Transcript An approach to confusion and agitation

An approach to the older
patient;
confusion and agitation
JMO Education
Deakin Education Room
30th November 2016
Ramesh Sahathevan
You are called at 1830 hrs on a weekend..
• This is X, nurse on 2N. I’m calling about Mrs. Y in bed 12A. She’s
become drowsy and we can’t seem to wake her. We’re not sure if we
should activate a MET call. She was awake half an hour ago but she
was a little agitated then. We need you to come see her now.
• You say…
What do you ask?
• What details should you request of Nurse X?
• What should you go assess for yourself?
From nurse X
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How old is the patient?
78 years old
How long has the patient been drowsy for?
She was fine until about an hour ago. I think she was asleep when I came on for
my shift
Why do you say she was agitated?
She was trying to climb out of her bed
What are her vital signs and general condition?
GCS 14, BP110/70 PR 98 T 37.2 Sats 95% on room air
What’s her underlying problem-why is she in hospital?
Admitted two days ago after a fall in the bathroom and has a fracture right NOF
You say….
• I’ll be there in 5 minutes
• As you walk to 2N from the carpark
(you were just going to drive and
out and grab something for dinner
since you last meal was at 1000
hrs), what’s running through your
mind?
• What can I get for dinner if I can
only leave the hospital at 2000 hrs?
• OR
• Why is this lady agitated?
Likely causes of confusion and agitation
• In a 78 year-old with a fracture Rt NOF or more accurately, with any older patient admitted to hospital, the
causes of confusion and agitation are myriad.
• Drugs e.g. new or increased (opiates, anticonvulsants, benzodiazepines, post-general anaesthetic) or lacking
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(pain relief, alcohol, recreational drugs)
Electrolyte imbalance e.g. sodium, potassium, calcium, phosphate
Low oxygen (hypoxia due to lung pathology, heart pathology, heart-lung pathology, central depression)
Infections e.g. lung infection, UTI, thrombophlebitis, infected surgical wound (VERY RARELY) encephalitis,
meningitis
Reduced sensory input e.g. poor vision, poor hearing, lack of sleep
Intracranial e.g. subdural (acute/acute on chronic), extradural, ischemic or haemorrhagic stroke
Urinary/faecal retention
Metabolic e.g., hypoglycaemia, uraemia, liver failure
What are the possible causes?
• Based on the list just revealed, what are the likely causes-you haven’t
arrived in 2N?
• 78 year-old woman with fracture NOF 2 days prior. You have no idea
about her background medical condition or current medications. To
refresh you memory, her vitals are:
• GCS 13, BP110/70mmHg PR 98 bpm T 37.2 Sats 95% on room air
• Possible causes?
You arrive on the ward
• You have a quick look at the patient.
• What do you assess?
• POD 1
• You assess airway, breathing and circulation-all clear
• GCS is 13-she’s drowsy and disorientated but rouseable; she knows who
she is, thinks she’s at home and is disorientated to time
• BP 135/80 mmHg, PR 100 regular, T 37.2 Sat 96% on RA
• CBS 4.0 mmol/L
• Urine output-catheter in-situ
• Not opened bowels since admission
What does your assessment mean?
• POD 1-type of surgery and type of anaesthesia
• You assess airway, breathing and circulation-all clear
• GCS is 13-she’s drowsy and disorientated; she knows who she is,
thinks she’s at home and is disorientated to time-typical picture
• BP 135/80 mmHg, PR 100 regular, T 37.2 Sat 96% on RA-acceptable?
• CBS 4.0 mmol/L-acceptable?
• Urine output-catheter in-situ-good urine output and clear
• Not opened bowels since admission-constipated?
More information
• 78 year-old, home alone; previously well
• Un-witnessed fall at home, getting out of the shower. Slipped and fell on
the bathroom floor.
• Activated alert when she fell. Denied feeling light-headed or presyncopal
prior and did not lose consciousness.
• Medical history:
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Hypertension
Type 2 DM
bilateral knee OA
Breast CA (2006-wide excision, axillary clearance, chemotherapy, radiotherapy)
Previous smoker (25 pack-years and stopped when diagnosed with CA breast)
Falls risk
• Was she at increased risk of falls prior to her admission?
