Transcript Delirium Case Presentation

Delirium Case Presentation
Case
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93 ♂
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PC
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4/7 Confusion, agitation + general
deterioration
3/7 poor urine output
PMH
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BPH
Long term catheter in situ
MI
DH
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Omeprazole 20mg po od
Betahistine 8mg po om
Aspirin 75mg po om
Calcichew D3 forte
SH
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Lives with wife
No carers
Independent around house
Enjoys doing crosswords
Recent falls
O/A
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Temp 35.8
Dehydrated
GCS 13/15
AMTS 7/10
Urine
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offensive odour
Dip +ve blood, leukocytes, nitrites
Bloods
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WCC 14.1
Neut 9.7
Hb 12.0
Na 126
K 4.4
Urea 3.8
Creat 78
CRP 10
Diagnosis
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Acute confusion
UTI
Hyponatraemia
Ciprofloxacin 5/7
Omeprazole + betahistine stopped
Day 2
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GCS 7/15
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CT Brain
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Small vessel ischaemia
No evidence of space occupying lesion,
intracranial haemorrhage or skull #
CRP 46
After 2/52
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GCS 15
AMTS 10/10
A/W discharge home
Prophylactic trimethoprim
Delirium
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Derived from Latin ‘off the track’
Delirium
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Transient global disorder of
cognition
Medical emergency
Affects 20% patients on general
wards
Affects 30% of elderly medical
patients
Associated with increased mortality,
increased nursing, failed rehab and
delayed discharge
Presentation
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Acute + relatively sudden onset
(over hours to days)
Decline in attention-focus,
perception and cognition
Change in cognition must not be
one better accounted for by
dementia
Fluctuating time course of delirium
helps to differentiate
Characterised by:
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Disorientation in time, place +/- person
Impaired concentration + attention
Altered cognitive state
Impaired ability to communicate
Wakefulness – insomnia + nocturnal
agitation
Reduced cooperation
Overactive psychomotor activity –
irritability + agression
Diagnosis
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Cannot be made without knowledge
of baseline cognitive function
Can be confused with
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1. dementia – irreversible, not assd
with change in consciousness
2. depression
3. psychosis – may be overlap but
usually consciousness + cognition not
impaired
Differentiating features of delirium and
dementia
Features
Delirium
Dementia
Onset
Acute
Insidious
Course
Fluctuating
Progressive
Duration
Days – weeks
Months - years
Consciousness
Altered
Clear
Attention
Impaired
Psychomotor
changes
Reversibility
Increased or
decreased
Usually
Normal (unless
severe)
Often normal
Rarely
Risk factors in elderly
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Age >80
Extreme physical frailty
Multiple medical problems
Infections (chest + urine)
Polypharmacy
Sensory impairment
Metabolic disturbance
Long-bone #
General anaesthesia
Risk factors
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Dementia is one of the most
consistent risk factors
Underlying dementia in 25-50%
Presence of dementia increases risk
of delirium by 2-3 times
Causes
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Severe physical or mental illness or any
process interfering with normal
metabolism or function of the brain
Causes mnemonic
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Infections (pneumonia, UTI)
Withdrawl (alcohol, opiate)
Acute metabolic (acidosis, renal failure)
Trauma (acute severe pain)
CNS pathology (epilepsy, cerebral haemorrhage)
Hypoxia
Deficiencies (B12, thiamine)
Endocrine (thyroid, PTH, hypo/hyperglycaemia)
Acute vascular (stroke, MI, PE, heart failure)
Toxins/drugs (prescribed tramadol, dig toxicity,
antidepressants, anticholinergics, corticosteroids)
recreational)
Heavy metals
Pathophysiology
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Not fully understood
Main theory = reversible impairment of cerebral
oxidative metabolism + neurotransmitter
abnormalities
Ach – anticholinergics = cause of acute
confusional states + Pts with impaired cholinergic
transmission (eg Alzheimers) are more
susceptible
Dopamine – excess dopamine in delirium
Serotonin – increased in delirium
Inflammatory mechanism – cytokines eg
interleukin-1 release from cells
Stress reaction + sleep deprivation
Disrupted BBB may cause delirium
NICE Guidelines
Management
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1. Identify + treat underlying cause
(return to pre-morbid state can take
up to 3 weeks)
2. Complete lab tests +
investigations eg. FBC, CRP, U+Es,
BM, LFTs, TFTs, B12, MSU, CXR
3. Rule out EtOH withdrawl
4. Assume an underlying organic
cause
Management
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5. Ensure adequate hydration +
nutrition
6. Use clear, straightforward
communication
7. Orientate the patient to
environment + frequent
reassurance
8. Identify if environmental factors
are contributing to confused state
Management
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Disturbed, agitated or
uncooperative patients often require
additional nursing input
Medication should not be regarded
as first line treatment
Consider medication if all other
strategies fail but remember all
psychotropic meds can increase
delirium + confusion
Medications
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Benzodiazepines
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Lorazepam 0.5-1mg tds orally
Shorter half life than diazepam +
effective at lower doses
S/E - Respiratory depression,
increased risk of falls, hypotension
Not for long term use
Medications
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Antipsychotics
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Avoid in PD
Haloperidol 0.5-1mg
S/E – cardiac, avoid in patients with
hypotension, tachycardia + arrhythmias,
extrapyramidal
Recent evidence suggests not to use in
patients with dementia or risk of CVD due to
increased risk of cerebral ischaemia
3X increase in risk of stroke when Risperidone
used in older patients with dementia
Medications
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Dementia with Lewy Bodies
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Severe reactions to antipsychotic drugs
that can lead to death
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Due to extrapyramidal effects
Urgent psychiatric opinion
Medication
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Review regime every 48h
Will not improve cognition
Can reduce behavioural disturbance
Start with lowest dose possible +
increase gradually
Offer orally first
Use as ‘fixed dose’ regime
Complications
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Malnutrition
Aspiration pneumonia
Pressure ulcers
Weakness, decreased mobility,
decreased function
Falls, #s
Outpatient Care
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Memories of delirium are variable
Educate patient, family + carers
about future risk factors
Elderly patients can require at least
6-8 weeks for a full recovery
For some patients the cognitive
effects may not resolve completely
RUH Algorithm for diagnosis + management of delirium in older adults