Delirium Case Presentation

Case  93 ♂  PC 4/7 Confusion, agitation + general deterioration 3/7 poor urine output

PMH  BPH  Long term catheter in situ  MI

DH  Omeprazole 20mg po od  Betahistine 8mg po om  Aspirin 75mg po om  Calcichew D3 forte

SH  Lives with wife  No carers  Independent around house  Enjoys doing crosswords  Recent falls

O/A  Temp 35.8  Dehydrated  GCS 13/15  AMTS 7/10  Urine offensive odour Dip +ve blood, leukocytes, nitrites

Bloods  WCC 14.1  Neut 9.7  Hb 12.0  Na 126  K 4.4  Urea 3.8  Creat 78  CRP 10

Diagnosis  Acute confusion  UTI  Hyponatraemia  Ciprofloxacin 5/7  Omeprazole + betahistine stopped

Day 2  GCS 7/15  CT Brain Small vessel ischaemia No evidence of space occupying lesion, intracranial haemorrhage or skull #  CRP 46

After 2/52  GCS 15  AMTS 10/10  A/W discharge home  Prophylactic trimethoprim

Delirium  Derived from Latin ‘off the track’

Delirium  Transient global disorder of cognition  Medical emergency  Affects 20% patients on general wards  Affects 30% of elderly medical patients  Associated with increased mortality, increased nursing, failed rehab and delayed discharge

Presentation  Acute + relatively sudden onset (over hours to days)  Decline in attention-focus, perception and cognition  Change in cognition must not be one better accounted for by dementia  Fluctuating time course of delirium helps to differentiate

Characterised by:  Disorientation in time, place +/- person  Impaired concentration + attention  Altered cognitive state  Impaired ability to communicate  Wakefulness – insomnia + nocturnal agitation  Reduced cooperation  Overactive psychomotor activity – irritability + agression

Diagnosis  Cannot be made without knowledge of baseline cognitive function  Can be confused with 1. dementia – irreversible, not assd with change in consciousness 2. depression 3. psychosis – may be overlap but usually consciousness + cognition not impaired

Differentiating features of delirium and dementia FeaturesDeliriumDementia OnsetAcuteInsidious CourseFluctuatingProgressive DurationDays – weeksMonths - years ConsciousnessAlteredClear AttentionImpairedNormal (unless severe) Psychomotor changes Increased or decreased Often normal ReversibilityUsuallyRarely

Risk factors in elderly  Age >80  Extreme physical frailty  Multiple medical problems  Infections (chest + urine)  Polypharmacy  Sensory impairment  Metabolic disturbance  Long-bone #  General anaesthesia

Risk factors  Dementia is one of the most consistent risk factors  Underlying dementia in 25-50%  Presence of dementia increases risk of delirium by 2-3 times

Causes  Severe physical or mental illness or any process interfering with normal metabolism or function of the brain

Causes mnemonic  Infections (pneumonia, UTI)  Withdrawl (alcohol, opiate)  Acute metabolic (acidosis, renal failure)  Trauma (acute severe pain)  CNS pathology (epilepsy, cerebral haemorrhage)  Hypoxia  Deficiencies (B12, thiamine)  Endocrine (thyroid, PTH, hypo/hyperglycaemia)  Acute vascular (stroke, MI, PE, heart failure)  Toxins/drugs (prescribed tramadol, dig toxicity, antidepressants, anticholinergics, corticosteroids) recreational)  Heavy metals

Pathophysiology  Not fully understood  Main theory = reversible impairment of cerebral oxidative metabolism + neurotransmitter abnormalities  Ach – anticholinergics = cause of acute confusional states + Pts with impaired cholinergic transmission (eg Alzheimers) are more susceptible  Dopamine – excess dopamine in delirium  Serotonin – increased in delirium  Inflammatory mechanism – cytokines eg interleukin-1 release from cells  Stress reaction + sleep deprivation  Disrupted BBB may cause delirium

NICE Guidelines

Management  1. Identify + treat underlying cause (return to pre-morbid state can take up to 3 weeks)  2. Complete lab tests + investigations eg. FBC, CRP, U+Es, BM, LFTs, TFTs, B12, MSU, CXR  3. Rule out EtOH withdrawl  4. Assume an underlying organic cause

Management  5. Ensure adequate hydration + nutrition  6. Use clear, straightforward communication  7. Orientate the patient to environment + frequent reassurance  8. Identify if environmental factors are contributing to confused state

Management  Disturbed, agitated or uncooperative patients often require additional nursing input  Medication should not be regarded as first line treatment  Consider medication if all other strategies fail but remember all psychotropic meds can increase delirium + confusion

Medications  Benzodiazepines Lorazepam 0.5-1mg tds orally Shorter half life than diazepam + effective at lower doses S/E -Respiratory depression, increased risk of falls, hypotension Not for long term use

Medications  Antipsychotics Avoid in PD Haloperidol 0.5-1mg S/E – cardiac, avoid in patients with hypotension, tachycardia + arrhythmias, extrapyramidal Recent evidence suggests not to use in patients with dementia or risk of CVD due to increased risk of cerebral ischaemia 3X increase in risk of stroke when Risperidone used in older patients with dementia

Medications  Dementia with Lewy Bodies Severe reactions to antipsychotic drugs that can lead to death  Due to extrapyramidal effects Urgent psychiatric opinion

Medication  Review regime every 48h  Will not improve cognition  Can reduce behavioural disturbance  Start with lowest dose possible + increase gradually  Offer orally first  Use as ‘fixed dose’ regime

Complications  Malnutrition  Aspiration pneumonia  Pressure ulcers  Weakness, decreased mobility, decreased function  Falls, #s

Outpatient Care  Memories of delirium are variable  Educate patient, family + carers about future risk factors  Elderly patients can require at least 6-8 weeks for a full recovery  For some patients the cognitive effects may not resolve completely

RUH Algorithm for diagnosis + management of delirium in older adults