THINK DELIRIUM

Matt Lambert

Clinical Lecturer and Specialty Registrar in Geriatric Medicine and Stroke

mlambert@nhs.net

What I’m going to talk about• Why am I here talking about delirium? Why is it

important?• How do we diagnose delirium and how bad are we at it?• How should we be managing delirium?• How can we do better?

What I’m going to talk about• Why am I here talking about delirium? Why is it

important?• How do we diagnose delirium and how bad are we at it?• How should we be managing delirium?• How can we do better?

Dear Receiving Doctor,

Re: Mrs Connie Fused 0101240125

Thank for admitting this 89 year old lady with confusion. She has a history of vascular dementia, TIAs, OA of her hips, depression and AF. She has recently been treated for recurrent UTIs. She normally lives alone with a carer once daily. Over the last few days her carers have noticed that she has become more confused and is incontinent of urine.

Her medication consists of aspirin, simvastatin, bendrofluazide, co-codamol 30/500, citalopram, levothyroxine and tolterodine.

Thank you for assessing her.Yours sincerely,

GP

Patient experience

Delirium Matters◦Loss of independence

◦Higher chance of being admitted to institutionalised

care - 83% of those with persisting delirium at

discharge, 68% with resolved delirium, 42% in those

who never had delirium.[1]

1.McAvay GJ, van Ness PH, Borgardus ST et al. Older adults discharged from hospital with delirium:

one year outcomes. J Am Geriatr Soc. 2006: 54: 1245-50.

Delirium Matters

◦Increased risk of mortality◦In patients who are admitted with delirium, mortality rates

are 10-26%[1]

◦Patients who develop delirium during hospitalization have

a mortality rate of 22-76% and a high rate of death during

the months following discharge.[2]

1.McCusker J, Cole M, Abrahamowicz M, Primeau F, Belzile E. Delirium predicts 12-month

mortality. Arch Intern Med. Feb 25 2002;162(4):457-63.

2. American Psychiatric Association. Practice guideline for the treatment of patients with

delirium. Am J Psychiatry. May 1999;156(5 Suppl):1-20.

Delirium Matters ◦Morbidity

◦In patients who are elderly and patients in the

postoperative period, delirium may result in a

prolonged hospital stay, increased complications,

increased cost, and long-term disability.[1]

1. Marcantonio ER, Kiely DK, Simon SE, et al. Outcomes of older people admitted to postacute facilities

with delirium. J Am Geriatr Soc. Jun 2005;53(6):963-9.

Delirium Matters• Partly preventable and treatable• Indicator of dementia

• ~2/3 of patients with delirium also have dementia

• Common• 15% of adult acute general hospital patients• 25% of acute geriatric patients• Post hip fracture surgery: 40-60%• 7% of everyone >65 will develop delirium annually

What I’m going to talk about• Why am I here talking about delirium? Why is it

important?• How do we diagnose delirium and how bad are we at it?• How should we be managing delirium?• How can we do better?

Recognition

• Often unrecognised• Fluctuation nature• Overlap with dementia• Lack of formal cognitive assessment• Underappreciation of its clinical consequences• Failure to consider the diagnosis important

Local Audit-AMU

• 20 case notes reviewed• Inclusion – 75 years or older, been admitted for

minimum of 8 hours• Exclusion – referred with “delirium”

Local Audit-AMU

• Results• All patients had potential precipitant or risk factor

identified (6 had 1, 11 had 2, 3 had all 3)• 7 patients had no cognitive screening performed• 13 had a change in function or cognition documented

• 3 of these did not have a cognitive screen• Delirium was likely in 11 patients

• Only diagnosed in 4• Delirium possible in further 3 patients

• Only excluded in 1 case

Local Audit-ASRU

• 5 sets of notes• All met criteria suggestive of delirium• 4 had existing dementia• 4 had polypharmacy• None had cognitive screening• None had function formally tested• None were described as “confused” or similar

Possible Conclusions

• Delirium under recognised• Lack of awareness?• Low on priorities?• Not seen as a diagnosis?

• No system in place to look for delirium/cognitive impairment

Diagnosing Delirium• “Acute confusion”• “Acute confusional state”• “Confusion”• “Agitation”• “Toxic psychosis”• “Off the legs”• “A bit knocked off”• “Non-compliant with examination”• “Disorientated in TPP”• “Acute brain failure”

• “Global brain dysfunction”• “Unable to obtain history”• “Vague”• “UTI”• “not themselves today”

Think Delirium

Tools to help diagnosis

• Confusion assessment method (CAM)• 4AT

CAM

• Does the patient have:• Inattention• Symptoms that are acute AND fluctuating• Disorganised thinking OR altered level of

consciousness

Who has the delirium?

4AT tool

www.the4AT.com

What I’m going to talk about• Why am I here talking about delirium? Why is it

important?• How do we diagnose delirium and how bad are we at it?• How should we be managing delirium?• How can we do better?

Delirium is a Medical Emergency

• A marker of:• physiological stress• acute illness

• It is not “normal”!

• Do ABC

What’s the cause?

Management1.Treat precipitating factors

2.Decrease impact of predisposing factors

3.Decrease distress (patients and carers)

4.Manage agitation

5.Prevent complications

6.Follow up –review meds, cognition, rehabilitation

What I’m going to talk about• Why am I here talking about delirium? Why is it

important?• How do we diagnose delirium and how bad are we at it?• How should we be managing delirium?• How can we do better?

Aims• Increase recognition and diagnosis of delirium• Encourage everyone to take it seriously and manage it

fully

Plans• Audit

• Audit management of patients with delirium• Audit detection and management in wards 5/6 and RVH.

• Tests of change• Trial delirium pathway in AMU initially for usability then role out

more widely• Being trialled on ASRU and ward 17

• Education• Delirium week

• Re-audit• Re-audit diagnosis and management of delirium after change

introduced.

Any Questions?