Transcript Delirium - City and Hackney CCG

Delirium & Dementia in
Hackney
misc. observations
Dr Cianán O’Sullivan, Geriatrician
(“Keen-on”, or “key-nawn”, O’Sullivan)
Dementia, Delirium
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Dementia – neglected, overlooked, now hardly out of the
news (e.g. Daily Mail, today)
– National Dementia Strategy
– Prime Minister’s Challenge on Dementia
– Drive to increase diagnosis
Diagnosis
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In ‘crisis’ vs early
Overdiagnosis? ‘pre-dementia’, mild cognitive impairment
When & Where to diagnose
“Screening” for Dementia in general, in GP, in acute care;
CQUIN for dementia
– Letters to GP, “Please (consider) referral to Memory Clinic”
– “Dementia screening blood tests”. Hmm…..
Dementia, Delirium
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Brain Imaging
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GP requested MRI, In-Health
‘cerebrovascular disease’
MRI very sensitive for subcortical, white matter changes
Normal ageing change vs ‘disease’
Hypertension = 141/90 or 211/70
Post-diagnosis
– Education, support – family, living alone, alzheimers soc,
social services (20% cuts),
– Anti-dementia drugs, (original 6month trials, donepezil
cheap now)
– Mental Capacity – what decision
– Crisis, 999 = Homerton admission,length of stay
Delirium
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What is it?
Why is it important?
How common?
Underdiagnosed?
Preventable
Case
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HM, 87 yo woman, fall
Fractured forearm
Seems confused,
Speaks little English
Urea / creat 10 / 126, Hb 10, WBC 16,
CRP 102
CXR poor insp film
Case
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Day 2, Febrile, treated with antibiotics
for chest infection
Agitation & drowsiness, sedation,
analgesia
Collateral hx daughter
Day 2-21 Variable oral intake /
drowsiness / poor mobility /
dehydration / parenteral fluids
Day 22 -
Delirium
– Delirium is a clinical syndrome characterised
by disturbed consciousness, cognitive function
or perception, which has an acute onset and
fluctuating course
– It is a common but serious and complex clinical
syndrome associated with poor outcomes
– Older people and people with dementia, severe
illness or a current hip fracture are more at risk
of delirium
– Delirium is preventable and treatable if dealt
with urgently
Clinical factors contributing
to delirium (NICE slide)
Addressing these clinical factors in a patient at risk of delirium can
prevent delirium
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cognitive impairment and/or disorientation
dehydration and/or constipation
hypoxia
infection
immobility or limited mobility
pain
multiple drugs (CO’S: guidelines = ever more drugs)
poor nutrition
sensory impairment
poor sleep patterns and sleep hygiene
Diagnosis – CAM, (Confusion
Assessment method)
1. Acute onset and fluctuating
course
2. Inattention
3. Disorganised thinking
4. Altered level of consciousness
The diagnosis of delirium by CAM
requires the presence of features
1 and 2 and either 3 or 4.
CAM, 1 and 2
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Acute onset and
fluctuating course
2.
Inattention
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Is there evidence of an
acute change in mental
functioning from the
patient’s usual? Does the
(abnormal) behaviour vary
in severity . NB Collateral
Does the patient have
difficulty focusing attention
– for example, are they
easily distracted, or do they
have difficulty keeping track
of what was being said
CAM, 3 or 4
3. Disorganised
thinking
4. Altered level of
consciousness
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Is the patient’s thinking
disorganised or
incoherent,rambling or
irrelevant conversation,
unclear or illogical flow of
ideas, or unpredictable
switching from subject to
subject.
Overall how would you rate
this patient’s level of
consciousness? Alert,
vigilant/agitated, lethargic
(drowsy, easily roused),
stupor
Abbreviated Mental Test
(AMT)
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Year
Age
Address for recall
DOB
Time (nearest hour)
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Place
Recognition of 2
people
20-1 backwards
Monarch
World War 2 (1)
Tests of attention
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20- 1 backwards
Days of week backwards
Months of year backwards
Serial 7s - education
“World” backwards
Delirium vs Dementia
Onset - Hours, days
Fluctuates over 24hrs
Attention impaired
Altered level of
consciousness
Physiological abnormality
Reversible (not always)
If in doubt treat as
delirium
Months, years
Stable (decline)
Attention preserved
Normal level of
consciousness
Normal physiology
Progressive
Causes of delirium
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Any acute medical condition, drug
adverse effect or drug withdrawal
Common causes include…
Any medical a condition except
don’t mention UTI!
Typical patterns
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Cortical and subcortical
AD short term memory first (ex Terry Pratchet)
visuospatial, later language, praxis, agnosia
VaD, mental slowing, attention,
executive/planning, gait / falls, or acute post stroke
DLB, visual halluc (not distressed), fluctuations,
parkinsonism (25% absent)
FTD (younger), language, behaviour, executive
function