delirium - metro north hospital and health servicewhat is delirium • disturbance in attention and...

DeliriumDenise Hobson

RBWH

Learning objectives

• Assess, diagnose and manage the older patients with delirium• Identify red flags in order to improve safety• Outline referral mechanisms and criteria • Recognise and use new clinical resources

Presenter

Presentation Notes

What is your experience with delirium? Have all of you seen patients with delirium? Do you send them to hospital? Why / why not? What worries you about these patients? What do you do with patients with delirium when they are discharged?

What is delirium?

• Disturbance in attention and awareness• Plus an additional disturbance in cognition

• Acute onset (hours to days) & tends to fluctuate during course of day

• Not better explained by another neurocognitive disorder• Evidence that disturbance is caused by a medical condition,

substance intoxication or withdrawal or medication side effect

American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.) 2013.

Presenter

Presentation Notes

What is delirium? There are 5 characteristics outlined in the DSM-V criteria: Attention - reduced ability to direct, focus, sustain, and shift Cognition - memory deficit, disorientation, language, visuospatial ability, or perception Evidence of medical condition – on history, physical examination, or laboratory findings Additional features that may accompany delirium and confusion include: Psychomotor behavioural disturbances (hypoactivity, hyperactivity with increased sympathetic activity, impairment in sleep duration and architecture) Variable emotional disturbances (fear, depression, euphoria, perplexity)

What is delirium

• Disturbance in attention and awareness• Plus an additional disturbance in cognition

• Acute onset (hours to days) & tends to fluctuate during course of day

• Not better explained by another neurocognitive disorder• Evidence that disturbance is caused by a medical condition,

substance intoxication or withdrawal or medication side effect

American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.) 2013.

Presenter

Presentation Notes

Medical emergency – analogous to acute renal failure, acute respiratory failure ** Is a syndrome, not a diagnosis – essential to look for underlying cause (although not always found) **

Why is delirium serious?

• Common – particularly in elderly patients• 10 – 31% have delirium at admission 1• 3 – 29% develop delirium 2

• Poorer outcomes• Medical, surgical and hospital associated complications• Longer length of stay• Functional and cognitive decline – increased institutionalisation• Increased mortality

1. Siddiqi N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing, 2006.2.Inouye SK. Delirium in older persons. N Engl J Med, 2006.

Why is delirium serious?

Beveridge, A. British Journal of Psychiatry, 2007.

Presenter

Presentation Notes

The other reason delirium is serious is it is a cause of patient, carer and staff distress Patient story (delirious lady with policeman husband) Carer (premature decision to place in RACF as thinks this will be permanent, upset by things said – damage to relationship) Staff (excess use of physical & chemical restraint)

What does delirium look like?

... pleasantly confused ...

... screaming in pain ...

... refused meals / meds / interventions ...

... drowsy, falling asleep ...

... unsettled & confused, crying out ...

... trying to get out of bed ...

Presenter

Presentation Notes

What patient presentations have you seen? What makes you think of delirium?

What does delirium look like?

... pleasantly confused ...

... screaming in pain ...

... refused meals / meds / interventions ...

... drowsy, falling asleep ...

... unsettled & confused, crying out ...

... trying to get out of bed ...

Presenter

Presentation Notes

Does anyone use a delirium screening / assessment tool???

4AT

Presenter

Presentation Notes

Screening test and RBWH – 4A’s Test Alertness AMT4 Attention Acue change – relies on collateral although can ask patient are they feeling more confused as in 3DCAM Set for high sensitivity (>1 likely cognitive impairment, >4 likely delirium)

What are the risk factors for delirium?

Presenter

Presentation Notes

Risk factors: (whiteboard if possible?) Predisposing Precipitating Perpetuating – why hospital is bad

Predisposing factors

Increasing age

Cognitive impairment

Sensory disturbances

Depression

Co-morbidity

CNS disease

History of delirium

Presenter

Presentation Notes

Age as marker of frailty Anything that makes your brain vulnerable Comorbidity / polypharmacy – makes your entire system vulnerable Impairment of sensory inputs

Precipitating factors

Electrolyte disturbance

Severe illness / injury

Pain Infection

Sleep disturbanceDehydration

Immobility

Disorientation

Restraints

Medications

CorticosteroidsOpioids

Benzodiazepines

Withdrawal

Malnutrition

Presenter

Presentation Notes

Illness factors Medications and withdrawal (particularly centrally acting agents) Symptoms & hospitalisation complications

Risk of delirium



Pain

Infection

Sleep disturbance Dehydration

Immobility

Disorientation

Restraints

Medications


Benzodiazepines

Withdrawal

Malnutrition

AgeCo-morbidity

Previous deliriumCognitive impairment

Sensory disturbanceCNS diseaseDepression

Presenter

Presentation Notes

Effect of one issue (eg. malnutrition) on the others

Risk of delirium



Pain

Infection


Immobility

Disorientation

Restraints

Medications


Benzodiazepines

Withdrawal

Malnutrition

AgeCo-morbidity



Presenter

Presentation Notes

Reciprocal effects that make the malnutrition worse

Risk of delirium



Pain

Infection


Immobility

Disorientation

Restraints

Medications


Benzodiazepines

Chemo / XRT

Withdrawal

Malnutrition

AgeCo-morbidity



Presenter

Presentation Notes

Cascade – demonstrates why single interventions don’t work and why need multifactorial interventions to prevent and treat delirium

Can delirium be prevented / treated?

Inouye SK et al, A multicomponent intervention to prevent delirium in hospitalized older patients. New Eng J Med, 1999.

Presenter

Presentation Notes

RBWH – Eat Walk Engage Treatment evidence much less than prevention No evidence for antipsychotics, melatonin, benzodiazepines, multiple other medications that have been trialled… Best evidence is for multi-faceted intervention targeting risk factors Focus on reversing underlying medical cause and preventing harm

How do we prevent / treat delirium?

• Early screening• Assessing for delirium• Interventions to prevent delirium• Identifying and treating underlying causes• Preventing falls and pressure injuries• Minimising use of antipsychotic medicines• Transition from hospital care

How do we support families?

http://www.health.gov.au/internet/publications/publishing.nsf/Content/CA2578620005D57ACA25794B001A23C5/$File/DeliriumPtBroch.pdf

What to do if your patient is delirious?

• Identify and treat underlying cause

• Education of patient and carer

• Consideration of hospital – risks vs benefits

• Minimise use of antipsychotic medications

• Monitoring cognition in vulnerable patient

Presenter

Presentation Notes

** Use of written case studies to stimulate discussion if GPs don’t bring own cases for discussion ** Intensity of investigations for delirium Increased risk of dementia in patients who have had delirium Unmask cognitive vulnerability?

delirium - metro north hospital and health servicewhat is delirium • disturbance in attention and...

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