Elderly - Delirium Flashcards
whata re the key features of delirum?
- Disturbed consciousness (fluctuation in conscious levels) - Hypoactive/hyperactive/mixed
- Change in cognition - Memory/perceptual/language/illusions/hallucinations
- Acute onset and fluctuant
Acute change in mental state
what are some otehr common features in delirum?
- Disturbance of sleep wake cycle
- Disturbed psychomotor behaviour – DELIRIUM AFFECTS YOUR PHYSICAL FUNCTION
- Emotional disturbance
Can make your walking bad
Can be confused with confusion
who gets delirum?
To do with frailty and not age
Most common in extremes in age
why does delirum happen?
no one really knows
DELIRIUM – WHAT PRECIPITATES IT?
- Having a sense of cognitive frailty will help you identify precipitants
- AS WITH EVERYTHING IN GERIATRICS COLLATERAL HISTORY IS REALLY IMPORTANT!
Often precipitated by external stressors
Have a sense of who the person is and how likely they are to develop delirium
delirum - what precipitates it? what things may trigger it?
Pretty much everything can cause
Don’t have to be medical physical problems
Usually a combination of these things rather than just one
- Infection (but not always a UTI!)
- Dehydration
- Biochemical disturbance
- Pain
- Drugs
- Constipation/Urinary retention
- Hypoxia
- Alcohol/drug withdrawal
- Sleep disturbance
- Brain injury - Stroke/tumour/bleed etc
- Changes in environment/emotional distress
•Sometimes no idea and often multiple triggers!
DELIRIUM – WHAT PRECIPITATES IT
whats happening here?
Get antidepressant after wife dies, these are associated with falls, the fall flares up arthritis that gives knee pain, constipation of dihydrochloride, dehydrated, then urinary retention
Even if you think one delirium trigger its important you work systematically to try and make sure there is not others
how common is delirum?
- Commonest complication of hospitalisation
- 20-30% of all in-patients
- Upto 50% of people post surgery
- Upto 85% of people at end of their life
Not just old people in the geriatric ward
why do we care about delrium?
More likely to accumulate hospital associated harm like falls and infections
Much less likely to get home and more likely to be discharged to a nursing home
Can have a horrible psychological harm and on carers aswell and we don’t address this enough
how do we diagnose delirium?
4AT
Delirium screening tool
what should you do when you find delirium?
•Treat the cause:
- Full history and exam (incl. neuro)
- TIME bundle - systematic way to work through when you find they have delirium, think of their triggers and managing them, explain diagnosis to the person and care givers and provide psychological support
- Explain the diagnosis!
- Pharmacological measures
- Non-pharmacological measures
Non-pharmacological is the main treatment
what is the non-pharmacological treatment of delirium?
- Re-orientate and reassure agitated patients - USE FAMILIES/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 or room transfers
- Avoid urinary catheterisation/venflons
- Discharge people (if in hospital) ASAP
Re-introduce yourself each time
what is the pharmacological treatment of delirium and how should it be done??
- Remember DRUGS ARE BAD (mostly….)
- STOP BAD DRUGS - Stop things that you think is making it worse, some drugs are particularly bad for the brain
- Drug treatment of delirium usually not necessary
- No evidence it improves outcomes
- Only if danger to themselves or others or distress which cannot be settled in any other way
- Start low and go slow
- 12.5mg quetiapine orally
- THIS SHOULD BE A CONSULTANT/REGISTRAR DECISION
(As with everything in geriatrics)
DELIRIUM IMPROVES WITH MULTIDISCIPLINARY INPUT
who may be involved?
phyios
nurses
HCWS
OT
pharmacists
geriatritians
psychiatrists
social work
Prevention - Delirium is preventable in 30% of cases!
how can the risk be reduced?
Preventable by doing simple interventions
Big impact economically as expensive due to iatrogenic harm and poor outcomes and institutionalisation that happens at the end of it
HOW COULD WE HAVE PREVENTED IT HERE?
Antidepressants are dangerous in people like carl so could of recognised this and done something else
Could of gave him something else for knee pain
Could of prevented dehydration
Could of recognised urinary retention was probably due to constipation and got the bowels going and bladder would empty and would prevent a catheter
Things could have been done differently at multiple parts in this pathway if we just recognised people of being at risk of delirium and of the other decompensated frailty syndromes like carl who also had falls
what is the trajectory and follow up of delirum?
