Delirium Case Presentation

Case

93 ♂

PC 4/7 Confusion, agitation + general

deterioration 3/7 poor urine output

PMH

BPH Long term catheter in situ MI

DH

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

SH

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

O/A

Temp 35.8 Dehydrated GCS 13/15 AMTS 7/10 Urine

offensive odour Dip +ve blood, leukocytes, nitrites

Bloods

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

Diagnosis

Acute confusion UTI Hyponatraemia

Ciprofloxacin 5/7 Omeprazole + betahistine stopped

Day 2

GCS 7/15

CT Brain Small vessel ischaemia No evidence of space occupying lesion,

intracranial haemorrhage or skull #

CRP 46

After 2/52

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

Delirium

Derived from Latin ‘off the track’

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

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

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

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

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

Risk factors in elderly

Age >80 Extreme physical frailty Multiple medical problems Infections (chest + urine) Polypharmacy Sensory impairment Metabolic disturbance Long-bone # General anaesthesia

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

Causes

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

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

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

NICE Guidelines

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, U+Es, BM, LFTs, TFTs, B12, MSU, CXR

3. Rule out EtOH withdrawl 4. Assume an underlying organic

cause

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

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

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

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

Medications

Dementia with Lewy Bodies Severe reactions to antipsychotic drugs

that can lead to death Due to extrapyramidal effects

Urgent psychiatric opinion

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

Complications

Malnutrition Aspiration pneumonia Pressure ulcers Weakness, decreased mobility,

decreased function Falls, #s

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

RUH Algorithm for diagnosis + management of delirium in older adults