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
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
