1. Delirium facts and figures
Daniel Davis
Senior Clinical Researcher
Consultant in Geriatric Medicine
University College London
Dementia Friendly Hospitals
Dementia Action Alliance
24th November 2015

2. Overview What is delirium Why is it important How to diagnose delirium
How to manage delirium
It’s also very clear, and well known clinically, that there are several predisposing factors which heighten the risk. 2

3. What is delirium?

4. A neuropsychiatric syndrome
DSM-IV:
Disturbance of consciousness
Change in cognition
Acute
Physiological precipitant
Cognitive decompensation under stress conditions
Psychiatrists – describe it,
Physicians naturally recognise the inverse nature of delirium:
PREDISPOISING FACTORS
PRECIPITATING FACTORS
(this is actually borrowed from psychiatric formulation)
There is evidence for this ... Inouye, Marcantonio
But the KEY MESSAGE is that any research into delirium must account for BOTH these factors:
from an EXPLANATORY point of view
in order to assess whether it is the DELIRIUM PER SE (or underlying predis / precip factors) that is driving the adverse outcomes

5. Range of delirium severity
Normal function
Range of abnormalities
of cognition:
quantifiable
Range of abnormalities
of level of arousal
Range of delirium severity
It’s also very clear, and well known clinically, that there are several predisposing factors which heighten the risk.
‘Untestable’ with most
cognitive tests
Coma 5

7. Subtype Mixed Hyperactive Hypoactive Wandering, aggressive
Hyper-alert, agitated
Strong
Difficult to reason with
Pulling at lines
Easily recognised
Often medicated
Hypoactive
Quiet, bewildered
Sleepy, innattenitve
“off-legs”
Highest mortality
– HR 1.6
Most often unrecognised
More common
Mixed
Geront Series A: 2007; 62:

8. Why does delirium matter?

9. Why delirium matters
Common 15% hospital Serious 20% mortality Marker for dementia 60% underlying Costly £13k / admission Distressing
15% prevalence in those aged 65 years and older, admitted to general medical beds
20% mortality in 3m = similar to anterior STEMI
As a marker for dementia, individuals with delirium are an enriched source of persons with underlying dementia
£13k per admission comes from the NICE economic analysis, and accounts for the short- and long-term complications of delirium.
There may be a perception that patients are amnestic for delirium. That is a myth. Recall of delirium symptoms after the event can approach a PTSD-like disorder. Delirium is undoubtedly distressing for relatives. There is also evidence that delirium is distressing for care staff.

10. Diagnosis and management

11. Action plan Diagnose Precipitating and predisposing
Optimise environment
Treat specific symptoms
It’s also very clear, and well known clinically, that there are several predisposing factors which heighten the risk. 11

12. Initial approach [1] Assess arousal [2] Test cognition
[3] Acute onset and/or fluctuating course? 12

13. Screening tests Confusion Assessment Method 4 “A”s Test
Nursing Delirium Screening Scale
Delirium Observational Screening Scale
Recognising Acute Delirium As Routine

14. Causes Precipitants Infections Drugs (on/off) Specific organ failures
Pain
Bladder
Bowels
Predisposing
Dementia
Frailty
Mobility

15. Management (+)/- Prevent Treat +/(-) Pharmacological +
Prevent
Treat
Pharmacological
 +/(-)
 (+)/-
Non-pharmacological  +