Delirium in the acute hospital Dr Louise Allan Clinical 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- cant 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? Its 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 doesnt 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 What are the most common causes? Pain
Infection Constipation Hydration Medication 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?
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?
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