Roshan Gunathilake MD
John Hunter Hospital
Newcastle, Australia
DELIRIUM IN THE WARD
Case scenario
 You are the evening RMO.
 You have been asked to see a 84-year-old
man on D2 post-elective R/TKR.
 Nurse...
Background
 84-year-old man
 Lives with wife in a retirement village
 Independent in ADLs
 Admitted for elective R/ TKR
Background
 Previous R/ PACI (2010)
 Mild cognitive impairment
 Hearing impairment
 Stable CAD
 Hypertension
 T2DM (...
Medications
 Aspirin
 Metoprolol
 Perindopril + indapamide
 Atorvastatin
 Meformin
 Vitamin D
 Temazepam
 Prophyla...
Physical Examination
 Agitated but cooperative
 Confused
 Disoriented
 Vitals P 104, BP 110/72, RR18, spO2 98 RA
 Che...
Questions
 What is the likely diagnosis?
 What might be the cause?
 What are his risk factors?
 What investigations wi...
Delirium
 Derived from Latin term meaning “off
track”
 Not a disease, but a syndrome with
multiple causes that result in...
Clinical hall marks
1. Acute onset + Waxing and waning
symptoms
2. ↓ Attention span
3. Disorganized thinking
4. Altered LOC
Incidence/ prevalence
 Very common but is often not detected or
misdiagnosed
 Prevalence and incidence varies across
pat...
Risk factors for delirium
 advanced age
 dementia
 Hx of delirium
 neurological
damage
 functional disability
 visua...
Precipitating factors
 Metabolic – hypoxaemia, hypoglycaemia, electrolyte
& acid-base derangements
 Infective – urinary ...
Medications known to cause
delirium
 Anticholinergics
 Antihistamines
 Narcotics
 Benzodiazepines
 Antiparkinson agen...
Risk factors & precipitating
factors
Moderate to high
risk
Very High Risk
Low risk Moderate to high
risk
Low High
High
Vul...
Clinical features
 Fluctuation of symptoms
 Clouding of consciousness
 Cognitive deficits (disorientation, inattention)...
Diagnosis
 Clinical features
 Collateral history
 Medication review
 Focused physical exam
 CAMI
 Several instruments for evaluating delirium are
available.
 The Confusion Assessment Method (CAM) is
used widely
 It h...
Further Investigation
 FBC
 EUC, Ca++, LFTs
 Random BSL
 ECG, cardiac enzymes
 CXR
 Urinalysis
 Brain imaging, CSF
...
Differential diagnosis
 Dementia
 Depression
 Psychotic illness
 Sun downing
FEATURE DELIRIUM DEMENTIA
ONSET Acute Gradual
DURATION Hours – weeks Months – years
COURSE Fluctuating Progressive
deterio...
Management of delirium
 Delirium is best managed by clinicians with
expertise in delirium management, and in most
cases s...
Components of delirium Mx
1. Identify the cause where possible
2. Correct the cause / precipitating factors
3. Manage the ...
Non-pharmacological management:
Environmental
 Calm, comfortable environment
 Lighting appropriate to time of day
 Orie...
Non-pharmacological management:
Nursing care-based
 Use of staff with training in delirium care
 One-on-one nursing wher...
Multicomponent Mx of delirium symptoms
Pharmacological interventions
 Cease/ ↓ drugs that cause delirium
 Manage discomfort or pain
 Regulation of bowel funct...
Pharmacological interventions
 Understudied area, with only a limited
number of small trials; Very few data
comparing dif...
Pharmacological interventions:
antipsychotics
 Antipsychotics are generally the 1st line (except
in delirium tremens)
 S...
Pharmacological interventions:
benzodiazepines
 Benzodiazepines are the treatment of choice
for delirium tremens & deliri...
Prognosis
Delirium is associated with ↑adverse outcomes:
o Mortality
o Hospital mortality 25 - 33%
o independent marker fo...
Course
 Delirium may be very persistent.
 Unresolved delirium:
 60% after 1 week
 20% after 2 weeks
 15% after 4 week...
Prevention strategies
 Reorient and mobilise the patient
 Reduce sensory deprivation
 Ensure the patient is hydrated
 ...
Summary
 Delirium is a common medical emergency, with
↑morbidity and mortality rates, affecting elderly.
