Delirium – a brief guide for nurses

Alicia Massarotto

Geriatric Advanced Trainee

2008

What this talk will cover

• Definition

• Risk factors

• Causes

• How to identify

• How to treat

• How to manage

• Some pictures of Cirque du Soleil

What is Delirium?

• Rapid onset of impairment and fluctuation

in CONCENTRATION• Altered CONSCIOUSNESS• Impaired COGNITION

How many people get it?

• 10-24% of older adults at time of admission to hospital

• 56% of older adults have an episode of delirium during hospital admission

Who gets it?-risk factors

• Hx of dementia (3x) • visual impairment(3x)• multiple or severe

medical problems(3x)• multiple meds• hearing impairment

•neurological damage•functional disability•advanced age•alcohol dependence•depression

These factors multiply rather than add to risk of developing delirium

When do they get it? - • acute illness

• dehydration

• infection

• U&E disturbance

• low O2, high CO2

•heart failure•liver failure•renal failure•CVA

When do they get it? II

• addition of >3 new meds

• low BSL

• pain

• restraint use

• immobilisation

• catheter

•alcohol withdrawal•benzodiazepine

withdrawal•cardiac surgery•orthopaedic surgery

A special note on medications

• They contribute up to 40% of cases

• older people have decreased renal excretion and hepatic metabolism

• drugs of concern:• antipsychotics• anti-convulsants• corticosteroids• opiates• NSAIDS

•anticholinergics•antiparkinsons•benzodiazepines•antidepressants

Why do they get it?

– Nobody really knows– Likely chemical imbalances caused by

stress/inflammation/medications or combination thereof.

What does it look like?

• “pre-delirium”: irritable, bewildered, evasive.

• Lucid periods

• evening + night

• distractible or inert

•disorientation in time•short-term memory loss•rambling, incoherent speech•paranoid delusions•visual hallucinations

distractible or inert?• Hyperactive delirium

– 30%– repetitive behaviour -

plucking at sheets– wandering– hallucinations– aggression

• Mixed -45%

•Hypoactive delirium–25%–quiet + withdrawn–looks like depression

How do we detect it?

• 30-60% not diagnosed!

• Cognitive assessment “a vital sign”

• formal tool:– Confusion Assessment Method (CAM)\

• Look for decreased concentration

• Seek history from family/friends of a sudden change in behaviour

What should you assess?• Basic observations –

– fever, hypoxia, hypotension, brady or tachycardia

• Sensory Impairment – – are they blind? Where are the hearing aids?

• Are they constipated?

• Urine dipstix

• BSL

What should the doctor assess?

• Use clinical picture to guide

• Full physical exam

• Blood tests:– FBC,U&E,Glucose,Ca,LFT’s,Trop,TFTs

• Investigations– MSU, CXR, Head CT, (LP, EEG)

How do we treat it?

• Treat risk factors and precipitants!!!!!

How do we treat while we wait for the definitive treatments to

work?

Non- pharmacological• encourage adequate fluids• glasses, hearing aids• quiet rooms, well lit• re-orientation - clocks, calendars• personal items• encourage self-care and mobility• avoid frequent staffing changes• avoid catheters, iv lines• Guard/PCA/Companion

Pharmacological

• stop the baddies if possible

• only use when patient is distressed, or is a danger to themselves or others

• use small amounts

• be acutely aware of side-effects - including INCREASE in agitation

• dose regularly. Times should coincide with distressing behaviour

What agents to use?

• Haloperidol• not much postural hypotension• lots of extrapyramidal/ or PARKINSONIAN side effects -

rigidity, tardive dyskinesia• DON’T give to patients with hx Parkinson’s

• Atypical anti-pyschotics• Olanzapine, Quetiapine, Risperidone• still some EP problems, also in diabetic patients

• Benzodiazepines• mainly for ETOH withdrawal• often make delirium worse otherwise

How long does it last?

• Can be for a long time!

Is it really that bad?

• Doubles length of stay

• 3X relative risk of developing dementia

• increases falls, incontinence and pressure areas

• in hospital mortality of 25-33%

• increased risk of ongoing clinical depression

How do we prevent it?• Identify high risk patients• Do cognitive assessment as routine• reduce bad drugs• maintain adequate analgesia• maintain U&E’s, Oxygenation, etc• try not to move patients• use the same nurse if possible• familiar things - pictures from home, clothes,

books

What you need to remember about delirium

• Confusion with altered Concentration + Consciousness

• Lots of Risk factors – dementia and blindness• Look for and treat underlying causes• Get history from family/friends• Avoid iv lines, catheters, changing rooms• Try familiar items, companions• Remember sedatives can make it worse!

Oh, and this Cirque du Soleil production was called

“Delirium”.