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Delirium

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Delirium

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Delirium ( some times called ‘ acute confusional state ‘ ) is a common clinical syndrome characterized by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course 
( NICE

Hyperactive type-heightened arousal restless agitated or aggressive hallucinations wandering. hypoactive type -Withdrawn Quite Sleepy Paranoid reduced conc and appetite. Mixed type -Person moves between the two subtypes -severity of symptoms can vary during the course of the day

How common-Prevalence depends on
○ setting eg very common in critically ill patients ( up to 15-80 % )
 50 % of older people in hospital
 30 % of older people in emergency department
 Upto 50 % who have hip fracture
 10-40 % of people aged 65 and more living in long term care
 0.4 % in general population
○ criteria used for diagnosis ( eg DSM V or ICD 10 )
○ Palliative phase 3-45 % ( predominantly hypoactive )

Barriers to recognition- Recognition and documentation of delirium is poor across most settings Barriers can be individual , patient related or due to working environment NICE has produced guidelines for clinicians , for care home managers , clinicians and nursing profession ( ” Being a Delirium Champion )
https://www.rcn.org.uk/clinical-topics/older-people/delirium/
delirium-champion Several factors can act as barriers to recognition of delirium in primary care – for eg
○ access to appointments
○ isolation ( eg elderly people living alone )
○ GP work burden ( non-urgent H/Vs can get delayed )
○ patient may fail to recognise him/herself (noticed by carers , neighbors )
○ lack of continuity of care
○ access to medical records ( for eg in OOH setting )
○ time constraints ( assessment cannot be completed in standard 10 minutes slots )

Why is delirium important- Increased morbidity and mortality ( ↑ ed risk of death ) Increased length of stay in hospital or in critical care Increased risk of dementia More incidence nosomcomial infections New institutionalization or re-admission to hospital More hospital-acquired complications such as falls and pressure sores Continence problems Malnutrition Functional impairment Distress ( person , family ,carers ) Economic cost

Often described as predisposing or precipitating factors.
Predisposing factors ( 1st box ) refer to those conditions that already exist in a person at baseline whereas precipitating factors are those that lead to a specific delirium episode

What causes delirium is not fully understood -Possibly complex interplay of various mechanisms which may include reduced cerebral blood flow , neurotransmitter changes , inflammatory response

Predisposing factors-Age > 65 Pre-existing cognitive impairment
( eg dementia ) Current hip fracture ( in-patient setting ) Depression Previous h/o delirium Multiple comorbidities Severe illness Hearing and visual problems Polypharmacy Male sex Immobility Urinary retention or use of a urinary catheter Cancer particularly terminal stage Alcoholism

Precipitating factors- Acute illness severe infection , sepsis metabolic disturbance organ failure eg AKI immobilisation dehydration drugs eg opiates , benzodiazepines , anti cholinergics , steroids endocrine ( thyroid disturbance ) , cushings cardiac- eg occult MI respiratory conditions eg PE , COPD exacerbation neurological – stroke , encephalitis , subdural haematoma GI-liver failure , constipation , malnutrition trauma – head injury , hip fracture alcohol or drug abuse or withdrawal psychosocial factors eg depression , sleep deprivation , emotional stress Surgery , ITU admission

Assessment- Assess people at risk for recent ( within hours or days ) changes in fluctuations in behaviour . Try and determine the precipitating factor eg infection or an adverse drug reaction Symptoms can fluctuate ( often worse at night ) Onset is usually acute , developing over a few hrs or days and often marked by sudden change in behaviour patients often described as confused

Cognitive function eg worsened concentration , slow response , confusion Change in perception – eg visual or auditory hallucinations Changes in physical function eg
reduced mobility
reduced movement 
restlessness , agitation
changes in appetite
sleep disturbances Altered social behaviour – eg lack of cooperation with reasonable requests , withdrawal or alterations in communication , ,ood and / attitude Altered level of consciousness Falls and loss of appetite ( warning signs )

History is the key – to assess pre-existing level of cognition and function ( ie comparing to what is normal for the patient )
Collateral history from carers , family , friends can be valuable to assess current versus previous functional status General medical and medications history Examine – focused based on suspected precipitating factor (s)

