Download Older adults-Delirium - The Cambridge MRCPsych Course

Older adults-Delirium
Dr. Malarvizhi Babu Sandilyan
ST5 OPMH
What we shall do today…
• Discuss main points of delirium- 30 min
• Discuss MCQs- 7 min
• Perform role play- 13 min
Delirium
• Occurs in 10-20% of hospitalized adult patients,
30-40% of elderly hospitalized patients and about
80% of ICU patients
• ICD 10 definition F 05, not induced by alcohol and
other psychoactive substance
• An etiologically nonspecific syndrome
characterized by concurrent disturbances of
consciousness and attention, perception,
thinking, memory, psychomotor behaviour,
emotion, and the sleep-wake cycle.
Diagnostic features
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•
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Impairment of consciousness
Global disturbance of consciousness
Psychomotor disturbances
Altered sleep wake cycle
Emotional disturbances
Diagnostic features
• All 5 features, acute onset, fluctuating course
for less than 6 months
• Underlying organic cause, not necessary for
diagnosis, EEG slowing of background activity
if in doubt
• Not a disease by itself
• Rather a syndrome
• Caused by brain dysfunction due to underlying
organic causes
• Therefore treatment requires treatment of the
cause
• Differentials- dementia, psychosis, depression
• Hyperactive delirium- increased psychomotor
activity, agitation and aggression
• Hypoactive delirium- quiet type, not able to
converse, or follow commands
Delirium- features
Acute onset and Fluctuating symptoms
Altered consciousness- range from mild
clouding to coma.
Reduced clarity in awareness of the
surroundings
Reduced ability to focus, sustain and direct
attention
Assessed by Glasgow coma scale and orientation
to T,P,P
• Cognitive changes
• Memory- ability to form short term memory
affected. Tested by asking to repeat telephone
numbers, delayed recall
• Ability to form new memories are affected but
previously formed long term memory is
usually preserved except in severe cases
• Changes in attention- inability to concentrate
enough for any purposeful activity
• Inability to do focused thinking so speech may
be disorganised
• Poor concentration result in person
performing meaningless disjointed activities
• Assessed by “world” backwards or serial
sevens
• Hallucinations- perceptions without external
stimuli ( usually visual) or distortion of
perception- size or intensity
• Delusions- not fixed, rather fluctuating and
fleeting
• Emotional changes- fluctuating rapidly
Duration
• Usually resolves once the cause is treated
• Cognitively normal people after experiencing
delirium, are at a risk of developing dementia
• Delirium can last up to months, especially in
the elderly
• Delirium is often a reaction to stress in the
elderly who already have mild cognitive
problems
Causes of delirium
• Physical illness
• Anything that interferes with normal
metabolism or function of brain- drugs,
metabolic, hypoxia, injury, sleep deprivation,
withdrawal form drugs/ alcohol
• Very common in ICU settings, especially
intubated patients- increased risk of death,
recognised a s vital sign and routine part of
management
Differential
• Acute psychosis or mania- can have
fluctuating symptoms
• Dementia
• Depression
• Congenital – learning disability
• EEG- generalised slowing of background
activity except delirium tremens ( slowing may
occur in dementia)
Distinguishing Characteristics of Delirium, Dementia, Psychotic Disorders, and Depression
Disorder
Distinguishing
feature
Associated
symptoms
Delirium
Fluctuating levels of
consciousness with
decreased attention
Disorientation, visual
hallucinations, agitation,
apathy, withdrawal,
impairment in memory
and attention
Dementia
Memory impairment
Disorientation, agitation
Psychotic disorders
Deficits in reality testing
Depression
Sadness, loss of interest
and pleasure in usual
activities
Course
Acute onset; most cases
remit with correction of
underlying medical
condition
Chronic, slow onset,
progressive
Social withdrawal, apathy Usually slow onset with
prodromal syndrome;
chronic with
exacerbations
Disturbances of sleep,
Single episode or
appetite, concentration, recurrent episodes; may
and energy; feelings of
be chronic
hopelessness and
worthlessness; thoughts
of suicide
Rating scales
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Delirium rating scale
Confusion assessment method
Memorial delirium assessment scale
MMSE, done on several occasions
Management
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Treat the cause
History from collateral
Investigations to find the organic cause
Physical examination- neurological exam
Symptomatic treatment
• Antipsychotics to control agitation, aggression
and psychotic symptoms
• Haloperidol most studied
• Risperidone and olanzepine studies in newer
atypicals
• Haloperidol 1- 2 mg ( elderly halve the dose)
from bd up to six times per day can be given
i.m, po and i.v ( need to be on cardiac
monitor)
• Tend to avoid sedative drugs, as can worsen
confusion in elderly
• Tend to avoid anticholinergic drugs, as can
worsen confusion
Environment
Communicate clearly and concisely; give repeated verbal reminders of the day, time,
location, and identity of key persons, such as members of the treatment team and
relatives.
