problem is it?
• Who has the problem?
Who has
a
problem?
• Patient
• Anxiety
• Psychosis
• Potential for harm e.g. wandering
• Family
• Apparent patient distress (? Restlessness ?
Psychosis)
•  ability to communicate
• Staff
• Apparent patient distress
•  ability to communicate
Before you see the patient
Resources
• Your memory (have you seen the patient before?)
• Reports from colleagues
• Medical notes
• Informant history-family and other carers
Whilst you are seeing the patient
First engage brain….
what do you see?
what do you hear?
what do you smell?
Best time of day?
Minimise threat……
What will this be like for the patient???
After you have seen the patient
• Are they how you thought they would be?
• Evidence of fluctuation
Within assessment
Compared to last time
• How do they make you feel? (=what will their
relatives be feeling?)
Management of delirium
Management
Prevention
Assessment
Treatment
Management Aims
• Prevention is the best cure! (Inouye 1999)
• Goal of returning the patient back to
baseline cognitive functioning NOT
behavioural control
Prevention
Prevention
• All patients at the end of life are vulnerable
• Strategies:
Familiar healthcare team
Avoid moving between wards
Early assessment for risk factors (THINK DELIRIUM!)
Maintain hydration and delirium
Encourage cognitive activity
Re-orientate regularly
Support good sleep patterns
Encourage mobilisation
Recruit patient and family
Evidence Based Thoughtfulness?
Incidence of delirium reduced from 15% to 9.9%
Total days of delirium reduced from 161 to 105
No change in delirium severity
Total cost of interventions
< $140 000
=
$327 per patient
Drug Primary Prevention
•
RCT of haloperidol prophylaxis (Kalisvaart 2005)
•
430 hip-surgery patients randomised to 1.5mg
haloperidol or placebo
•
No difference in incidence
•
Reduced delirium severity
•
Halved length of delirium episode
•
Reduced post-op stay in hospital
Treatment
Key Management Strategies
• Identify and treat underlying cause(s) if appropriate
• Manage current symptoms
- Non-pharmacological
- Pharmacological
What to treat
• Few accounts of what delirium is like (but see Crammer BJPsych 2002)
• Treat specific symptoms – especially anxiety
• There is no drug treatment for either disorientation or wandering
• Reserve antipsychotics for distressing hallucinations delusions or
agitation?
(http://www.leeds.ac.uk/lpop/documents/Delirium%20guidelines.doc)
.
Pharmacological Management
• NICE recommended use if (and only if):
- Patient is distressed
- Considered a risk to themselves or others
- Verbal and non-verbal de-escalation techniques unsuccessful
“Pharmacological interventions are currently used in
clinical practice to manage the symptoms of delirium
but the evidence for this is limited” (NICE)
Medication
•
To relieve symptoms
•
Antipsychotic medication
- But significant risks (see Inouye 2014)
•
Anxiolytic medication
- But significant risks
- High quality evidence difficult to obtain
Legal issues
Mental Capacity Act 2005
• Came into force in 2007 - 2009
• Sets out a framework for decision-making on behalf of
adults who lack capacity to make decisions themselves
• Incorporates aspects of ‘common law’ – (codifies Best Interests)
• Introduces ‘Lasting Power of Attorney’ to cover all aspects of a
person’s care – medical and social care, housing, finances
• Defines new role of Independent Mental Capacity Advocate
(IMCAs)
• Introduces a new criminal offence of ‘wilful neglect’
• Living wills/advance directives
• Deprivation of Liberty Safeguards (amended by MHA 2007)
The Mental Capacity Act 2005
A person’s ability to make a particular decision at a specific time or in a specific
situation
It is presumed that adults have capacity to make decisions unless proven
otherwise
Two stage process:
Is there an impairment of mind or brain?
Is the impairment sufficient to impair decision making capacity?
Capacity Test (decision-specific not ‘global’):
Can the person understand the information?
Can the person retain the information (long enough to make a judgement)?
Can the person use or weigh the information?
Can the person communicate the decision?
Failure in one or more parts of this test indicates lack of capacity
Mental capacity law in practice
Health professionals or decision makers will be exempt from liability if they
have a reasonable belief that the person:
(i) lacks capacity AND
(ii) the decision is in the person’s best interests
Reasonable use of restraint may be lawful to effect necessary treatment.
Advance directives refusing treatment – now have legal power except where a
patient is subject to compulsory treatment under the Mental Health Act
ECHR ruled that it is never lawful to deprive a person of their liberty so the
original MCA was amended by the MHA 2007 to set up a framework to
legally detain/deprive compliant incapacitated persons in hospitals or
nursing homes (DOLS).
The Mental Health Act 2007
Implemented in October 2008 – unchanged provisions
• Section 2 – 28 days assessment
• Section 3 – up to 6 months treatment – renewable
• Section 5(2) – up to 72 hours in order to arrange full
assessment for Section 2 or Section 3