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Delirium

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 hypoactive type -Withdrawn Quite Sleepy Paranoid reduced conc and appetite.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

RESOURCES FOR CLINICIANS

CGA Toolkit plus https://www.cgakit.com/p-2-delirium

References

  1. Detection, Prevention and Treatment of Delirium in Critically Ill Patients  Mark Borthwick
    Richard Bourne ,Mark Craig ,Annette Egan ,Julia Oxley The Intensive Care Society UKCPA

    https://www.scottishintensivecare.org.uk/uploads/2014-07-24-19-57-26-UKCPADeliriumResourcepdf-92654.pdf
  2. Stephens, J. (2015), Assessment and management of delirium in primary care. Prog. Neurol. Psychiatry, 19: 4-5. doi:10.1002/pnp.400 https://onlinelibrary.wiley.com/action/showCitFormats?doi=10.1002%2Fpnp.400
  3. CKS NHS Delirium November 2016 https://cks.nice.org.uk/delirium
  4. Hypoactive delirium BMJ 2017 ; 357;j2047 https://www.bmj.com/content/357/bmj.j2047
  5. Recognising and managing delirium BMJ 2013 ; 346 : f2398
  6. Delirium : prevention , diagnosis and management NICE CG 103 updated March 2019 https://www.nice.org.uk/guidance/cg103/chapter/1-Guidance
  7. Raju, K. and Coombe‐Jones, M. (2015), An overview of delirium for the community and hospital clinician. Prog. Neurol. Psychiatry, 19: 23-27. doi:10.1002/pnp.406 
  8. Tahir, Tayyeb & Mahajan, Deepali. (2016). Delirium. Medicine. 44. 10.1016/j.mpmed.2016.09.017.
  9. Risk reduction and management of delirium SIGN 157 March 2019 https://www.sign.ac.uk/assets/sign157.pdf
  10. Bocatto MQShiozawa PTrevizol AP, et al Risperidone for delirium: where do we stand? 
  11. Efficacy of risperidone in the treatment of delirium in
    elderly patients Koji IKEZAWA,1,2 Leonides CANUET,1 Ryouhei ISHII,1 Masao IWASE,1 Yoshio TESHIMA2 and Masatoshi TAKEDA https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1479-8301.2008.00227.x
  12. BOETTGER, Soenke; BREITBART, William  y  PASSIK, Steven.Haloperidol and risperidone in the treatment of delirium and its subtypes. Eur. J. Psychiat. [online]. 2011, vol.25, n.2, pp.59-67. ISSN 0213-6163.  http://dx.doi.org/10.4321/S0213-61632011000200001.

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