Old Age Psychiatry Delirium

Dr Asso Fariadoon Ali Amin MRCP(UK)

Internal Medicine and Care of Elderly

Delirium • Delirium is a syndrome of disturbance of consciousness

accompanied by change in cognition not accounted for by dementia.

• Delirium is typically common in post operative patient , 43-61% after hip fracture.

• Acute condition with symptoms developing over hours or days. People with delirium appear disoriented and unable to focus their attention. Conversation difficult to follow, fluctuation of symptoms occur, often with diurnal variation ( worse at night).

• Diagnosis is difficult , patients can be miss diagnosed when they are deaf, blind, or dysphasic. More commonly missing the diagnosis, therefore routine screening is very useful using AMT.

Risk factors for delirium developing as an inpatient

• Old age• Severe illness• Pre-existing dementia, depression or previous delirium• Physical frailty – functional dependence, falls• Infection• Dehydration or malnutrition• Sensory impairment• Polypharmacy especially with psychoactive drugs• Surgery especially #NOF• Previous alcohol excess• Renal or hepatic impairment• Metabolic derangement e.g. hyponatraemia• Terminal illness

Causes• Infection:- Usually UTI, Chest infection, cellulitis, CNS, endocarditis,

biliary infection.

• Drug:- anti-cholinergic (like atropin), antipsychotic, anti-histamines, hypnotic and anxiolytic (diazepam), antidepressant specially tricyclic, anti-convulsant, opiates, corticosteriod, lithium, L-dopa like sinemet or madopar.

• Metabolic:- dehydration, hpo/hypernatraemia , uremia, hypercalcaemia.

• Vascular:- MI and stroke

• Alcohol and drug withdrawal.• Organ failure:- cardiac, respiratory, liver.

• Endocrine:- Hypothyroidism , hypo/hyperglycaemia

• Epileptic• Intracranial pathology like subdural haematoma, space occupying

lesions, pre-existing dementia, CVA.

Psychomotor Forms of Delirium

Hyperactive: Marked by increased motor activity, agitation, hallucinations, inappropriate behaviour & vigilanceHypoactive: Marked by lethargy with a decrease in motor activity, has a poorer prognosis. It is often missed (up to 2/3rds cases)Mixed

Diagnosis • Key Features:- I. Acute onset with fluctuation II. Disturbance of consciousness III. Impaired cognition not due to pre-existing dementia IV. Evidence of acute general medical condition, intoxication, or substance

withdrawal. Other features 1. Disturbance of sleeping –insomnia, daytime drowsiness, nocturnal

worsening of symptoms, nightmares revoke sleeping2. Behaviour change mainly restless, agitated, or apathy 3. Memory loss4. Inattention 5. Delusion, hallucination, and illusion 6. poor insight 7. Slurred speech

Clinical Assessment• History:- Taking full history from patient as well as collateral history ,

with concentration on any possible history of underlying infection.

• Examination:- May be difficult with distraction , focus again on any signs of infection, neurological deficit,

• Objective assessment:- AMT (Abbreviated Mental Test) Normal score 8 and more1. How old are you?

2. When is your birthday?

3. What time is it? Nearest

4. What Month or Year

5. Remember an address

6. Where are you? Place

7. What is my job or recognise people around

8. Second world war?

9. Name of Monarch/ President

10. Count from 20-1

Clinical Assessment Confusion Assessment Method (CAM) 1. Acute onset with fluctuating course AND

2. Inattention ( e.g. Count 20-1) unable to maintain or shift AND EITHER

3. a. Disorganised thinking ( disorganised or incoherent speech) OR

b. Altered level of consciousness.

