Roshan Gunathilake MD
John Hunter Hospital Newcastle, Australia
DELIRIUM IN THE WARD
Case scenario
You are the evening RMO. You have been asked to see a 84-year-
old man on D2 post-elective R/TKR. Nurses state that he is confused since
1800, spitting out his medications, yelling at the staff, and wandering in the ward.
Background
84-year-old man Lives with wife in a retirement village Independent in ADLs Admitted for elective R/ TKR
Background
Previous R/ PACI (2010) Mild cognitive impairment Hearing impairment Stable CAD Hypertension T2DM (metformin) OA Alcohol 1-2 Units/day
Medications
Aspirin Metoprolol Perindopril + indapamide Atorvastatin Meformin Vitamin D Temazepam Prophylactic SC heparin Regular paracetamol, PRN Oxycodone
Physical Examination
Agitated but cooperative Confused Disoriented Vitals P 104, BP 110/72, RR18, spO2 98 RA Chest clear Abdomen SNT No focal neurology, pupils normal Clean surgical wound No DVT
Questions
What is the likely diagnosis? What might be the cause? What are his risk factors? What investigations will you request? How will you manage him? What is his prognosis?
Delirium
Derived from Latin term meaning “off track”
Not a disease, but a syndrome with multiple causes that result in a similar constellation of symptoms
An acute syndrome characterized by altered attention, cognition and consciousness
May be the only sign of a serious medical illness in an older person
Clinical hall marks
1. Acute onset + Waxing and waning symptoms
2. ↓ Attention span3. Disorganized thinking4. Altered LOC
Incidence/ prevalence
Very common but is often not detected or misdiagnosed
Prevalence and incidence varies across patient populations and health care settingso Prevalent delirium 10 - 24% o Incident delirium up to 56%
among older hospitalized patients
Risk factors for delirium
advanced age dementia Hx of delirium neurological
damage functional
disability visual and hearing
impairment
polypharmacy psychoactive
drugs alcoholism multiple / severe
chronic medical conditions
dehydration depression
Precipitating factors
Metabolic – hypoxaemia, hypoglycaemia, electrolyte & acid-base derangements
Infective – urinary tract infection, pneumonia, CNS infection
Structural – Cerebrovascular event, urinary retention
Toxic – drugs (incl. withdrawal) or poisons Environmental – being in hospital or ICU,
physical restraints, bladder catheter, multiple procedures, surgery, pain
Medications known to cause delirium
Anticholinergics Antihistamines Narcotics Benzodiazepines Antiparkinson agents Digoxin Lithium Steriods
Risk factors & precipitating factors
Moderate to high risk
Very High Risk
Low risk Moderate to high risk
Low High
High
Vulnerability
Level of insult
Inouye SK, Charpentier PA, Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275(11): 852-7
Clinical features
Fluctuation of symptoms Clouding of consciousness Cognitive deficits (disorientation,
inattention) Psychomotor abnormalities:
floridly agitated, hyperactive drowsy, hypoalert, quiet (Hypoactive delirium)
Sleep–wake cycle disturbance Perceptual & thought disturbances (e.g.
misinterpretations, illusions, hallucinations)
Diagnosis
Clinical features Collateral history Medication review Focused physical exam CAMI
Several instruments for evaluating delirium are available.
The Confusion Assessment Method (CAM) is used widely
It has reported sensitivity > 94% and specificity > 90%
Further Investigation
FBC EUC, Ca++, LFTs Random BSL ECG, cardiac enzymes CXR Urinalysis Brain imaging, CSF Drug levels
Differential diagnosis
Dementia Depression Psychotic illness Sun downing
FEATURE DELIRIUM DEMENTIA
ONSET Acute GradualDURATION Hours – weeks Months – years
COURSE Fluctuating Progressive deterioration
CONSCIOUSNESS Impaired NormalPERCEPTUAL
DISTURBANCECommon Occurs in late
stagesSLEEP-WAKE CYCLE Disrupted Usually normal PROGNOSIS Potentially
reversible Not reversible
PRIMARILY AFFECTS Attention Memory MEDICAL EMERGENCY? Yes No
Management of delirium
Delirium is best managed by clinicians with expertise in delirium management, and in most cases should involve a multidisciplinary team.
Components of delirium Mx
1. Identify the cause where possible2. Correct the cause / precipitating
factors3. Manage the symptoms of delirium4. Provide a supportive care environment5. Prevent complications6. Educate the patient and their carers
Non-pharmacological management: Environmental Calm, comfortable environment Lighting appropriate to time of day Orientation cues – clock, calendar Familiar objects or photographs from home Encourage family and carer involvement Remove hazards : low bed, secure facility Avoid restraints (aggravate delirium,
increase injuries ) Avoid room changes
Non-pharmacological management: Nursing care-based Use of staff with training in delirium care One-on-one nursing where relevant Same staff members to care for the
patient during and across shifts Minimize sensory deprivation Validation and reality orientation
strategies Providing relaxation strategies to assist
with sleep.
Multicomponent Mx of delirium symptoms
Pharmacological interventions
Cease/ ↓ drugs that cause delirium Manage discomfort or pain Regulation of bowel function Drug therapy is reserved for patients
who are at risk of harming self /others
Pharmacological interventions Understudied area, with only a
limited number of small trials; Very few data comparing different drugs
Even drugs that are used to treat delirium, particularly if given in excess, can prolong or worsen delirium.
Pharmacological interventions: antipsychotics
Antipsychotics are generally the 1st line (except in delirium tremens)
Start low and go slow (e.g. haloperidol 0.5 mg, risperidone 0.5 mg or olanzapine 2.5 mg)
Titrate dose, review periodically, monitor for oversedation
No clear evidence that atypical antipsychotics are more effective > typical
But have fewer extrapyramidal side effects
Pharmacological interventions: benzodiazepines
Benzodiazepines are the treatment of choice for delirium tremens & delirium associated with benzo- withdrawal
Geriatric patient populations are at greater risk of developing complications from benzo- use
Long acting benzo-s, in particular, have been shown to increase the risk of delirium.
Prognosis
Delirium is associated with ↑adverse outcomes:
o Mortalityo Hospital mortality 25 - 33%o independent marker for mortality <
12 months after discharge (HR 2.11) o length of stay (x2)o Complications : falls, bed sores,
incontinence o Cognitive and functional declineo Nursing home admission
Course
Delirium may be very persistent. Unresolved delirium:
60% after 1 week 20% after 2 weeks 15% after 4 weeks 5% persists >4 weeks
Inattention, memory impairment and disorientation may be still present at up to 12 months.
Prevention strategies
Reorient and mobilise the patient Reduce sensory deprivation Ensure the patient is hydrated Implement a non-pharmacologic sleep
regimen Limit catheters and restraints
Summary
Delirium is a common medical emergency, with ↑morbidity and mortality rates, affecting elderly.
Risk for delirium should be assessed in all older persons admitted to a health care setting.
Timely diagnosis, multicomponent intervention and judicious use of medications can improve outcomes.
Antipsychotics are reserved for patients with severe behavioral and psychological symptoms.
References
1. Caplan G. Managing delirium in older patients. Aust Prescr 2011;34:16–18)
2. Inouye AK. Delirium in older persons. NEJM 2006;354: 1157-65
3. Australian Society for Geriatric Medicine; Position Statement No.13 : Delirium in Older People (2005)
4. Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines for the Management of Delirium in Older People. (AHMAC 2006)
5. Inouye SK, Charpentier PA, Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275(11): 852-7