Download 4._Delirium

Old Age Psychiatry
Delirium
Dr Asso Fariadoon Ali Amin
MRCP(UK)
Internal Medicine and Care of Elderly
Delirium
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Delirium is a syndrome of disturbance of consciousness
accompanied by change in cognition not accounted for by
dementia.
• Delirium is typically common in post operative patient , 4361% after hip fracture.
• Acute condition with symptoms developing over hours or
days. People with delirium appear disoriented and unable to
focus their attention. Conversation difficult to follow,
fluctuation of symptoms occur, often with diurnal variation (
worse at night).
• Diagnosis is difficult , patients can be miss diagnosed when
they are deaf, blind, or dysphasic. More commonly missing the
diagnosis, therefore routine screening is very useful using
AMT.
Risk factors for delirium developing as an
inpatient
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Old age
Severe illness
Pre-existing dementia, depression or previous delirium
Physical frailty – functional dependence, falls
Infection
Dehydration or malnutrition
Sensory impairment
Polypharmacy especially with psychoactive drugs
Surgery especially #NOF
Previous alcohol excess
Renal or hepatic impairment
Metabolic derangement e.g. hyponatraemia
Terminal illness
Causes
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Infection:- Usually UTI, Chest infection, cellulitis, CNS, endocarditis,
biliary infection.
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Drug:- anti-cholinergic (like atropin), antipsychotic, anti-histamines,
hypnotic and anxiolytic (diazepam), antidepressant specially tricyclic, anticonvulsant, opiates, corticosteriod, lithium, L-dopa like sinemet or
madopar.
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Metabolic:- dehydration, hpo/hypernatraemia , uremia, hypercalcaemia.
• Vascular:- MI and stroke
• Alcohol and drug withdrawal.
• Organ failure:- cardiac, respiratory, liver.
• Endocrine:- Hypothyroidism , hypo/hyperglycaemia
• Epileptic
• Intracranial pathology like subdural haematoma, space occupying
lesions, pre-existing dementia, CVA.
Psychomotor Forms of Delirium
Hyperactive:
Marked by increased motor activity,
agitation, hallucinations, inappropriate
behaviour & vigilance
Hypoactive:
Marked by lethargy with a decrease in
motor activity, has a poorer prognosis. It is
often missed (up to 2/3rds cases)
Mixed
Diagnosis
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Key Features:-
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Acute onset with fluctuation
Disturbance of consciousness
Impaired cognition not due to pre-existing dementia
Evidence of acute general medical condition, intoxication, or substance
withdrawal.
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Other features
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Disturbance of sleeping –insomnia, daytime drowsiness, nocturnal
worsening of symptoms, nightmares revoke sleeping
Behaviour change mainly restless, agitated, or apathy
Memory loss
Inattention
Delusion, hallucination, and illusion
poor insight
Slurred speech
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Clinical Assessment
History:- Taking full history from patient as well as collateral history ,
with concentration on any possible history of underlying infection.
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Examination:- May be difficult with distraction , focus again on any
signs of infection, neurological deficit,
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Objective assessment: AMT (Abbreviated Mental Test) Normal score 8 and more
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How old are you?
When is your birthday?
What time is it? Nearest
What Month or Year
Remember an address
Where are you? Place
What is my job or recognise people around
Second world war?
Name of Monarch/ President
Clinical Assessment
 Confusion Assessment Method (CAM)
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Acute onset with fluctuating course AND
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Inattention ( e.g. Count 20-1) unable to maintain or shift AND EITHER
a. Disorganised thinking ( disorganised or incoherent speech) OR
b. Altered level of consciousness.
