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Delirium: developing a clinical pathway for Scotland. Alasdair MacLullich Professor of Geriatric Medicine Consultant in Geriatric Medicine University of Edinburgh. What is delirium? Severe, acute neuropsychiatric syndrome Cognitive impairments Reduced or increased level of consciousness

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slide1

Delirium: developing a clinical pathway for Scotland

Alasdair MacLullich

Professor of Geriatric Medicine

Consultant in Geriatric Medicine

University of Edinburgh

slide2
What is delirium?

Severe, acute neuropsychiatric syndrome

Cognitive impairments

Reduced or increased level of consciousness

Psychotic features are common

Resolves in 80%

Mainly affects older people in hospital

slide3
Delirium is common and serious

>120 patients per 1000-bedded hospital

1 in 5 dead in a month

New institutionalisation

Strong marker of dementia

Accelerates existing dementia; linked with new onset dementia

Distressing

High healthcare and social costs

Yet …

Only 20-25% detected

Generally poorly managed

slide6

Detection of delirium

      • “THINK DELIRIUM”
  • NICE GUIDELINES, 2010
slide7

Core features

      • Acute onset/fluctuating course
  • Inattention
  • Additional features
      • Altered alertness (eg. drowsiness)
      • Other cognitive deficits, eg. in memory
      • Poor comprehension
  • Psychotic features
  • Sleep-wake cycle disturbance
slide8

Delirium: many formal and informal terms

  • Creates problems: imprecision
  • Delirium and dementia get mixed up
  • ‘Delirium’ triggers specific actions
  • ‘Cognitive impairment’, ‘confusion’ usually don’t
  • best to use the term ‘delirium’
slide9

What method should be used for detection?

Draft pathway states: local tools

Most sites don’t have delirium screening implemented

The 4AT being used in some sites: www.the4AT.com

slide11

Looking for causes 1: acute, severe illness

    • If delirium suspected, treat as a medical emergency
    • (1 in 5 are dead in one month)
    • Nursing / medical input early
    • ABC
    • Pulse / BP / RR / saturations / temp / BM / check drugs
slide12

Looking for causes 2: general assessment

  • Standard history and examination, +
  • FBC, U&E, Ca, LFTs, glucose
  • CRP
  • TFTS
  • ECG/CXR
  • ABGs
  • Urinalysis/MSU
  • CT head / MRI (if head injury or focal neurological signs or if persisting delirium after 5 days)
slide13

Looking for causes 3: drug review

Opioids

Benzodiazepines

Antipsychotics

Amitriptyline

Anti-spasmodics, eg. oxybutinin, buscopan

Anti-epileptics when not used for epilepsy, eg carbamazepine

Anti-histamines eg cetirizine

Anti-hypertensives (when causing hypotension)

slide14

Informant history

Mental status change:

Onset, duration, fluctuating?, character

Helpful in detecting BPSD

Also to detect previously undiagnosed dementia

Drug/alcohol use

Activities of daily living

Personality, preferences, etc.

slide16

Treat causes

Infections

Drugs

Other acute illnesses

Pain

Drug effects

Drug and/or alcohol withdrawal

Etc.

treating agitation distress
Treating agitation & distress
  • Non-pharmacological
      • look for acute cause (pain, thirst, hunger, urinary retention)
      • repeated orientation
      • reassurance
      • avoidance of confrontation
      • avoidance of physical contact (can be perceived as assault)
  • Pharmacological
      • haloperidol 0.5mg 20-30 min intervals
      • risperidone 0.25mg nocte
      • consider lorazepam 1mg, but SECOND LINE (PD, DLB, BDZ/EtOH w/d)
slide18

General care

  • Provide calm environmental & personal orientation
  • Hearing aids, glasses
  • Oxygen, hydration, nutrition
  • Treat pain
  • Avoid constipation (treat if in doubt)
  • Do not catheterise unless necessary
  • Observe sleep pattern, correct if possible
  • Involve relatives & carers
slide20

Specialist referral

In 5 days if delirium persisting, sooner if delirium is severe

Liaison psychiatry or geriatric medicine

Assessment of possible dementia

Cognitive testing if delirium resolved

IQCODE

Follow-up by GP or specialist clinic

slide21

Resources (eg. clinical pathways, patient information sheets) at:

  • www.scottishdeliriumassociation.com
  • __________________________________________________
  • www.europeandeliriumassociation.com
  • 8th Annual Meeting
  • Leuven, Belgium, Sep 20-21, 2013