Summary:  Jeff Duncan

Editor:  Eve McClure

 

With Dr Scott Murray, Geriatrician, Royal Prince Alfred Hospital, Sydney, Australia

James speaks with Dr Scott Murray, Geriatric Physician, about an issue that concerns all of us late at night or in the early mornings on the wards.

Scott Murray is a Director of Prevocational Education and Training and a Senior Staff Specialist in Geriatric Medicine at Royal Prince Alfred and Balmain Hospitals, Sydney. Scott commenced Advanced Training at Royal Prince Alfred and Concord Hospitals before completing his FRACP at University College London and St. Pancras Hospitals in London. His special interests include acute care for older patients, continence, and JMO education.

Introduction

Delirium, sometimes called 'acute confusional state', is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1-2 days.

  1. It is a common clinical problem and a challenge for junior doctors afterhours. It is underrecognised with rates of approximately 20-30% in general medical wards, 50% on geriatric wards and in orthopaedic patients, can approach 85%. Hyperactive delirium manifesting as agitation, confusion and restlessness is often easy to recognise, whilst hypoactive delirium, manifesting as sedation, quietness and psychomotor retardation, is very easy to miss
  2. Early intervention in hospitalised patients reduces the risk of delirium, the severity and the duration of symptoms. With inattention and fluctuation signify the hallmarks of delirium, the CAM score is a rapid assessment tool for nursing and medical staff and may help distinguish delirium from other conditions such as depression, dementia and acute psychosis

Case – You are a junior doctor working afterhours covering the acute medical ward. You are called to see Joan, a 78 year old female who was admitted three days prior with community-acquired pneumonia and has been worrying the nurses this evening. She is crying out, moaning and, whilst attempting to get out bed, had a fall.
The nurses are requesting an assessment and the prescription of a tranquiliser to limit future activities.

 

1. Initial Assessment

  • How sick is the patient?
    • Observations including blood sugar
  • Risk assessment
    • To yourself, staff and the patient

2. Outline your assessment by the bedside

  • Approach
    • The patient with a calm manner
    • In a non-threatening way
    • Ask simple questions
  • History
    • Has there been any previous cognitive impairment?
    • Severity of the admission illness?
  • Examination
    • Brief cognitive assessment – orientation, attention, simple questions
    • Assess hydration status – examine for hypotension, low urine output
    • Generalised cardio-respiratory examination – examine for hypercapnia, hypoxia, respiratory rate etc
    • Gastrointestinal system examination
    • Neurological assessment where possible – although this is admittedly very difficult and it may be sufficient to focus on tone, power and brief sensory testing
    • An assessment of urinary retention
    • Important to assess the blood sugar level by the bedside

3. Investigations for delirium – both acutely at time of review and the following day

  • Full Blood Count, Biochemistry, Electrolytes/Urea/Creatinine
    • Specifically hyponatraemia, renal failure, hypercalcaemia, abnormal liver function (encephalopathy)
  • Urinalysis (U/A)
    • A positive U/A in a confused patient with fever may warrant antibiotics
    • A negative U/A can be VERY helpful in ruling out urinary tract infection
  • Chest X-ray
    • Look for pulmonary oedema or infection
  • ECG
    • Look for confusion secondary to underlying myocardial infarction

4. Causes of delirium

  • Which aetiologies of delirium are worthwhile considering in this patent?
    • Community-acquired pneumonia
    • Urinary retention
    • Constipation
    • Electrolyte abnormalities
    • Hypoglycaemia
    • Recent fall, with resultant haemorrhage
  • General categories of delirium to consider in the work-up
    • Infection (anywhere)
    • Medications
  • Anticholinergic medications e.g. antidepressants
  • Digoxin toxicity
  • Antiepileptics toxicity
    • Acute withdrawal – especially alcohol, substances, benzodiazepine withdrawal

5. Approach to initial management

  • Treatment of delirium is multifactorial
  • Non-pharmacological means first
    • Well-lit, quiet environment
    • Simple communication that is straightforward and easy to follow
    • Regular meal times
    • Adequate hydration
    • Good bowel care
    • Frequent re-orientation
    • Mobilisation
    • Inviting a family member to sit with the patient
      • Useful and may be facilitated at night-time in specific instances

6. In what situations is the prescription of a sedative medication appropriate and which agent?

  • In elderly patients, it’s important to start with lower doses and go slowly
  • Less frequent doses
  • Risperidone 0.5-1mg with reassessment in approximately 1 hour
  • Haloperidol 0.5-1mg with reassessment in approximately 1 hour
  • Olanzapine 2.5-5mg
  • Quetiapine 50-100mg – particularly useful in Parkinson’s Disease
  • Benzodiazepines
    • Very little evidence of use in delirium
    • With the exception of specific indications, such as acute withdrawal of alcohol and benzodiazepines

7. What are the long-term impacts of an episode of delirium?

  • Higher mortality
  • Longer length of stay
  • Common hospital complications – pressure ulcers, pneumonia etc.
  • Increased risk of discharge to a nursing home

Take home messages

  • Think about delirium in all patients, but particularly in acute surgical and often orthopaedic surgical patients
  • Prioritise your safety and your patient’s safety at all times
  • Identify delirium as a satisfying medical challenge and strive to identify underlying triggers
  • Most treatments of delirium produce their effects quite rapidly within 24-48 hours
  • Seek advice from senior staff in your team
  • Consult specialist staff e.g. geriatrics, psychiatry, addiction medicine

References

National Institute for Health and clinical Excellence (NICE). Delirium: diagnosis, prevention and management.

2010. July. Available from: https://www.nice.org.uk/guidance/cg103

Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2013. August. Available from: http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)60688-1.pdf

 

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Podcast

Delirium