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Delirium (or: It's not a bloody UTI)

Graeme Hoyle Consultant Geriatrician. Delirium (or: It's not a bloody UTI). Overview. What is delirium? Why is it important? How to recognise it How to manage it. Case History. OOH GP admission to medicine. Thanks for seeing Jeannie, 85, who's normally independent.

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Delirium (or: It's not a bloody UTI)

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  1. Graeme Hoyle Consultant Geriatrician Delirium(or: It's not a bloody UTI)

  2. Overview • What is delirium? • Why is it important? • How to recognise it • How to manage it

  3. Case History

  4. OOH GP admission to medicine • Thanks for seeing Jeannie, 85, who's normally independent. • Neighbours concerned as she was wandering the Sheltered Housing complex confused and partially dressed. • When I attended, house a mess, struggling to get out of bed, doubly incontinent. • Drugs: Aspirin, frusemide 40mg, ramipril 2.5mg, codydramol, amitriptyline 10mg, oxybutynin, ferrous sulphate • Dx: Not coping at home. • ?UTI

  5. 3 Major Errors • 1. Nobody is independent • This only seems to be a problem for old people • 2. Everyone is admitted to hospital because they're not coping at home • We only point this out for old people • 3. It's usually not a UTI • It's never just a UTI

  6. Delirium

  7. Delirium • ‘Acute confusional state’ • Known about for a long time • Why does a UTI make you confused?

  8. Why is delirium important? • Delirium: • Is very common (1/3 of elderly admissions) • Has a high mortality (10-26%) • Has high rates of morbidity (LoS, instit.) • Despite this, delirium: • Is under-recognised • Is under-diagnosed • Is poorly managed

  9. Pathology • Poorly understood • Neurotransmitters • ACh, Dopa • Inflammatory process • High levels of inflam cytokines • Hypothalamic-pituitary-adrenal axis • Overactivity with hypercortisolism • Leads to inflammatory process

  10. Aetiology • Predisposing vs. Precipitating factors • A highly susceptible person only needs a minor insult to develop delirium • A fit person requires a major insult to develop delirium (eg pneumonia – CURB)

  11. Predisposing factors • Old age • Frailty • Dementia • Past history of delirium • Visual/hearing impairment • Malnutrition • Polypharmacy • Comorbidity (esp. renal/hepatic impairment)

  12. Precipitating factors • Infection • Dehydration • Constipation • Pain • Immobility • Medication use/withdrawal • Sleep deprivation • Catheterisation • Use of physical restraints

  13. Clinical features • Altered level of consciousness • Cognitive deficit or perceptual disturbance • Acute onset, fluctuating course • Evidence of cause (also frequently altered sleep-wake cycle, emotional lability)

  14. Forms of delirium • Hyperactive • Vigilant, agitated, wandering • Hypoactive • Drowsy, apathetic, frequently missed • More common, higher morbidity • Mixed

  15. Management - overview • Assessment and screening • Prevention • Treatment • Complications • Discharge • Follow up

  16. 1) Assessment and screening • At admission: • Identify those with delirium • Identify those at risk of developing delirium • Screening tests: • AMT • Delirium or dementia? • HISTORY IS KEY • SQiD

  17. SQiD • 'Do you think …….. has been more confused lately?'

  18. Assessment (cont’d) – identification of those at risk • Old age • Frailty • Dementia • Past history of delirium • Visual/hearing impairment • Malnutrition • Polypharmacy • Comorbidity (esp. renal/hepatic impairment)

  19. 2) Prevention • Identify those at risk • Avoid/rapidly treat precipitating factors • Review drugs • Stop anticholinergic medication (eg TCAD) • Reduce or stop benzodiazepines • Management as per established delirium

  20. Precipitating factors • Infection • Dehydration • Constipation • Pain • Immobility • Medication use/withdrawal • Sleep deprivation • Catheterisation • Use of physical restraints