 Risk for delir...
References
1. Caplan G. Managing delirium in older patients. Aust
Prescr 2011;34:16–18)
2. Inouye AK. Delirium in older pe...
Delirum in the ward
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Delirum in the ward

  1. 1. Roshan Gunathilake MD John Hunter Hospital Newcastle, Australia DELIRIUM IN THE WARD
  2. 2. Case scenario  You are the evening RMO.  You have been asked to see a 84-year-old man on D2 post-elective R/TKR.  Nurses state that he is confused since 1800, spitting out his medications, yelling at the staff, and wandering in the ward.
  3. 3. Background  84-year-old man  Lives with wife in a retirement village  Independent in ADLs  Admitted for elective R/ TKR
  4. 4. Background  Previous R/ PACI (2010)  Mild cognitive impairment  Hearing impairment  Stable CAD  Hypertension  T2DM (metformin)  OA  Alcohol 1-2 Units/day
  5. 5. Medications  Aspirin  Metoprolol  Perindopril + indapamide  Atorvastatin  Meformin  Vitamin D  Temazepam  Prophylactic SC heparin  Regular paracetamol, PRN Oxycodone
  6. 6. Physical Examination  Agitated but cooperative  Confused  Disoriented  Vitals P 104, BP 110/72, RR18, spO2 98 RA  Chest clear  Abdomen SNT  No focal neurology, pupils normal  Clean surgical wound  No DVT
  7. 7. Questions  What is the likely diagnosis?  What might be the cause?  What are his risk factors?  What investigations will you request?  How will you manage him?  What is his prognosis?
  8. 8. Delirium  Derived from Latin term meaning “off track”  Not a disease, but a syndrome with multiple causes that result in a similar constellation of symptoms  An acute syndrome characterized by altered attention, cognition and consciousness  May be the only sign of a serious medical illness in an older person
  9. 9. Clinical hall marks 1. Acute onset + Waxing and waning symptoms 2. ↓ Attention span 3. Disorganized thinking 4. Altered LOC
  10. 10. Incidence/ prevalence  Very common but is often not detected or misdiagnosed  Prevalence and incidence varies across patient populations and health care settings o Prevalent delirium 10 - 24% o Incident delirium up to 56% among older hospitalized patients
  11. 11. Risk factors for delirium  advanced age  dementia  Hx of delirium  neurological damage  functional disability  visual and hearing impairment  polypharmacy  psychoactive drugs  alcoholism  multiple / severe chronic medical conditions  dehydration  depression
  12. 12. Precipitating factors  Metabolic – hypoxaemia, hypoglycaemia, electrolyte & acid-base derangements  Infective – urinary tract infection, pneumonia, CNS infection  Structural – Cerebrovascular event, urinary retention  Toxic – drugs (incl. withdrawal) or poisons  Environmental – being in hospital or ICU, physical restraints, bladder catheter, multiple procedures, surgery, pain
  13. 13. Medications known to cause delirium  Anticholinergics  Antihistamines  Narcotics  Benzodiazepines  Antiparkinson agents  Digoxin  Lithium  Steriods
  14. 14. Risk factors & precipitating factors Moderate to high risk Very High Risk Low risk Moderate to high risk Low High High Vulnerability Level of insult Inouye SK, Charpentier PA, Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275(11): 852-7
  15. 15. Clinical features  Fluctuation of symptoms  Clouding of consciousness  Cognitive deficits (disorientation, inattention)  Psychomotor abnormalities: floridly agitated, hyperactive drowsy, hypoalert, quiet (Hypoactive delirium)  Sleep–wake cycle disturbance  Perceptual & thought disturbances (e.g. misinterpretations, illusions, hallucinations)
  16. 16. Diagnosis  Clinical features  Collateral history  Medication review  Focused physical exam  CAMI
  17. 17.  Several instruments for evaluating delirium are available.  The Confusion Assessment Method (CAM) is used widely  It has reported sensitivity > 94% and specificity > 90%
  18. 18. Further Investigation  FBC  EUC, Ca++, LFTs  Random BSL  ECG, cardiac enzymes  CXR  Urinalysis  Brain imaging, CSF  Drug levels
  19. 19. Differential diagnosis  Dementia  Depression  Psychotic illness  Sun downing
  20. 20. FEATURE DELIRIUM DEMENTIA ONSET Acute Gradual DURATION Hours – weeks Months – years COURSE Fluctuating Progressive deterioration CONSCIOUSNESS Impaired Normal PERCEPTUAL DISTURBANCE Common Occurs in late stages SLEEP-WAKE CYCLE Disrupted Usually normal PROGNOSIS Potentially reversible Not reversible PRIMARILY AFFECTS Attention Memory MEDICAL EMERGENCY? Yes No
  21. 21. Management of delirium  Delirium is best managed by clinicians with expertise in delirium management, and in most cases should involve a multidisciplinary team.