Usually settles down quickly
More likely to get delirium again so may impact on what drugs we prescribe and what community based models of care we offer to try and keep these people as fit and well and out of hospital
what do you need ot think about in regards to capacity in delirum?
- Is the person capable of making decisions about their care? - Remember capacity decision specific
- Do they have a legally appointed proxy decision maker? - Welfare POA or guardian
Lots of people with delirium do retain capacity
4.5x more likely to ____ if have delirium
Delirium prevention interventions reduce _____ also
fall
falls
what is there an overdiagnosis of when dealing with delirum?
UTIs
Important in relation to delirium – often blamed on a UTI
UTI can cause delirium but no where near as much as we blame it to be
Prevalence of asymptomatic bacteriuria in older adults in Scotland:
So Doris who is a 90 year old woman falls into this group. So this means that if we cultured the urine of all the ladies in Doris’ care home almost 6 out of 10 would grow a bug and certainly they don’t all have UTIs
Number needed to harm – every third person that gets a pointless antibiotics course for asymptomatic bacteria rather an infection, you are causing harm to them
If dip urine and got leukocytes and nitrites you don’t need to start antibiotics
Carl:
Phonecall at 5pm on a Friday afternoon to GP from niece
Confused last few days
Had a fall
Worried about not being safe at home
Think he’s got a UTI
what would you do?
As the GP
Recognise this is an emergency and delirium is a serious health problem and risk so carl needs seen
would you admit him? homoe or hospital?
GP factors – experience, comfort level, resources
Patient factors – unwellness, degree of delirium, preferences
Family factors – what support, their views and ability to manage risk
Healthcare resource factors – what services available (in the community)
Go out and see him
Try and figure out the triggers
Need to think where he will be best cared for? – lots of different factors that change your decision about this
Are people needs treatment that is only available in hospital?
Making a decision about home or hospital is a very complex decision that if done wrong can cause lots of harm, often more harm is caused by admitting people to hospital
Carl – ARRIVES IN AMIA AT 11PM:
- Seen by FY1
- ‘poor historian, confused, smells of urine’
- Obs – HR 100, BP 100/60, T 36.4
- Looks dry, GCS 14/15, no focal neurology, abdo soft, tender lower abdomen
- Urea 22, Cr 220, CRP 200, Ca 2.7
- CXR – right basla consolidation
- Bladder scan – 700ml
what can you take form this information?
Bit tachycardic and a bit hypotensive
Right basal pneumonia
Urinary retention is a cause of delirium
Lots of delirium precipitants
Hypercalcaemia
Urinary retention is often precipitated
Carls drugs – what are you going to change?
- Zopiclone 7.5mg at night
- Furosemide 80mg
- Amitriptyline 10mg night
- Ramipril 10mg
- Bisoprolol 2.5mg
- Paracetamol 1g as required
- Tamsulosin 400mcg
Paracetamol is okay
Tamsulosin is for BPH so keep on that is BP allows it
may neeed to change rest as all have different effects
CARL – what are you going to do now?
- To drip or not to drip?
- How will you manage his urinary retention?
- How will you manage his pneumonia?
- What members of the MDT does he need to see ASAP?
1 – sometimes okay not to
2 – needs a PR examination and if constipated needs enema
3 – often not follow formula in geriatric, get a CGA
4 – geriatrician, nursing staff, physios, OTs
CARL – WHAT HAPPENS OVERNIGHT:
- Carl becomes very distressed, wanting to leave, tries to hit a member of staff who are stopping him
- You are the FY1 on overnight and you get a bleep as the nurse thinks he needs sedated
- What are you going to do??
Go in and diffuse the situation
Reassure the members of the team
Try distract carl
Junior doctor shouldn’t be the one making the decision about that if the other techniques don’t work
Carl:
•Next day much improved
- Remains disorientated
- E + D well
- Blood tests better
•Undergoes process of CGA
•Discussion with Carl and NOK about risks/benefits of remining in hospital – all agree home today with ACAH (acute care at home) input to offer support in his own home until delirium settles
