Delirium Case Presentation

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Delirium Case Presentation
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Case

• 93 ?
• PC
• 4/7 Confusion, agitation general deterioration
• 3/7 poor urine output

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PMH

• BPH
• Long term catheter in situ
• MI

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DH

• Omeprazole 20mg po od
• Betahistine 8mg po om
• Aspirin 75mg po om
• Calcichew D3 forte

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SH

• Lives with wife
• No carers
• Independent around house
• Enjoys doing crosswords
• Recent falls

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O/A

• Temp 35.8
• Dehydrated
• GCS 13/15
• AMTS 7/10
• Urine
• offensive odour
• Dip ve blood, leukocytes, nitrites

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Bloods

• WCC 14.1
• Neut 9.7
• Hb 12.0
• Na 126
• K 4.4
• Urea 3.8
• Creat 78
• CRP 10

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Diagnosis

• Acute confusion
• UTI
• Hyponatraemia
• Ciprofloxacin 5/7
• Omeprazole betahistine stopped

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Day 2

• GCS 7/15
• CT Brain
• Small vessel ischaemia
• No evidence of space occupying lesion,
  intracranial haemorrhage or skull
• CRP 46

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After 2/52

• GCS 15
• AMTS 10/10
• A/W discharge home
• Prophylactic trimethoprim

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Delirium

• Derived from Latin off the track

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Delirium

• Transient global disorder of cognition
• Medical emergency
• Affects 20 patients on general wards
• Affects 30 of elderly medical patients
• Associated with increased mortality, increased
  nursing, failed rehab and delayed discharge

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Presentation

• Acute relatively sudden onset (over hours to
  days)
• Decline in attention-focus, perception and
  cognition
• Change in cognition must not be one better
  accounted for by dementia
• Fluctuating time course of delirium helps to
  differentiate

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Characterised by

• Disorientation in time, place /- person
• Impaired concentration attention
• Altered cognitive state
• Impaired ability to communicate
• Wakefulness insomnia nocturnal agitation
• Reduced cooperation
• Overactive psychomotor activity irritability
  agression

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Diagnosis

• Cannot be made without knowledge of baseline
  cognitive function
• Can be confused with
• 1. dementia irreversible, not assd with change
  in consciousness
• 2. depression
• 3. psychosis may be overlap but usually
  consciousness cognition not impaired

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Differentiating features of delirium and dementia
Features Delirium Dementia
Onset Acute Insidious
Course Fluctuating Progressive
Duration Days weeks Months - years
Consciousness Altered Clear
Attention Impaired Normal (unless severe)
Psychomotor changes Increased or decreased Often normal
Reversibility Usually Rarely
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Risk factors in elderly

• Age gt80
• Extreme physical frailty
• Multiple medical problems
• Infections (chest urine)
• Polypharmacy
• Sensory impairment
• Metabolic disturbance
• Long-bone
• General anaesthesia

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Risk factors

• Dementia is one of the most consistent risk
  factors
• Underlying dementia in 25-50
• Presence of dementia increases risk of delirium
  by 2-3 times

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Causes

• Severe physical or mental illness or any process
  interfering with normal metabolism or function of
  the brain

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Causes mnemonic

• Infections (pneumonia, UTI)
• Withdrawl (alcohol, opiate)
• Acute metabolic (acidosis, renal failure)
• Trauma (acute severe pain)
• CNS pathology (epilepsy, cerebral haemorrhage)
• Hypoxia
• Deficiencies (B12, thiamine)
• Endocrine (thyroid, PTH, hypo/hyperglycaemia)
• Acute vascular (stroke, MI, PE, heart failure)
• Toxins/drugs (prescribed tramadol, dig toxicity,
  antidepressants, anticholinergics,
  corticosteroids) recreational)
• Heavy metals

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Pathophysiology

• Not fully understood
• Main theory reversible impairment of cerebral
  oxidative metabolism neurotransmitter
  abnormalities
• Ach anticholinergics cause of acute
  confusional states Pts with impaired
  cholinergic transmission (eg Alzheimers) are more
  susceptible
• Dopamine excess dopamine in delirium
• Serotonin increased in delirium
• Inflammatory mechanism cytokines eg
  interleukin-1 release from cells
• Stress reaction sleep deprivation
• Disrupted BBB may cause delirium

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NICE Guidelines
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Management

• 1. Identify treat underlying cause (return to
  pre-morbid state can take up to 3 weeks)
• 2. Complete lab tests investigations eg. FBC,
  CRP, UEs, BM, LFTs, TFTs, B12, MSU, CXR
• 3. Rule out EtOH withdrawl
• 4. Assume an underlying organic cause

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Management

• 5. Ensure adequate hydration nutrition
• 6. Use clear, straightforward communication
• 7. Orientate the patient to environment
  frequent reassurance
• 8. Identify if environmental factors are
  contributing to confused state

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Management

• Disturbed, agitated or uncooperative patients
  often require additional nursing input
• Medication should not be regarded as first line
  treatment
• Consider medication if all other strategies fail
  but remember all psychotropic meds can increase
  delirium confusion

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Medications

• Benzodiazepines
• Lorazepam 0.5-1mg tds orally
• Shorter half life than diazepam effective at
  lower doses
• S/E - Respiratory depression, increased risk of
  falls, hypotension
• Not for long term use

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Medications

• Antipsychotics
• Avoid in PD
• Haloperidol 0.5-1mg
• S/E cardiac, avoid in patients with
  hypotension, tachycardia arrhythmias,
  extrapyramidal
• Recent evidence suggests not to use in patients
  with dementia or risk of CVD due to increased
  risk of cerebral ischaemia
• 3X increase in risk of stroke when Risperidone
  used in older patients with dementia

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Medications

• Dementia with Lewy Bodies
• Severe reactions to antipsychotic drugs that can
  lead to death
• Due to extrapyramidal effects
• Urgent psychiatric opinion

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Medication

• Review regime every 48h
• Will not improve cognition
• Can reduce behavioural disturbance
• Start with lowest dose possible increase
  gradually
• Offer orally first
• Use as fixed dose regime

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Complications

• Malnutrition
• Aspiration pneumonia
• Pressure ulcers
• Weakness, decreased mobility, decreased function
• Falls, s

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Outpatient Care

• Memories of delirium are variable
• Educate patient, family carers about future
  risk factors
• Elderly patients can require at least 6-8 weeks
  for a full recovery
• For some patients the cognitive effects may not
  resolve completely

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RUH Algorithm for diagnosis management of
delirium in older adults