The Prevention, Assessment and Management of Delirium

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The Prevention, Assessment and Management of
Delirium Dr Nicholas Waldron Advanced Geriatric
Trainee
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First Questions to start

• What drug is first line if required to treat
  delirium
• 1. Risperidone
• 2. Lorazepam
• 3. Diazepam
• 4. Haloperidol
• 5. Olanzepine

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Second Question

• What oral dose would you use ?
• 1. 0.25mg
• 2. 0.5mg
• 3. 1mg
• 4. 5mg
• 5. 10mg

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Last Question

• You are called as a patient is becoming agitated,
  what would you do ?
• 1. Ask nurse to manage nonpharmacologically and
  contact if ongoing problem
• 2. Administer Haloperidol on phone order
• 3. Assess patient medically
• 4. Recommend call psych services
• 5. Call on-call medical registrar

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• Overview of Delirium
• Prevention
• Assessment
• Management

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Why delirium

• Few ill health situations are more degrading to
  people of any age than loss of reasoning,
  faculties, and personhood. These are the
  unpleasant consequences of delirium a common
  condition affecting ill older people,
  particularly those with some degree of dementia.
  
• Young and Inouye, BMJ, 2007

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Delirium is common

• Arrive at hospital with delirium (prevalent)
  10-15
• Develop during hospital stay (incident) 5-40

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Importance

• Increased length of stay, increased mortality and
  increased risk of institutional placement
• Hospital mortality rates of patients with
  delirium range from 6 to 18

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Under-recognised and Misdiagnosed

• RPH, 30 incidence, 50 recognised (CAM day)
• 0.11 delirium recorded as Primary diagnosis 2006
• Fremantle 11 incidence, 35 recogntion rate
  (notes audit)
• hypoactive are overlooked
• misdiagnosed as depression
• lack of awareness or understanding of health and
  ageing

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PREVENTION

• Excellent nursing care is the cornerstone.
• Addressing Modifiable risk factors.
• 1)Cognitive impairment
• 2) Sleep deprivation
• 3) Immobilisation
• 4) Vision impairment
• 5) Hearing impairment
• 6) Dehydration

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ASSESSMENT

• Screening Identify people at risk and improve
  recognition
• Diagnosis CAM method
• Finding the cause with medical and medication
  review often multifactorial

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Assessment - Clinical Moments

• You feel frustration assessing your patient
• Patient labelled poor historian or acopic
• Sleeping with mouth open
• Nursing staff note confusion or report agitation
• Altered sleep wake cycle
• Overnight - prescribed haloperidol by telephone
  order
• Cant be discharged due to functional decline,
  referring for ACAT for high level cares
• AMTS lt 8, MMSE lt24

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Diagnosis requires

• Knowing patients baseline cognitive function
• Appreciating fluctuations
• Appreciating what is happening at night
• Recognising the behaviours above as likely
  representing delirium

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Confusion Assessment Method

• The CAM was specifically designed for use with
  the hospitalised older person, to improve
  delirium identification and recognition
• sensitivity and specificity varies, 70 -100 and
  84 -100
• Delirium is the default diagnosis

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Using the CAM

• Formal cognitive testing
• Collateral history

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Diagnosis of Delirium

• Acute onset and fluctuating
• Disturbance in attention
• Altered consciousness
• Disordered thinking
• diffuse process

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Other Features

• DISORIENTATION
• MEMORY IMPAIRMENT
• PERCEPTUAL DISTURBANCE - hallucinations,
  misinterpretations
• DECREASED MOTOR ACTIVITY - sluggishness, staring
  into space..
• INCREASED MOTOR ACTIVITY - restlessness, picking
  at bedclothes
• ALTERED SLEEP WAKE CYCLE

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Differential

• Delirium
• Acute onset
• Inattention
• Consciousness
• Speech

• Dementia
• Insidious
• Memory loss
• Cognitive deficits

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What causes Delirium
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Finding the cause

• Medical review History, Examination,
  Investigations
• Medications review occult use

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Examination

• Vitals
• Infection
• Neurology
• Bladder scan
• PR

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Investigations

• Full blood count
• C Reactive Protein
• Urea and electrolytes
• Calcium
• Liver function tests
• Glucose
• Blood cultures
• Chest X-ray
• ECG
• Dipstick (if abnormal) /- MSU

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MANAGEMENT

• Treating the causes The cornerstone of
  management
• Support and Prevent complications
• Managing symptoms with Non pharmacological
  measures
• Consider whether drug therapy is indicated

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Non- Pharm Treatment Strategies

• Patient oriented
• Trained support person
• validation and reality orientation strategies
• family visits
• Regular staff
• Utilising Interpreters
• Regular analgesia
• Discourage daytime sleeping
• Manage constipation.
• External factors
• Reduce or eliminate restraints
• Reduce invasive equipment (IV lines, IDC etc)
• Avoid anticholinergic drugs
• Eliminate extraneous noise (e.g. pump alarms).
• Schedule treatments and observations

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Environment

• Lighting appropriate to time of day
• Provision of single room where possible
• Quiet environment especially at rest times
• Provision of clock and calendar that clients can
  see
• Encourage family and carer involvement
• Avoid room changes where possible

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Pharmacology Guide

• INDICATIONS
• In order to carry out essential investigations or
  treatment
• To prevent patient endangering themselves or
  others
• To relieve distress in a highly agitated or
  hallucinating patient

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Practice points

• Aim to use one drug, least invasive
  administration
• Keep doses to a minimum, increment 2 hourly
• Use antipsychotic First Line
• Avoid escalating doses
• Seek advice
• Review prescription every 24hours

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The Future of Aged Care