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