 Determining Underlying Cause (Investigation)
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FBC
Urea and Electrolyte
LFT
TFT
Glucose
Calcium and Phosphate
ESR and CRP
Urinalysis
CXR, ECG, Pulse Oximetry
Other Possible Investigation ABG, CT scan brain ,EEG Culture and sensitivity
Differential Diagnosis of delirium
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Dementia
Depression
Hysteria
Mania
Schizophrenia
Dysphasia
Non convulsive epilepsy / temporal lobe epilepsy
Assessment in delirium
• Collateral history from a carer or the NOK is essential to
establish the onset & course of confusion to distinguish
between dementia & delirium
• CAM
• Assess cognitive function if possible on admission (AMTS
or MMSE) & subsequent serial measurements can track
patients’ progress
• Assess for cause of delirium
Assessment in delirium – the history
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Previous intellectual function & functional status
Full drug history including recent cessations
History of fluid & food intake, alcohol history
History of bladder & bowel voiding
Sensory deficits & aids used
Previous episodes of acute or chronic confusion
Co morbidities
Symptoms suggestive of underlying cause
Pre-admission social circumstances & care package
Management
5 Main stages
• Prevention and Early Detection
• Treatment of Underlying Causes
• Environmental Measures
• Pharmacology
• Prevention of Complication
MANAGEMENT
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Prevention and early detection:- All older patient with acute illness
should be screened for delirium and should have AMT done. Consider
delirium with a score of 8 and less.
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Identifying Underlying Causes:- Consider medication review ,
Infection, dehydration, electrolyte imbalance , MI, drug and alcohol
withdrawal, urinary retention and faecal impaction and neurological like
stroke or subdural haematoma.
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Environmental Measures:Avoid overstimulation.
Avoid sensory deprivation like spectacles or hearing aids
Provide personal and environmental orientation
Minimise discontinuity of care
Ensure good hydration
Ensure good nutrition
Encourage mobility
Avoid sleep deprivation
Management
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Pharmacology :-
 Stop possible causative drugs
 Agitated patients could be treated with 2 drugs :- lorazepam 0.5mg od or
haloperidol 0.5 mg . Should only be used to 1. prevent patients to endanger
themselves and others 2. to allow essential investigation or treatment 3. to
relieve distress in a highly agitated patients .
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Preventing Complication
Falls
Pressure Sore
Hospital acquired infection
Functional impairment
Incontinence
Over-sedation
Malnutrition
Wandering
• Close observation in a safe & reasonably
secure environment
• Supervise them walking rather than trying
to stop them
• Identify the cause of agitation – pain, thirst,
looking for the toilet
• Distraction – involve family members if
possible
Wandering
Rambling speech
• Do not agree with rambling speech as my
re- enforce any paranoid component
• Tactfully disagree
• Change the subject
• Acknowledge the feelings expressed but
not the content
Rambling speech
Sedation - indications
• In order to carry out essential investigations
or treatment
• To prevent a patient endangering
themselves or others
• To relieve distress in a highly agitated or
hallucinating patient, after assessing
whether there is a physical cause for that
distress
Sedation – options 1
• Always try to use the oral route, as im injections can be
seen as an escalation in hostilities!
• When dosing – start low & go slow
• Options:
Haloperidol 0.5 – 1mg bd with additional doses every four
hours aim for maximum dose of 5mg, but may need to go
higher.
Avoid in patients with PD & Dementia with Lewy Bodies,
hepatic insufficiency, drug or alcohol withdrawal &
neuroleptic malignant syndrome
Sedation - options 2
• Lorazepam 0.5 – 1mg:
Which may be given up to 2 hourly, maximum dose
3mg/24hrs
• Atypical anti-psychotics:
Olanzapine 2.5 – 5mg od
• Use in those with PD, Dementia with Lewy Bodies
Example
• 78 years old patient admitted with acute confusion
for the last 3 days. The family have noted change in
urine colour as well as change in odour, also had low
grade fever. O/E looked dehydrated, AMT 6/10 ,
temperature 37.9 , RR 24 , HR 90 bpm. Past medical
history:- severe OA of both knees , Hypertension, on
tramadol, paracetamol, bendrofluazide. Blood test
shows high urea, Na 125 , FBC normal. , ESR 60,
CRP 80, TFT normal, LFT normal, Urine dip
positive.