investigation and management of the patient with delirium

Excellence in Health putting People first

Investigation and management of the patient with delirium

Dr Lesley Young

Consultant geriatrician, Sunderland royal Hospital


Mary

• 83 year old lady from a care home presents to A&E

• Unwell for ~2/52

• “just not right”

• Reduced oral intake

• Drowsy

• More muddled


• “poor historian” - Appears confused,

• Background from medical records:

– Hypertension

– IHD

– OA

• From care home:

Normally “pleasantly confused”

1/12 ago Blood pressure tablets changed

1/52 ago treated for “presumed” UTI

Much more confused over past few days


• Medications:

– Bendroflumethiazide 5mg od

– Bisoprolol 5mg od

– Lisinopril 5mg od

– Simvastatin 20mg od

– Aspirin75mg od

– Codeine 30mg qds

– Trimethoprim for 5 days

• NEWS = 1 (sats 95% on air)

• Awake, but confused, apyrexial

• CVS – NAD BP 134/78

• Chest- NAD

• Abdo – NAD

– PR – hard stool

• No focal neurology

• Incontinent of urine


Initial investigations

• Hb N

• WBC 9

• CRP 14

• Na 122

• Urea 14

• Creat 161

• Urinalyisis - NAD

• CXR – NAD


Question 1?

Does she have a delirium?

YES?

NO?


What is delirium – DSM V

1. disturbance in attention (ie, reduced ability to direct, focus, sustain & shift attention) and orientation to the environment;

2. disturbance develops over a short period of time and represents an acute change from baseline, not solely attributable to another neurocognitive disorder and tends to fluctuate in severity during the course of a day;

3. a change in an additional cognitive domain, e.g. memory deficit, disorientation, or language disturbance, or perceptual disturbance not better accounted for by a pre-existing, established, or evolving other neurocognitive disorder

4. disturbances in 1 & 3 must not occur in the context of a severely reduced level of arousal, such as coma.


Types of delirium

Hypoactive


Question 2

• What proportion of adults in an acute hospital will have delirium?

1. 2%

2. 5%

3. 10%

4. 15%

5. 20%

6. 30%


How common is delirium?

• Most hospital beds occupied by older people

• Dementia v common in hospital population

• Dementia and age biggest risk factors for delirium

• Cork point prevalence study (Ryan BMJ Open 2013)

– 52% inattentive or “confused” – 20.7% delirium + 8.6% subsyndromal delirium

• 50.9% had pre-existing dementia (only 1 in 5 noted) • 64% recognised as “confused” by nurses • only 44% noted in medical case notes


But… Delirium is under-recognised:

• NHS coding data: Prevalence 0.7% (2013-14 data)

• In published studies only 20-50% of delirium noted in medical records(Foreman 2004)

• Hypoactive more easily overlooked (Inouye Arch Int Med 2001)

• In dementia patients with delirium (Fick J Geront Nurs 2000):

– Family members report change in cognition but not identified by clinical staff

“If they are known to have Alzheimer's then I usually don’t even try to ask the questions”


Failure to recognise

Risk factors for missing delirium:

• Hypoactive delirium

• Delirium superimposed on dementia

• Lack of staff knowledge

• Lack of tools

• Impaired vision

• Age >80years

Factors associated with poor outcome:

• Hypoactive delirium

• Delirium superimposed on dementia

• Prolonged duration of delirium

Failure to

recognise


delirium at the front door

• Level of arousal?

• Tests of attention

• Listen to carers

• Collateral

• Age 75+

• Cognitive impairment

• Visual / hearing loss

• Infection/dehydration

• Pain/trauma

Suspect it

• Acute confusion”

• Poor concentration

• Poor communication

• Change in behavior

• Hallucinations

• Fluctuations

Spot it


For Delirium detection(Chester J

Hosp med 2012)

M-RASS 0

For delirium superimposed on dementia (morandi JAMDA 2016)

Sens Spec

Single 64% 93%

Serial 85% 92%

Arousal

mRASS Sens Spec

0 70.5% 84.8%

>+1 or <-1 30.6% 95.5%

mRASS


Question 3

• Which of the following are measures of attention (chose 2)?

