management strategies for patients with delirium, both postoperative and in the ed: ensuring best...
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Management of Delirium,
Postoperative Adjustment
Disorders and Depression
following Hip Fractures
Dr H. Anderson
Consultant Psychiatrist
MBBS, M.Psych, FRANZCP
Delirium Aetiology
� Brain insult;
� Systemic disease
� Central nervous system disease
� Intoxication/withdrawal
� Involves dysfunction of reticular formation and
acetlycholine transmission
Why is Delirium Important?
� Adversely effects rates of post hospitalisation mortality
� May lead to functional decline
� And…especially in elderly may lead to nursing home
placement
Delirium
� DSM-IV-TR diagnostic criteria
� Disturbed consciousness, reduced ability to focus, sustain, shift
attention
� Change in cognition (memory deficit, disorientation, language
disturbance), development of perceptual disturbance
� Develops over short period of time(hours to days), fluctuating
during course of day
� Evidence from history, examination and laboratory workup that
disturbance is caused by physiological consequences of a general
medical condition, substance induced, substance withdrawal,
multiple etiologies
Clinical Features
� Onset – usually acute
� Disorientation and confusion
� From alert/awake/no disruption through to drowsiness and stuporous or
comatose periods
� Fluctuation – sleep-wake cycle disturbance and nocturnal exacerbation.
� Cognitive deficits
� Mild inattention to severe and diffuse cognitive deficits affecting
orientation, registration, recall and concentration
� Intermittent misperceptions, illusions, macropsia and micropsia
� Depersonalisation and derealisation
Clinical Features
� Hallucinations esp. visual, tactile, olfactory, gustatory
� Auditory too but these commonly occur in other conditions so less discriminatory
� Delusions – usually poorly formed, typically paranoid and sometimes resulting from misperceived environmental cues
� Perplexity and apathy
� Labile mood – from normal to fear, agitation, tearfulness, laughter, crying
� Psychomotor behaviour - hyperactive vs hypoactive types (from severe agitation/combativeness to withdrawal)
� Presence of a potential underlying physical disorder
Causes
� Metabolic
� Systemic
� Central nervous
system
� Haematological
� Renal
� Hepatic
� Endocrine
� Substance/medication induced
� Multiple aetiologies
� Not otherwise specified
� Etc., etc., etc.
Risk Factors
� Age
� Cognitive Impairment
� Visual Impairment
� Severe Illness
� Dehydration
� Physical Restraints
� Malnutrition
� Bladder Catheter
� Addition of >3 Medications
whilst in hospital
History
� Surgical and medical
� Medications (pre-operative and post-operative)
� Drug and alcohol
� Psychiatric
Delirium vs. Dementia
Examination
� General, including neurological
� Vitals – Blood pressure, temperature, pulse, oxygen
saturation
Investigations
Delirium Rating Scales
� The 10 item delirium rating scale by Trzepacz et al which
was updated in 2000 to 16 item version which offers
increased flexibility and breadth of symptom coverage
� CAM (Confusion Assessment Method) – Based on DSM-III.
It has high positive predictive accuracy in recognising
delirium. Also has a shorter version which can be
administered to intubated patients and doesn’t require
verbal responses (sensitivity and specificity of this is
comparable to the standard version)
Management
� Emergency department, medical/surgical wards,
intensive care unit
� Collateral from chart, staff and family
� Usually involve consultation liaison psychiatry
� Mini mental state examination, other psychological tests
Behavioural Interventions
� Frequent assessment required due to fluctuating nature
� Optimise hearing, vision and sensory inputs
� Reassurance
� Reorientation – clocks and calendars
� Optimise sensory environment
� Minimise environmental stimuli – startle easily, keep it constant. Avoid sensory overstimulation and deprivation
� Photos and familiar objects in room
Behavioural Interventions
� Familiar staff – hard given staff changes
� Information/explanation to patient and visitors – Keep it simple though
� Physical restraint rarely required
� 1:1 staffing, psychiatric “special”
� Wanderers bracelet/alarm
� Post delirium education and reassurance to patient and family
Biological Interventions
� Investigate and treat underlying cause e.g. pain requires analgesia
� Correct metabolic and electrolyte abnormalities
� Hydration and nutrition
� Reduce/rationalise medications – Beware those with strong anticholinergic activity (e.g. chlorpromazine, tricyclics etc.)