Provide clear signposts to patient’s location, including a clock, calendar, and chart with
the
day’s schedule.
Place familiar objects from patient’s home in the room.
Ensure consistency in staff (e.g., a key nurse).
Use television or radio for relaxation and to help the patient maintain contact with the
outside world.
Involve family members and caregivers to encourage feelings of security and orientation.
Simplify care area by removing unnecessary objects; allow adequate space between beds.
Consider using private room to aid rest and avoid extremes of sensory experience.
Avoid using medical jargon in patient’s presence because it may encourage paranoia.
Ensure that lighting is adequate; provide a 40- to 60-watt night light to reduce
misperceptions.
Control sources of excess noise (e.g., staff, equipment, visitors); aim for fewer than 45 dB
during the day and fewer than 20 dB during the night.
Maintain room temperature between 21.1 C (69.98 F) and 23.8 C (74.8 F)
Prognosis
• Poor if elderly
• Need to stay longer in hospital
• Have more hospital acquired complications
such as falls and pressure sores
• Have increased incidence of dementia
• Increased mortality
• More likely to be admitted to long term care if
in hospital
NICE guidelines
• Risk assessment- age >65, dementia, current
hip fracture, severe illness are at increased risk
• Assessment- indicators of delirium as above
• Confirm- DSM 4 or short CAM
• Management- environmental, reassurance,
involve family
NICE guidelines
• If distressed or at risk and de escalation
techniques fail- use short term (<I week)
haloperidol or olanzepine
• If delirium does not resolve, then reassess for
underlying causes
• Follow up and assess for dementia
MCQs
• The following is a risk factor for delirium
except:
1. Sleep deprivation
2. Living alone
3. Age >65
4. Current hip fracture
5. Severe pneumonia
MCQs
• The following tools are useful in assessing
delirium except:
1. MDAS
2. DRS
3. CAM
4. MMSE
5. BADLS
MCQs
• The following is suggestive of delirium as
opposed to depression
1. Apathy
2. Reduced psyhcomotor activity
3. Poor concentration
4. Altered sleep wake cycle
5. Fluctuating course
Scenario for role play
• You are the on call psychiatrist who has been
called to see Mr. D’Arcy on the acute medical
ward. Mr. D’Arcy is an elderly gentleman who
has been admitted for confusion. He is
increasingly agitated and is at risk of getting
violent. He is usually a bit confused but now
he is much worse than before. Speak to the
ward sister and address her concerns.
Instructions for the role player
• You are the ward sister and have been looking after Mr. D’Arcy since
yesterday after he was transferred from A&E where he came with
increasing confusion. He lives in a care home and is known to be
usually confused but this is much worse. He is constantly walking
around the ward aimlessly and interferes with other patients. He
doesn’t sleep at night and refuses to take medications. He had all
the blood tests which has been normal. He is awaiting a CT scan of
brain. This is because he has had several falls and may have
bumped his head. You speak to the psychiatrist and enquire what is
the matter with the patient. You are worried that he will attack
someone and ask if he can be moved to psychiatric hospital. You
feel he is psychotic, as he has been seeing little animals on the ward
( visual hallucinations) and he will be better placed on a psychiatric
ward. You ask if he can be sedated so that he will not cause any
more problems. You ask if any medications can be given to treat his
confusion. You ask if anything you can do to help Mr. D’Arcy.