1. Recalling an address

2. Recalling current date / time

3. Giving own date of birth / address

4. Serial 7`s

5. Months of the year backwards


Attention

• Ability to follow a conversation

• Serial 7`s or WORLD backwards in MMSE

• 20-1

• MOYB

• Months Of the Year Backwards:

• 83.3% sensitivity

• 90% specificity


4AT www.the4AT.com [1] ALERTNESS

Normal (fully alert, but not agitated, throughout assessment) 0

Mild sleepiness for <10 seconds after waking, then normal 0

Clearly abnormal 4

[2] AMT4 Age, date of birth, place (name of the hospital or building), current year.

No mistakes 0

1 mistake 1

2 or more mistakes/untestable 2

[3] ATTENTION Months of the year backwards

Achieves 7 months or more correctly 0

Starts but scores <7 months / refuses to start 1

Untestable (cannot start because unwell, drowsy, inattentive) 2

[4] ACUTE CHANGE OR FLUCTUATING COURSE Evidence of significant change or fluctuation in: alertness, cognition, other mental function (eg. paranoia, hallucinations) arising over the last 2 weeks and still evident in last 24hrs

No 0

Yes 4


Validity of delirium screening tools

Sensitivity Specificity

4AT >3 92.7% 89.7% 100%

53.7% 84.1% 82%

Hendry Age and ageing 2016 (V specialist) Bellelli Age and Ageing 2014 (v specialist) Lees Stroke 2013 (v CAM)

AMT 10 <4/10

73% 65% Lees Stroke 2013 (v CAM)

SQiD 58% 80%

85% 71%

Lees Stroke 2013 (v CAM) Sands Palliat Med 2010 (v specialist)

BCam 70.3% 40% (untrained)

91.4% Hendry Age and ageing 20162016 (V specialist) Sands Palliat Med 2010 (v specialist)


If you don’t look for it you wont find it!

Failure to recognise delirium is associated

with worse outcomes (Young, Age and Ageing 2003)

For each 48 hours of active delirium

mortality increases by 11% (Gonzales 2009)


What next?

Does she have a delirium? YES

How can we test for this at the front door? YES

simple tests of:

arousal (mRASS)

attention (MOYB)

What is the cause?

What are her risk factors?

How should we manage her?


Mary • 83 year old lady from a

care home

• Unwell for ~2/52, recent change in medication

• Drowsy, “just not right”, More muddled

• Reduced oral intake

• Hyponatraemia, AKI

• Constipation

– Bendroflumethiazide 5mg od

– Bisoprolol 5mg od

– Lisinopril 5mg od

– Simvastatin 20mg od

– Aspirin75mg od

– Codeine 30mg qds

– Trimethoprim for 5 days


Question 4

• What is the most likely cause(s) of the delirium? (chose up to 3)

1. Urinary tract infection

2. Dementia

3. Hyponatraemia

4. Constipation

5. Hyponatraemia due to drugs

6. Acute Kidney injury

7. Old age


Mary – causes of delirium

Triggers (causes)

• Hyponatraemia: – Trimethoprim

– Bendrofluamethiazide

• AKI – Bendroflumethiazide

– ACE

• Constipation – Codeine

• Drugs – Codeine

Risk factors (vulnerability)

• Age

• Cognitive impairment

• ?poor hearing / vision??

• frailty

Not all delirium is a

UTI


Causes of delirium

• Infections

• Drugs, especially opiates and anticholinergics

• Organ failure

• Biochemical disturbances

• Constipation

• Surgery

• Pain

• Infection

• Constipation

• Hydration

• Medication

• Environment & Electrolyte

Multiple causes


Drugs causing delirium

Consistent association

• Opiates OR 2.5

• Benzodiazepines OR 3

• Dihydropyradines OR 2.4

• Antihistamines OR 1.8 (Clegg Age and Ageing 2011)

Anticholinergic burden

• polypharmacy

Uncertain - individual

• H2 antagonists

• Tricyclic antidepressants

• Parkinson's med

• Steroids

• NSAID

• Anitmuscarinics


Other tests?