  21. 3) Treatment of delirium • Identify and treat precipitating factors • Full HISTORY and examination (inc PR) • FBC, U&E’s, LFT’s, Ca, CRP, TFTs, Glc • ECG • CXR • Non - pharmacological management • Pharmacological management

  22. = being nice to your granny Non-pharmacological management

  23. Preventing & managing delirium • Reorient patients to environment and time • Encourage early mobility and self-care (early involvement of multidisciplinary team) • Maintain fluid intake and nutrition • Correction of sensory impairment (spectacles and hearing aids) • Avoid constipation

  24. Preventing & managing delirium • Normalise sleep-wake cycle • discourage daytime naps • ensure undisturbed night-time rest in a quiet room with low-level lighting • Ensure continuity of care • avoid frequent ward or room transfers • Avoid urinary catheterisation • Avoid physical restraint

  25. Management of the agitated patient • Talk to the patient before reaching for the needle • Reorientate and reassure • Adopt a non-confrontational approach: • do not argue • tactfully disagree with abnormal beliefs • change the subject of conversation • acknowledge patient’s feelings whilst ignoring the content of their speech • Involve family / carers

  26. Pharmacological management • Sedation/antipsychotics should only be used as second-line measures in the following situations: • To allow essential investigation or treatment • To prevent patient endangering themselves or others • Relief of distress in an agitated or hallucinating patient

  27. What drug to use? • Haloperidol has greatest evidence-base • Small doses, titrated as needed - 0.5-1mg orally, 1mg im/iv, Max 5mg/24h • Avoid benzodiazepines unless • Alcohol withdrawal • Sensitivity to antipsychotics (PD, LBD – even then, consider quetiapine) • ALWAYS document in notes • Consider Adults with Incapacity Form

  28. 4) Complications • Complications in delirium result from: • Immobility (e.g. pressure sores, nosocomial infection, DVT/PE) • Instability (falls) • Iatrogenic disease (over-sedation) • Malnutrition and dehydration • Screening, early recognition and early management (using multidisciplinary team) is essential

  29. 5) Discharge • Delirium is a risk factor for dementia • ?delirium uncovering latent dementia • ?brain damage caused by delirium • Adequate functional assessment and discharge planning essential following resolution of delirium • May retain unpleasant memories of delirium • support, counselling and information for patient and family

  30. 6) Follow up • May be persistent delirium for up to 1 year • Follow up assessment of cognitive function important - ?dementia • ? Formal psych review • Document Dx of delirium on discharge letter – high risk of further delirium

  31. OOH GP admission to medicine • Thanks for seeing Jeannie, 85, who's normally independent. • Neighbours concerned as she was wandering the Sheltered Housing complex confused and partially dressed. • When I attended, house a mess, struggling to get out of bed, doubly incontinent. • Drugs: Aspirin, frusemide 40mg, ramipril 2.5mg, codydramol, amitriptyline 10mg, oxybutynin, ferrous sulphate • Dx: Not coping at home. • ?UTI

  32. In AMAU • Not making much sense: tells you she has to get home as she's going to the shops tomorrow • Febrile, smells of urine, dry • AMT 5/10

  33. What do you do next?

  34. History! • Mildly forgetful • No care • Recent fall and hurt knee • PR exam: faecal impaction • Urine dipstick: blood/prot/nitrites/pus

  35. Hb 138 MCV 88 Plt 385 WCC 15.2 Neut 13.2 Bloods • Na 132 • K 3.8 • Urea 13 • Creat 83 • CRP 86

  36. What's your Diagnosis?

  37. Delirium, secondary to: • Constipation • Dehydration • UTI • Drugs • Probable background cognitive impairment

  38. What's your management?

  39. Management • Stop drugs • Frusemide, codydramol, amitriptyline, oxybutynin, iron • Rehydrate • Laxatives • Empirical antibiotics for UTI • Early MDT assessment • Early mobilisation • Aim for early discharge

  40. What do you do? Agitated and wandering at night

  41. What's your advice to GP? 2 days later, much better

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