Transcript Delirium
THE CONFUSED OLDER PATIENT Sadia Ismail Consultant Geriatrician Aim and Learning Outcomes • Aim: • To provide a clinical approach to the confused older person • Learning Outcomes: • Identify risk factors for developing delirium • State how you would use the Confusion Assessment Method to assess patients • Employ a multi-factorial approach to assessing and treating delirium Case Study 1 • • • • • • 92 year old woman Diagnosis of dementia Flat redecorated whilst inpatient Upon return, agitated + + Fell, fractured tib/fib CIC bed Agitated, distressed in CIC bed • Identify causes / risk factors • What would you do? Case Study 2 •88 year old man •Mild dementia •Residential home resident •Carers concerned: • Sleepy, not interacting as usual • Not E&D much • No effect from antibiotics • GP Requesting hospital admission •What would you do? Age Group % Prevalence Males % Prevalence Females 60-64 0.4 0.4 65-69 1.6 1.0 70-74 2.9 3.1 75-79 5.6 6.0 80-84 11.0 12.6 85-89 12.8 20.2 90+ 22.1 30.8 Dementia and Delirium Dementia Breakdown in Social Circumstances Delirium Negative impact of Delirium Common ~ 30% of elderly inpatients Very common in the community 2/3 cases in patients with dementia •Increased mortality •More pressure sores, falls, infections etc •Longer hospital stay •More likely to require 24 hr care on discharge HOW DO WE ASSESS A CONFUSED PATIENT? Confusion Assessment Method •Acute onset and fluctuating course AND •Inattention AND EITHER •Disorganised thinking OR •Altered level of consciousness (eg stuporose) Inouye SK et al (1990) WHAT CAUSES DELIRIUM? And the Answer is … •A UTI?? • … Well yes, but not JUST their UTI! Channel your inner detective … •Literally ANYTHING could cause it •But the hallmark is multifactorial: •Predisposing factors •Precipitating factors Inuoye SK 2006 HOW DO WE TREAT DELIRIUM? Treatment •Treat any underlying causes found •“Good nursing care” – what does this consist of? Multi-interventional techniques • Aimed at prevention in those at high risk and relief of symptoms and distress • Environment • Lighting, regular orientation cues, hearing aids and glasses, good sleep hygiene, no irritating noises, continuity of nursing care, analgesia, mobility, family visits, rehydration, nutrition, treat pain, prevent constipation • avoid transfers, drugs or catheters Evidence – multi-interventional •Mainly focussed on prevention but similar principles for treatment •Cochrane review 2007 • 6 studies of prevention of delirium in surgical patients – 833 patients in total • 1 study in 126 pts with hip # - proactive geriatric consultation targeting 10 RF vs usual care • NNT to prevent 1 case delirium was 5.6 • No effect in duration, length of stay, cognitive status or institutional care on discharge Multi-interventional cont. • Inouye SK et al NEJM 1999 • 852 hospitalised patients > 70 yrs admitted to gen med • Intervention arm vs usual care • Protocols for assessment and management of 6 RF: • Cognitive imp, sleep deprivation, immobility, visual imp, hearing imp, dehydration • Delivered by MDT • Delirium 9.9% vs 15% [OR 0.6 (0.39-0.92)] • No. of days and episodes significantly less • Reduction in use of sleeping pills • Severity and recurrence rates not affected Pharmacological • Only for severe distress, or dangerous agitation when other interventions have been tried and been ineffective • One drug only, start low, increase slowly • Haloperidol 0.5mg PO preferred or • Lorazepam 0.5 – 1mg PO especially in PD • Atypical antipsychotics increase QTc and mortality • Trazadone – no robust evidence • Cholinesterase inhibitors – no evidence • Avoid anticholinergics Evidence - Pharmacological • Cochrane review 2007 • 3 controlled studies of haloperidol with risperidone, olanzapine or placebo • 2 looked at antipsychotics in treatment and 1 in prevention of delirium • Variety of assessment methods – CAM, DRS, MDAS • Antipsychotics shown to be effective in varying doses • Haloperidol, risperidone and olanzapine equally effective – data from first 2 studies only • High dose haloperidol associated with more a/e • Olanzapine/risperidone recommended but caution QTc and mortality • Cochrane review 2008 • No evidence for use of benzodiazepines in delirium • But evidence in ICU patients – likely to be younger patients NICE guidance 2010 CG 103 •Aimed at prevention in inpatients + treatment •Similar themes: • Person-centred care • Multi-interventional techniques • Pharmacological treatments a last resort • No mention of benzodiazepines – no evidence yet Patient experience • Delirium can be distressing and frightening • Hallucinations common • Fear of previously familiar things / people • Also very distressing for family • Many examples in literature: • Description of a delirious man in “The Stroller’s tale” (The Pickwick Papers by Charles Dickens) • Description of the life-threatening fever of Marianne Dashwood in Sense and Sensibility by Jane Austen • Description of distressing, disorientating, fluctuating delirium during illness with smallpox of Esther Summerson in Bleak House How quickly does Delirium Improve? a) b) c) d) A few hours? A few days? A few weeks? A few months? And the answer is … • ALL of the above! Case Study 1 • • • • • • 92 year old woman Diagnosis of dementia Flat redecorated whilst inpatient Upon return, agitated + + Fell, fractured tib/fib CIC bed Agitated, distressed Case Study 1 • Identify causes / risk factors Dementia Change of environment – redecoration, multiple moves Pain • What would you do? • What actually happened … Case Study 2 •88 year old man •Mild dementia •Residential home resident •Carers concerned: • Sleepy, not interacting as usual • Not E&D much • No effect from antibiotics • Requesting hospital admission Case Study 2 • Risk factors / causes Dementia Possible constipation A couple of disturbed nights sleep? Medications OK No real evidence of infection • What happened Case Study 3 •97 year old man •Well-supported by 2 daughters •Several delirious episodes: • Hyponatraemia • UTI • Constipation • Seizure activity QUESTIONS? Take Home Message •Delirium is very common •Serious consequences and complications •Confusion Assessment Method is a useful diagnostic tool •If recognised use a multi-factorial approach to management •Avoid changes in environment •Pharmacological treatments as a last resort THANK YOU