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Hypertension
Type 2 DM
bilateral knee OA
Breast CA (2006-wide excision, axillary clearance, chemotherapy,
radiotherapy)
• Previous smoker (25 pack-years and stopped when diagnosed with CA breast)
Giants of Geriatrics
Term coined by Sir Bernard Issacs (1924-1995) to
explain the role that one (or more likely more than
one) of the following factors had on the morbidity
of older patients
Originally four but now expanded to five; the 5 ‘I-s’
in no particular order
• Instability
• Incontinence
• Immobility
• Impaired intellect
• Iatrogenesis
Medication list
Existing medication
• Metformin 1gm bd
• Gliclazide MR 30mg daily
• Irbersartan 150mg daily
• Aspirin 100 mg daily
• Panadol Osteo 2 capsules bd
• Risperidone 2.5mg daily
• Venlafaxine 75 mg daily
Added this admission
• Oxycodone
• Diazepam
Medicines with clinically significant anticholinergic effects that
are commonly used in older people with dementia
Strong
anticholinergic
effects – avoid
using in people with
dementia
Moderate
anticholinergic
effects – use with
caution in people
with dementia
Antipsychotics
Antidepressants
Medicines for
urinary
incontinence
Chlorpromazine
Olanzapine
Pericyazine
Tricyclic
antidepressants
(eg. amitriptyline,
doxepin,
imipramine)
Darifenacin
Oxybutynin
Propantheline
Solifenacin
Tolterodine
Haloperidol
Prochlorperazine
Quetiapine
Risperidone
Ziprasidone
Desvenlafaxine
Duloxetine
Fluoxetine
Mirtazapine
Paroxetine
Reboxetine
Venlafaxine
Antihistamines
Brompheniramine
Chlorpheniramine
Cyproheptadine
Diphenhydramine
Promethazine
Examples of anticholinergic side effects
Confusion/hallucinations/delirium
Dry mouth
Pupil dilatation/blurred vision
Urinary retention
Constipation
Tachycardia/arrhythmias
Clinical examination
• Drowsy but rouseable and disorientated; able to obey simple (onestage) commands but appears distractible
• Vital signs stable
• Lungs-reduced air-entry in the bases; no crepitations
• CVS-DRNM, JVP not elevated
• Abdomen-soft; non-tender
• CNS-grossly intact
• Operation site-not swollen or tender, dressing in-situ and not soaked
What now?
• 78 year-old with uncomplicated fracture Rt NOF following an
unwitnessed, unprovoked mechanical fall
• POD 1 (general anaesthesia)
• Catheterised prior to surgery
• Possibly constipated
• Borderline hypoglycaemia
• Over/under-medicated for pain?
• Polypharmacy-large number of medications (although most indicated)
and irrational use (?) of medication
Investigations
• What do you want to request?
Investigations
• FBC: Hb 109 /TWBC 10.1/Platelets 220
• UEC Na 130/K 3.5/Urea 12.1/Creat 133
• Ca2+ (corrected ) 2.4/PO4-1.1
• Glucose 5.8
• Urine analysis-normal
• CXR-poor film (supine) but no obvious consolidation changes
• ECG (with repeat)-sinus tachycardia, no ischemic/dynamic changes
and no right ventricular strain pattern
Investigations
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FBC: Hb 109 /TWBC 10.1/Platelets 220
UEC Na 130/K 3.5/Urea 12.1/Creat 133
Ca2+ (corrected ) 2.4/PO4-1.1
Glucose 5.8
Urine analysis-normal
CXR-poor film (supine) but no obvious consolidation changes
ECG (with repeat)-sinus tachycardia, no ischaemic/dynamic changes and no
right ventricular strain pattern
• CT brain-atrophy and significant deep white matter hyperintensity but no
acute pathology-indicated?
What’s going on?
• What does this patient have?
• Delirium in the setting of recent NOF fracture (with surgery)
• Precipitants of delirium?
• Multi-factorial-fracture and
surgery/GA/dehydration/constipation/hypoglycaemia/pain
• What are the risk factors for delirium?
• Multi-factorial-age/multiple co-morbid
conditions/polypharmacy/underlying cognitive impairment?
What do you do?
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Identify and treat/alleviate precipitant(s)
Address risk factors
Use non-pharmacological measures to help with delirium
Use pharmacological means as a last resort-if the patient becomes a risk to
themselves or others
• Use of anti-psychotics is considered off-label but commonly practised
(haloperidol; initial dose of 0.5-1.0 mg)
• Use of the newer anti-psychotics is permissible although long-term use is
not encouraged due to increased risk of mortality and cardiovascular
events
• DO NOT use benzodiazepines
In summary
• Older, hospitalised patients are at high-risk for delirium
• Best to identify patients at risk of delirium and take preventative
measures-multifactorial
• Patients who develop delirium must be investigated to determine a
correctable cause-multifactorial
• Investigations are often normal
• Non-pharmacological measures come first in treating delirium
• Not mentioned in this scenario-but do not forget the patient with
hypodelirium
Thanks and questions