Management Strategies For Patients With Delirium, Both Postoperative And In The ED: Ensuring Best Practice For Prevention And Treatment


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Holly Anderson, Psychiatrist, Bendigo Health Service delivered this presentation at the 2012 Hip Fracture Management conference in Australia. The only regional event to discuss practical innovations and improvement processes for the management of hip fractures in the hospital setting. For more information on the annual conference, please visit the website:

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Management Strategies For Patients With Delirium, Both Postoperative And In The ED: Ensuring Best Practice For Prevention And Treatment

  1. 1. Management of Delirium, Postoperative Adjustment Disorders and Depression following Hip Fractures Dr H. Anderson Consultant Psychiatrist MBBS, M.Psych, FRANZCP
  2. 2. Delirium Aetiology Brain insult; Systemic disease Central nervous system disease Intoxication/withdrawal Involves dysfunction of reticular formation and acetlycholine transmission
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. Causes Metabolic Systemic Central nervous system Haematological Renal Hepatic Endocrine Substance/medication induced Multiple aetiologies Not otherwise specified Etc., etc., etc.
  8. 8. Risk Factors Age Cognitive Impairment Visual Impairment Severe Illness Dehydration Physical Restraints Malnutrition Bladder Catheter Addition of >3 Medications whilst in hospital
  9. 9. History Surgical and medical Medications (pre-operative and post-operative) Drug and alcohol Psychiatric
  10. 10. Delirium vs. Dementia
  11. 11. Examination General, including neurological Vitals – Blood pressure, temperature, pulse, oxygen saturation
  12. 12. Investigations
  13. 13. 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)
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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
  22. 22. 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
  23. 23. 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
  24. 24. 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
  25. 25. Treatment Consider the patient’s safety Psychosocial therapies Cognitive, behavioural, interpersonal, psychoanalytic Pharmacological therapies As per those used for adjustment disorders mentioned previously
  26. 26. 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
  27. 27. 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