delirium

Question 1

what are the key features of delirium

Answer 1

disturbed consciousness - hypoactive/hyperactive/mixed

change in cognition - memory, perceptual, language, illusions, hallucinations

acute onset and fluctuant

Question 2

other common features of delirium

Answer 2

disturbance of sleep-wake cycle

disturbed psychomotor behaviour - delirium affects physical function, esp. walking

emotional disturbance

Question 3

who gets delirium

Answer 3

people w/ frailty and frail brains

most common at extremes of age

Question 4

why does delirium happen

Answer 4

not fully understood

probably a maladaptive, pro-inflammatory state

as you get older and develop cognitive frailty you are more likely to develop delirium in response to external stimuli

Question 5

what precipitates delirium - why is hx important

Answer 5

having a sense of level of cognitive frailty will help you identify precipitants - good hx and knowing the patient is important

collateral hx is very important

gives you an idea of the severity of precipitants you are looking for

Question 6

what precipitates delirium

Answer 6

infection - not always UTI
dehydration
biochemical disturbance
pain 
drugs 
constipation/urinary retention
hypoxia
alcohol/drug withdrawal
sleep disturbance
brain injury - stroke, tumour, bleed
changes in environment, emotional distress

sometimes unknown, often multiple triggers

Question 7

how common is delirium

Answer 7

commonest complication of hospitalisation

20-30% of all in-patients

up to 50% of people post-op

up to 85% of people at the end of their life

Question 8

why is delirium important

Answer 8

massive morbidity and mortality

increased risk of death

longer length of stay

increased rates of institutionalisation

persistent functional decline

Question 9

how to diagnose delirium

Answer 9

4AT - delirium screening tool

everyone >65y/o should have a 4AT done when admitted to hospital

Question 10

what to do when you find delirum

Answer 10

treat the cause - full hx and exam (incl neuro); TIME bundle

explain the diagnosis

pharmacological and non-pharmacological measures

Question 11

what is the TIME bundle

Answer 11

systematic way to work through the management of delirium

think about possible Triggers - hx (meds and alcohol), SEWS (sepsis), BG, urinary retention and constipation

Investigate and Intervene to correct causes - fluid balance, bloods (FBC, U+E, TFT, LFT CRP)
ECG, CXR, CT head

Manage - initiate treatment of All underlying causes found

Explain - document delirium diagnosis, explain diagnosis to patient and family/carers

Question 12

non-pharmacological treatment of delirium

Answer 12

re-orientate and reassure agitated patients - use family and carers

encourage early mobility and self-care

correction of sensory impairment

normalise sleep-wake cycle

ensure continuity of care - avoid hospitalisation if possible, avoid frequent ward/room transfers

avoid urinary catheterisation/venflons

discharge people ASAP

Question 13

pharmacological management of delirium

Answer 13

drugs are (mostly) bad so stop bad drugs if you can

drug treatment of delirium isn’t usually necessary
- no evidence of improved outcomes

only use if a danger to themselves/others or distress which cannot be settled any other way

• start low and go slow
• 12.5mg quetiapine orally
• this should be consultant/reg decision

Question 14

what improves delirium

Answer 14

comprehensive geriatric assessment and MDT input

physios, nurses, HCSW, OT, pharmacist, geriatricians, psychiatrists, social work

Question 15

what % of delirium cases are preventable

Answer 15

30%

Question 16

ways of preventing delirium

Answer 16

orientation and ensuring pts have glasses and hearing aids

promoting sleep hygiene

early mobilisation

pain control

prevention, early identification and treatment of post-op complications

maintaining optimal hydration and nutrition

regulation of bladder/bowel function

provision of supplementary O2 if appropriate

all pts at risk of delirium should have medication review

Question 17

delirium trajectory and follow up

Answer 17

usually settles quickly w/ management of underlying causes

increasingly recognise that a lot of people don’t get back to previous level

may unmask previously undiagnosed cognitive impairment

more likely to go on and develop dementia

risk factor for further episodes of delirium/dementia/frailty syndromes - record and communicate diagnosis, organise follow up

Question 18

delirium and capacity

Answer 18

is the person capable of making decisions about their care - remember capacity is decision specific

do they have a legally appointed proxy decision maker - welfare POA or guardian
- if a patient doesn’t have this in place, have a conversation about the benefits of having a POA to prevent issues in the future

Question 19

association between delirium and falls

Answer 19

4.5x more likely to fall if you have delirium

delirium prevention interventions also help reduce falls

Question 20

prevalence of asymptomatic bacteriuria in older adults in scotland

Answer 20

e.g. F >75y/o in an institutional setting, more likely than not to have +ve urine culture but this doesn’t mean that 57% have a UTI

Question 21

SIGN 88 guidelines - UTI

Answer 21

in elderly women (>65) treatment of asymptomatic bacteriuria doesn’t reduce mortality of symptomatic episodes

abx treatment significantly increases the risk of adverse events (NNTH 3 - for every 3rd person who gets uneeded abx, you are causing)

DO NOT USE DIPSTICK TESTS FOR THE DIAGNOSIS OF UTI IN OLDER PEOPLE