  22. 22. Components of delirium Mx 1. Identify the cause where possible 2. Correct the cause / precipitating factors 3. Manage the symptoms of delirium 4. Provide a supportive care environment 5. Prevent complications 6. Educate the patient and their carers
  23. 23. Non-pharmacological management: Environmental  Calm, comfortable environment  Lighting appropriate to time of day  Orientation cues – clock, calendar  Familiar objects or photographs from home  Encourage family and carer involvement  Remove hazards : low bed, secure facility  Avoid restraints (aggravate delirium, increase injuries )  Avoid room changes
  24. 24. Non-pharmacological management: Nursing care-based  Use of staff with training in delirium care  One-on-one nursing where relevant  Same staff members to care for the patient during and across shifts  Minimize sensory deprivation  Validation and reality orientation strategies  Providing relaxation strategies to assist with sleep.
  25. 25. Multicomponent Mx of delirium symptoms
  26. 26. Pharmacological interventions  Cease/ ↓ drugs that cause delirium  Manage discomfort or pain  Regulation of bowel function  Drug therapy is reserved for patients who are at risk of harming self /others
  27. 27. Pharmacological interventions  Understudied area, with only a limited number of small trials; Very few data comparing different drugs  Even drugs that are used to treat delirium, particularly if given in excess, can prolong or worsen delirium.
  28. 28. Pharmacological interventions: antipsychotics  Antipsychotics are generally the 1st line (except in delirium tremens)  Start low and go slow (e.g. haloperidol 0.5 mg, risperidone 0.5 mg or olanzapine 2.5 mg)  Titrate dose, review periodically, monitor for oversedation  No clear evidence that atypical antipsychotics are more effective > typical  But have fewer extrapyramidal side effects
  29. 29. Pharmacological interventions: benzodiazepines  Benzodiazepines are the treatment of choice for delirium tremens & delirium associated with benzo- withdrawal  Geriatric patient populations are at greater risk of developing complications from benzo- use  Long acting benzo-s, in particular, have been shown to increase the risk of delirium.
  30. 30. Prognosis Delirium is associated with ↑adverse outcomes: o Mortality o Hospital mortality 25 - 33% o independent marker for mortality < 12 months after discharge (HR 2.11) o length of stay (x2) o Complications : falls, bed sores, incontinence o Cognitive and functional decline o Nursing home admission
  31. 31. Course  Delirium may be very persistent.  Unresolved delirium:  60% after 1 week  20% after 2 weeks  15% after 4 weeks  5% persists >4 weeks  Inattention, memory impairment and disorientation may be still present at up to 12 months.
  32. 32. Prevention strategies  Reorient and mobilise the patient  Reduce sensory deprivation  Ensure the patient is hydrated  Implement a non-pharmacologic sleep regimen  Limit catheters and restraints
  33. 33. Summary  Delirium is a common medical emergency, with ↑morbidity and mortality rates, affecting elderly.  Risk for delirium should be assessed in all older persons admitted to a health care setting.  Timely diagnosis, multicomponent intervention and judicious use of medications can improve outcomes.  Antipsychotics are reserved for patients with severe behavioral and psychological symptoms.
  34. 34. References 1. Caplan G. Managing delirium in older patients. Aust Prescr 2011;34:16–18) 2. Inouye AK. Delirium in older persons. NEJM 2006;354: 1157-65 3. Australian Society for Geriatric Medicine; Position Statement No.13 : Delirium in Older People (2005) 4. Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines for the Management of Delirium in Older People. (AHMAC 2006) 5. Inouye SK, Charpentier PA, Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275(11): 852-7

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