delirium in the acute hospital dr louise allan clinical senior lecturer and honorary consultant...
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Delirium in the acute hospital
Dr Louise AllanClinical Senior Lecturer and Honorary Consultant
Geriatrician
British Geriatrics Society
What is delirium?
• Acute brain failure
• It can be acute without previous brain failure
• It can be recurrent
• Acute on chronic (previous chronic brain failure aka dementia)
• It can lead to chronic brain failure
What is delirium? DSM IV criteria
• Disturbance of consciousness (ie, reduced clarity of awareness of the environment) occurs, with reduced ability to focus, sustain, or shift attention.
• Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) occurs that is not better accounted for by a preexisting, established, or evolving dementia.
• The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.
• Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.
What is delirium?• Change in consciousness or alertness• Change in cognition
– Memory– Thinking– Perception (the senses)– Behaviour
• It happens over a short period• It goes up and down• It is usually caused by a physical illness
Behaviours
• Just “more confused”
• Poor attention- can’t give a history
• Looks around the room
• Agitated, plucking at bed clothes
• Hallucinating
• Very quiet or drowsy
• Reduced ability to care for self
• Loss of mobility
Why is it important?
• It is often not diagnosed• A common problem• Increased length of stay and complications• Poor outcomes- mortality, admission to care
home • It often takes a long time to get better• It doesn’t always get better
Why is it important?
• It can be prevented
• It can be treated
• If it does happen, good care will shorten the duration
• Good communication reassures and also provides realistic expectations
• Good practice saves money
How common is it?
• Delirium is common in acute hospitals e.g.– 22% in general medicine– 28% acute orthopaedics– 80% medical ICU
Who gets delirium?Anyone!
• Age over 65• Dementia• Frailty• Sensory impairment
• Severe illness• Recent surgery/
fracture• Drugs• Alcohol
• Pain
• Infection
•
Constipation
• Hydration
• Medication
•
Environment
What are the most common causes?
How is it diagnosed?Short Confusion Assessment
Method
1. Acute onset or fluctuating course
AND
2. Inattention
AND EITHER
3. Disorganised thinking/ incoherent speech
OR
4. Altered level of consciousness
Other features
– Memory impairment– Disorientation to time, place or person– Agitation e.g. the patient is repeatedly pulling at her
sheets and IV tubing – Retardation – Visual or auditory misinterpretations, illusions, or
hallucinations– Change in sleep wake cycle e.g. excessive daytime
sleepiness with insomnia at night
How is it prevented?
The environment:
• Hearing aids • Spectacles • Orientation aids• Lighting• Encourage food and fluid intake• Encourage mobility• Maintain sleep pattern • Involve relatives and carers
Avoid:
• Constipation• Catheters• Restraint• Sedation• Bed or Ward moves • Arguing with the
patient
How is it treated?
• Treat infection• Correct metabolic abnormalities• Correct hypoxia• Review medication but ensure adequate
analgesia• Many episodes of delirium are
multifactorial• Treat all the underlying causes
After delirium
• Frightening experience
• Post traumatic stress
• Embarrassment
• Need for reassurance
• Need for information
• Need for recognition of dementia after delirium
What are we up against?
• Culture
• Lack of training
• Competition from other patient safety initiatives