Delirium in the acute hospital Dr Louise Allan Clinical Senior Lecturer and Honorary Consultant Geriatrician British Geriatrics Society.

Delirium in the acute hospital

Dr Louise AllanClinical Senior Lecturer and Honorary Consultant

Geriatrician 

British Geriatrics Society

What is delirium?

What is delirium?

• Acute brain failure

• It can be acute without previous brain failure

• It can be recurrent

• Acute on chronic (previous chronic brain failure aka dementia)

• It can lead to chronic brain failure

What is delirium? DSM IV criteria

• Disturbance of consciousness (ie, reduced clarity of awareness of the environment) occurs, with reduced ability to focus, sustain, or shift attention.

• Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) occurs that is not better accounted for by a preexisting, established, or evolving dementia.

• The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.

• Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.

What is delirium?• Change in consciousness or alertness• Change in cognition

– Memory– Thinking– Perception (the senses)– Behaviour

• It happens over a short period• It goes up and down• It is usually caused by a physical illness

Behaviours

• Just “more confused”

• Poor attention- can’t give a history

• Looks around the room

• Agitated, plucking at bed clothes

• Hallucinating

• Very quiet or drowsy

• Reduced ability to care for self

• Loss of mobility

Three types of delirium

• Hyperactive

• Hypoactive

• Mixed

Why is it important?

• It’s the cognitive “superbug”

Why is it important?

• It is often not diagnosed• A common problem• Increased length of stay and complications• Poor outcomes- mortality, admission to care

home • It often takes a long time to get better• It doesn’t always get better

Why is it important?

• It can be prevented

• It can be treated

• If it does happen, good care will shorten the duration

• Good communication reassures and also provides realistic expectations

• Good practice saves money

How common is it?

• Delirium is common in acute hospitals e.g.– 22% in general medicine– 28% acute orthopaedics– 80% medical ICU

Who gets delirium?Anyone!

• Age over 65• Dementia• Frailty• Sensory impairment

• Severe illness• Recent surgery/

fracture• Drugs• Alcohol

• Pain

• Infection

•

Constipation

• Hydration

• Medication

•

Environment

What are the most common causes?

How is it diagnosed?Short Confusion Assessment

Method

1. Acute onset or fluctuating course

AND

2. Inattention

AND EITHER

3. Disorganised thinking/ incoherent speech

OR

4. Altered level of consciousness

Other features

– Memory impairment– Disorientation to time, place or person– Agitation e.g. the patient is repeatedly pulling at her

sheets and IV tubing – Retardation – Visual or auditory misinterpretations, illusions, or

hallucinations– Change in sleep wake cycle e.g. excessive daytime

sleepiness with insomnia at night

How is it prevented?

The environment:

• Hearing aids • Spectacles • Orientation aids• Lighting• Encourage food and fluid intake• Encourage mobility• Maintain sleep pattern • Involve relatives and carers

Avoid:

• Constipation• Catheters• Restraint• Sedation• Bed or Ward moves • Arguing with the

patient

How is it treated?

• Treat infection• Correct metabolic abnormalities• Correct hypoxia• Review medication but ensure adequate

analgesia• Many episodes of delirium are

multifactorial• Treat all the underlying causes

After delirium

• Frightening experience

• Post traumatic stress

• Embarrassment

• Need for reassurance

• Need for information

• Need for recognition of dementia after delirium

What are we up against?

• Culture

• Lack of training

• Competition from other patient safety initiatives

THINK DELIRIUM

Table top exercise

• Does your group have experience of delirium?

• Were you given information about it?

• What can you organisation do?

• What can the DAA do?