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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 Increased or Often normal
changes decreased
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