Various strategies have been suggested for recognition- eg
 Diagnostic tools eg 4As test ( 4AT) Routine screening and severity monitoring NICE recommends – following an initial assessment
○ Using DSM-V criteria or
○ Short Confusion Assessment Method

Short confusion assessment method ( S-CAM )
 Acute onset and fluctuating course Inattention Disorganized thinking Altered level of consciousness

Admit if delirium suspected- If admission is declined consider your options
 Referral to community resource team ( same day assessment ) Advice from elderly care consultant or Psychiatrist Capacity assessment and Mental Capacity Act 2005 Detention under the Mental Health Act 
( 1983 and amended 2007 ) Family , carers and social situation -inform and keep them on-board ( Holistic assessment ) Management in primary care

Some cases may be appropriate to manage
 in primary care- for eg ( CKS )
 Person is clinically well Symptoms are not harmful to the patients and close clinical f/u is possible Benefits of keeping in community outweigh benefits of admission Cause is known and treatable Constant supervision from a health care professional is possible to minimize complications

Think of the common precipitating factors and correct wherever possible – remember delirium is treatable and reversible
 Infection Drugs Constipation Urinary retention Dehydration Electrolyte imbalance Inadequate pain relief Mobility , sensory issues ( hearing , vision ) Optmise any co-morbid condition

Investigations – consider 
( Often referred to as Confusion screen )
 Urine Sputum Bloods – FBC, Us/Es, Urea ,LFTs , Bone profile , Folate , B12 , Hba1c , CRP , ESR, TFTs , drug levels CXR and ECG Blood culture could be considered

Non-pharmacological strategies include
 educating nursing staff early medical consultation mobilizing patients environmental and sensory modifications medication monitoring

Haloperidol-Often used in aggressive , agitated patients and in ITU setting Use is off- label Evidence base for use is weak ie efficacy or safety is not established
Start at lowest clinically appropriate dose
Carefully check for contraindications / interactions and cautions before prescribing ( suggest use the clinical system eg Vision or Emis )
Dose varies – suggest follow advice from BNF , but 24 hr dose should not exceed 2 mg Larger doses associated with Parkinsonian/ Extrapyramidal adverse effects CKS suggests an ECG before initiation if CV risk factors present or h/o CVD is present and BP monitoring ( ECG- this will not always be possible in primary care )

CKS suggests that lorazepam can be used in low dose for treatment of challenging behaviour associated with delirium following advice of a specialist Start at lowest possible dose ( 0.5 to 1 mg ) and titrate in increments after an interval of 2 hrs – max 24 hr dose should not exceed 2 mg Refer to BNF for CI/Interactions Common SEs are drowsiness , dizziness , muscle weakness and ataxia Review and monitor with the aim of stopping use within 24-48 hrs

Levopromazine –Used usually in palliative care setting ( discuss with the palliative care team first ) Sedating first generation anti-psychotic Subcutaneous route is the most commonly seen Side effects are usually not seen if the dose does not exceed 12.5 mg/ 24 hrs

References Detection, Prevention and Treatment of Delirium in Critically Ill Patients The Intensive Care Society UKCPA Assessment and management of delirium in primary care Jane Stephens Progress in Neurology and Psychiatry November / December 2015 CKS NHS Delirium November 2016 Hypoactive delirium BMJ 2017 ; 357;j2047 Recognising and managing delirium BMJ 2013 ; 346 : f2398 Delirium : prevention , diagnosis and management NICE CG 103 updated March 2019 An overview of delirium for the community and hospital clinician Dr Keerty Raju et al Progress in Neurology and Psychiatry November / December 2015 What Do we Really Known About the Treatment of Delirium with Antipsychotics ? Ten Key Issues for Delirium Pharmacotherapy American Journal of Geriatric Psychiatry 2013-12-01, Issue 12, Pages 1223-1238 Tahir TA , Mahajan D, Delirium, Medicine 2016 Risk reduction and management of delirium SIGN 157 March 2019

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