� If known cause e.g. alcohol withdrawal then implement diazepam as per alcohol withdrawal scale + thiamine and multivitamins
Biological Interventions
� Pharmacological treatment particularly for psychosis and
insomnia
� Low doses of high potency antipsychotic for agitation
� Haloperidol 2-5mg o/IM QID
� Oral dose is 1.5x the parenteral dose
� Total daily dose 5-40mg
� Atypical antipsychotics
� Olanzapine, Quetiapine, Risperidone
� Best to use Quetiapine, Clozapine in patients with
Parkinson’s as least likely antipsychotics to exacerbate
symptoms
Biological Interventions
�Monitor for side effects and titrate as
appropriate
� Benzodiazepines o/IM for agitation esp. if
seizures, alcohol related. Also beneficial for
insomnia
� Use short to intermediate half life
benzodiazepines e.g. Lorazapam 1-2mg nocte
� Neuroleptics and benzodiazepines can
exacerbate delirium
Course/Prognosis
� Course usually rapid
� Symptoms usually recede 3-7 days after underlying cause is treated
� Symptom resolution may take longer especially in elderly
� May be followed by depression or post traumatic stress disorder
� At risk of subsequent delirium episodes
� Delirium increases risk of functional decline and death
Adjustment Disorder
� One of the most common psychiatric disorders in
hospitalised surgical and medical patients
� Psychological stress
� Difficulties with adjustment
� Up to 50% of persons with medical problems/stressors are
diagnosed with an adjustment disorder
� Patient’s emotional response to a stressful event i.e. the
fracture and its treatment
Adjustment Disorder
� May involve symptoms of depression, anxiety or disturbed
conduct
� Influence of personality, culture, social circumstances,
psychodynamic, family and genetic factors
� Usually begin within three months of the stressor and remit
within 6 months after its removal
� Poor subjective health, pain, disability, increased
distance from usual supports and familiar environment
can be stressful
Adjustment Disorder Treatment
� Individual psychotherapy
� Explore the meaning of the stressor and work through earlier traumas
� Help to adapt to stressor
� Beware of secondary gain for the patient – illness role may be rewarding for some and exempt them from roles and responsibilities
� Pharmacotherapy
� Usually used to augment psychosocial strategies
� Antidepressants – esp. Serotonin Selective Reuptake Inhibitors e.g. sertraline
� Anxiolytics – e.g. benzodiazepines for brief periods only
� Antipsychotics – usually an atypical if decompensating, impending psychosis
Mood Disorder: Depression
� Often adjustment disorders can become depressive illnesses (secondary depression)
� May be a reaction to the fracture
� Can affect self-esteem, independence, work capacity, relationships, social interactions, living arrangements, compliance with medication, treatments and follow-up
� Mortality in depressed medical inpatients is higher
� Difficulties in diagnosis – overlap of symptoms. Difficulties in differentiating between physical and psychiatric causes
Treatment
� Consider the patient’s safety
� Psychosocial therapies
� Cognitive, behavioural, interpersonal, psychoanalytic
� Pharmacological therapies
� As per those used for adjustment disorders mentioned
previously
Benefits of Recognition and
Treatment
� Improved mental health and self esteem may increase
capacity to cope/adjust following the fall/operation
� Reduced dependence/reliance on others
� Reduced use of medical services, unnecessary
investigations, prolonged admissions and possibly
residential care placement
Role of Consultation Liaison
� Team of psychiatrists, registrars and nurse able to provide
input to wards
� Support
� Education
� Provision of screening tools
� Recommendations for treatment and follow-up
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