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Alasdair MacLullich
Professor of Geriatric Medicine
Consultant in Geriatric Medicine
University of Edinburgh
What is delirium?
Severe, acute neuropsychiatric syndrome
Cognitive impairments
Reduced or increased level of consciousness
Psychotic features are common
Resolves in 80%
Mainly affects older people in hospital
Delirium is common and serious
>120 patients per 1000-bedded hospital
1 in 5 dead in a month
New institutionalisation
Strong marker of dementia
Accelerates existing dementia; linked with new onset
dementia
Distressing
High healthcare and social costs
Yet …
Only 20-25% detected
Generally poorly managed
Core features
Acute onset/fluctuating course
Inattention
Additional features
Altered alertness (eg. drowsiness)
Other cognitive deficits, eg. in memory
Poor comprehension
Psychotic features
Sleep-wake cycle disturbance
Delirium: many formal and informal terms
Creates problems: imprecision
Delirium and dementia get mixed up
‘Delirium’ triggers specific actions
‘Cognitive impairment’, ‘confusion’ usually don’t
best to use the term ‘delirium’
Draft pathway states: local tools
Most sites don’t have delirium screening implemented
The 4AT being used in some sites: www.the4AT.com
What method should be used for detection?
Looking for causes 1: acute, severe illness
If delirium suspected, treat as a medical emergency
(1 in 5 are dead in one month)
Nursing / medical input early
ABC
Pulse / BP / RR / saturations / temp / BM / check drugs
Looking for causes 2: general assessment
Standard history and examination, +
FBC, U&E, Ca, LFTs, glucose
CRP
TFTS
ECG/CXR
ABGs
Urinalysis/MSU
CT head / MRI (if head injury or focal neurological
signs or if persisting delirium after 5 days)
Looking for causes 3: drug review
Opioids
Benzodiazepines
Antipsychotics
Amitriptyline
Anti-spasmodics, eg. oxybutinin, buscopan
Anti-epileptics when not used for epilepsy, eg
carbamazepine
Anti-histamines eg cetirizine
Anti-hypertensives (when causing hypotension)
Informant history
Mental status change:
Onset, duration, fluctuating?, character
Helpful in detecting BPSD
Also to detect previously undiagnosed dementia
Drug/alcohol use
Activities of daily living
Personality, preferences, etc.
Treat causes
Infections
Drugs
Other acute illnesses
Pain
Drug effects
Drug and/or alcohol withdrawal
Etc.
Non-pharmacological
look for acute cause (pain, thirst, hunger, urinary retention)
repeated orientation
reassurance
avoidance of confrontation
avoidance of physical contact (can be perceived as assault)
Pharmacological
haloperidol 0.5mg 20-30 min intervals
risperidone 0.25mg nocte
consider lorazepam 1mg, but SECOND LINE (PD, DLB, BDZ/EtOH
w/d)
Treating agitation & distress
General care
Provide calm environmental & personal orientation
Hearing aids, glasses
Oxygen, hydration, nutrition
Treat pain
Avoid constipation (treat if in doubt)
Do not catheterise unless necessary
Observe sleep pattern, correct if possible
Involve relatives & carers
Specialist referral
In 5 days if delirium persisting, sooner if delirium is
severe
Liaison psychiatry or geriatric medicine
Assessment of possible dementia
Cognitive testing if delirium resolved
IQCODE
Follow-up by GP or specialist clinic