Determining Underlying Cause (Investigation) • FBC

• Urea and Electrolyte

• LFT

• TFT

• Glucose

• Calcium and Phosphate

• ESR and CRP

• Urinalysis

• CXR, ECG, Pulse Oximetry

• Other Possible Investigation ABG, CT scan brain ,EEG Culture and sensitivity

Differential Diagnosis of delirium

• Dementia• Depression• Hysteria• Mania• Schizophrenia• Dysphasia• Non convulsive epilepsy / temporal lobe epilepsy

Assessment in delirium

• Collateral history from a carer or the NOK is essential to establish the onset & course of confusion to distinguish between dementia & delirium

• CAM• Assess cognitive function if possible on admission (AMTS

or MMSE) & subsequent serial measurements can track patients’ progress

• Assess for cause of delirium

Assessment in delirium – the history

• Previous intellectual function & functional status• Full drug history including recent cessations• History of fluid & food intake, alcohol history• History of bladder & bowel voiding• Sensory deficits & aids used• Previous episodes of acute or chronic confusion• Co morbidities• Symptoms suggestive of underlying cause• Pre-admission social circumstances & care package

Management5 Main stages

• Prevention and Early Detection

• Treatment of Underlying Causes

• Environmental Measures

• Pharmacology

• Prevention of Complication

MANAGEMENT • Prevention and early detection:- All older patient with acute illness should be

screened for delirium and should have AMT done. Consider delirium with a score of 8 and less.

• Identifying Underlying Causes:- Consider medication review , Infection, dehydration, electrolyte imbalance , MI, drug and alcohol withdrawal, urinary retention and faecal impaction and neurological like stroke or subdural haematoma.

• Environmental Measures:- Avoid overstimulation. Avoid sensory deprivation like spectacles or hearing aids Provide personal and environmental orientation Minimise discontinuity of care Ensure good hydration Ensure good nutrition Encourage mobility Avoid sleep deprivation

Involve relative and family Treat constipation and avoid catheter Ensure regular medical, nursing and medication review

Management• Pharmacology :- Stop possible causative drugs Agitated patients could be treated with 2 drugs :- lorazepam 0.5mg od or

haloperidol 0.5 mg . Should only be used to 1. prevent patients to endanger themselves and others 2. to allow essential investigation or treatment 3. to relieve distress in a highly agitated patients .

Preventing Complication Falls Pressure Sore Hospital acquired infection Functional impairment Incontinence Over-sedation Malnutrition

Wandering

• Close observation in a safe & reasonably secure environment

• Supervise them walking rather than trying to stop them

• Identify the cause of agitation – pain, thirst, looking for the toilet

• Distraction – involve family members if possible

Wandering

Rambling speech

• Do not agree with rambling speech as my re- enforce any paranoid component

• Tactfully disagree• Change the subject• Acknowledge the feelings expressed but

not the content

Rambling speech

Sedation - indications

• In order to carry out essential investigations or treatment

• To prevent a patient endangering themselves or others

• To relieve distress in a highly agitated or hallucinating patient, after assessing whether there is a physical cause for that distress

Sedation – options 1

• Always try to use the oral route, as im injections can be seen as an escalation in hostilities!

• When dosing – start low & go slow• Options: Haloperidol 0.5 – 1mg bd with additional doses every four

hours aim for maximum dose of 5mg, but may need to go higher.

Avoid in patients with PD & Dementia with Lewy Bodies, hepatic insufficiency, drug or alcohol withdrawal & neuroleptic malignant syndrome

Sedation - options 2

• Lorazepam 0.5 – 1mg: Which may be given up to 2 hourly, maximum dose

3mg/24hrs

• Atypical anti-psychotics:

Olanzapine 2.5 – 5mg od

• Use in those with PD, Dementia with Lewy Bodies

Example • 78 years old patient admitted with acute confusion

for the last 3 days. The family have noted change in urine colour as well as change in odour, also had low grade fever. O/E looked dehydrated, AMT 6/10 , temperature 37.9 , RR 24 , HR 90 bpm. Past medical history:- severe OA of both knees , Hypertension, on tramadol, paracetamol, bendrofluazide. Blood test shows high urea, Na 125 , FBC normal. , ESR 60, CRP 80, TFT normal, LFT normal, Urine dip positive.