CT head

• Commonly abnormal

• Rarely diagnostic

• Work up for ? Underlying dementia

• Falls/ head injury

• Focal neurological symptoms

EEG

• Second line test

• Abnormal in delirium – Diffuse irregular theta

slowing

• Delirium v psychiatric illness

• ? Non-convulsive status

LP

• Consider if encephalitis suspected


What now? TIME

HIS/SDA TIME Bundle

Think exclude and treat triggers

Investigate and intervene to correct underlying

causes

Management plan

Engage and explore


“Icanpreventdelirium”

Suspect it

• Age 75+ Cognitive impairment

• Visual / hearing loss Infection/dehydration

• Pain/trauma

Spot it

• “Acute confusion” Poor concentration

• Poor communication Change in behavior

• Hallucinations Fluctuations

Stop it

• Treat cause Explain and reassure

• Environment Physical needs

• Psychological needs Social needs

(Krishnan&Fixter TEWV)


Targeted multi-component interventions in delirium

Risk factor Intervention

Cognitive impairment Reality orientation

Therapeutic activities

Vision/hearing impairment Vision/hearing aids

Adaptive equipment

Immobilisation Early mobilisation

Minimising immobilising equipment

Psychoactive medication use Non-pharmacological approaches to sleep/anxiety

Restricted use of sleeping tablets

Dehydration Early recognition

Volume repletion

Sleep deprivation Noise reduction strategies

Sleep enhancement program

Hospital elder life programme, Inouye NEJM 1999


HELP in dementia

• HELP reduces incidence of delirium most in highest risk patients (Inouye NEJM1999)

Control HELP RR reduction

All at risk patients

15% 9.9% 34%

Dementia 32%

17% 47%


Delirium Toolbox study Rudolph JAMDA 2014

• Patient safety outcomes in patients at risk of delirium

• Intervention:

– Delirium tool box

• Identify risk (3 risk factors)

• Modify risk (using tool box)

• Monitor for delirium


Delirium tool box

Tool box

Sensory impairment

Pocket amplifier

Reading glasses

Magnifying glass

Stress ball

Cognition

Puzzles

Cards

dominos

Sleep promotion

Ear plugs

Eye mask

Head phones


Outcomes (Rudolph 2015)


Prevention is better than cure

• Up to 40% incident delirium is preventable:

• targeted multi-component intervention (Inouye NEJM 1999)

• Delirium toolbox study (Rudolph JAMDA

2014)

• But little evidence for improved 6/12 outcomes in prevalent delirium with non-pharmacological interventions

(Laurila, Helsinki study J Geront 2006)

Vu

lnera

bil

ity

insult

Age

Dem

entia

low risk, severe insult

High risk, small insult


Managing delirious patients

• Medical /nursing

– Document / explain diagnosis

– Assess/treat pain

– Ensure O2 sats maintained

– Avoid/treat constipation

– Avoid catheterisation

– Person centred care tool

– Consider if swallow is safe

• Environment & general

measures

– Sensory aids

– Sleep chart

– Encourage to mobilise

– Encourage diet and fluids (maintain charts)

– Reduced stress to patient

– Minimise ward moves (right ward first time)

– Avoid unnecessary interventions


• Drugs NICE Guidelines CG103 (2010).

– Limited evidence base

– Low dose antipsychotics safe

• Haloperidol 0.5mg

• Olanzapine

– Benzodiazepines not recommended (Cochrane

review 2009)

• Unless PD / LBD

• Treatment of symptoms

– Encourage family visits • Johns campaign

– Consider additional staff

– Assess for psychotic symptoms

• Treat if distressing

– Inform/explain to next of kin

– Assess capacity


What about outcomes?

• Delirium is an independent risk factor for poor outcomes:

– Mortality

• at discharge

• 12 months OR 1.95 (witlox JAMA 2010)

– Length of stay

– Institutionalisation OR 2.41-3.19 (witlox JAMA 2010, Siddiqi Age and ageing 2006)

– ADL decline

– Cognitive decline


Mary

• 83 year old lady from a care home

• Delirium due to AKI / Hyponatraemia / drugs

• “pleasantly confused”

– Consider formal diagnosis ? Dementia

• Follow up to ensure full resolution of delirium

• “at risk” of future delirium

– Delirium prevention advice to care home


Take home messages

• Delirium is common

• Delirium is a serious problem with poor outcomes

• Delirium can be prevented

– Prevention is better than cure

• If you don’t look for it, you wont find it

– Use a tool: arousal + attention

• Failure to recognise is associated with worse outcomes

Thank you Any questions?

[email protected]

investigation and management of the patient with delirium

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