Jason BolandSenior Clinical Lecturer and Honorary Consultant in Palliative MedicineDirector, Gateway to Medicine YearAcademic lead for Palliative careWolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UKCare Plus Group and St Andrews Hospice, NE Lincs, UK

Hypoactive Delirium and Other Causes of Impaired Consciousness

Overview

Impaired Consciousness• Causes• Medication

Hypoactive Delirium• Causes• Diagnosis• Management

Impaired Consciousness

Hypoactive delirium DyingDepressionInfection Seizure (post-ictal); also non-convulsive seizuresHepatic/uraemic encephalopathyRaised ICPStrokeHypoglycemia/ hyperglycemiaIllicit drugsMedication

Medication causing Impaired Consciousness

Opioidsexcess opioid dosing (prescription, ++PRNs, SD, patches, renal failure) –check RR and Sats

• opioid-induced neurotoxicity

Levomepromazine, benzodiazepines, pregabalin/gabapentin (esp if renal failure)Review PRNs given; repeated doses

Serotonin syndromeNeuroleptic malignant syndrome

Illicit drugs, cannabis, alcohol

Why care?

Hypoactive delirium is associated with poorer outcomes, including:

Increased mortality, length of stay, falls and admission to longer term care

Presents or is diagnosed later - docile patients may not come to HCPs attention

Most delirium is missed, especially hypoactive

Why hypoactive delirium can be missed

• Too withdrawn to alert a HCP, particularly if isolated without family / carers

• Elderly patients may be isolated

• Fluctuates - periods of near-normality may coincide with a clinician’s assessment

• Diagnosis - longitudinal overview, shift from baseline, careful assessment

• Lack of continuity of care, poor access to the latest records (medication changes,

recent admissions, or other risk factors - dementia or sensory impairment)

• Delayed assessment because the patient is not deemed urgent

Independent risk factors

Use of physical restraintsMalnutritionUse of a bladder catheterAny iatrogenic eventUse of 3 or more medications

Factors particularly associated with hypoactive delirium• Increasing age• Prior cognitive impairment• Organ failure• Metabolic disturbance• Dehydration

Diagnosis - overview

Need all of the following:

1. Disturbance in consciousness - attention and awareness

2. Disturbance in cognition

3. Develops acutely and fluctuates

4. Not better explained by other neurocognitive disorder

5. Evidence of physiological consequence of another medical condition

Diagnosis

Disturbance in attention - reduced ability to direct, focus, sustain, and shift attention

Awareness - reduced orientation to the environment

Cognition - memory deficit, disorientation, language, visuospatial ability, perception

4AT:

– Attention - name the months of the year backwards

– Awareness - age, date of birth, place (name of the hospital or building), and year

Diagnosis

Develops acutely (hours -days) from baseline attention and awareness

Fluctuates in severity during the day

Collateral information—family, staff, carers, case notes containing reference

to previous cognitive states

Diagnosis

Not better explained by a pre-existing, established, or evolving neurocognitive

disorder and do not occur in the context of a severely reduced level of arousal

such as coma

Collateral history to determine whether cognitive changes are longstanding

and therefore more likely to be due to dementia, which may or may not have

been diagnosed previously

Diagnosis

Evidence from history, examination, or investigations that the disturbance is a

direct physiological consequence of another medical condition, substance

intoxication or withdrawal (alcohol/drugs/medication), multiple causes

careful history taking and examination and the use of appropriate

investigations

Tools

4A’s Test (4AT) and the Nursing Delirium Screening Checklist (NuDESC)

validity in hypoactive patients and suitable for busy clinical practice

• Sensitivity >85%

• Specificity >85%

Management

Current evidence does not support the use of antipsychotics for prevention or treatment of delirium.

You can still do and help without drugs…….

Management

Manage acute, life-threatening causes of deliriumhypoxia, hypotension, hypoglycaemia, drug intoxication / withdrawal

Prevent delirium complications immobility, falls, pressure sores, dehydration, infections, isolation

Identify and treat potential causes (medications, acute illness). Multiple causes

Explanation including written information

Reorientation

Memory cues - calendar, clocks, and family photosEnvironment should be stable, quiet, and well-litSensory deficits should be corrected - eyeglasses and hearing aidsFamily members / staff should explain who they are & proceedings at every opportunity, reinforce orientation (day, date, time, and location), reassure Support from a familiar nurse and family

No physical restraints• may pull out lines, climb out of bed, not compliant

Perceptual problems lead to agitation, fear, combative behaviour, and wandering

Drugs

No evidence for antipsychotics for prevention or treatment of delirium

• Additional methodologically rigorous studies using standardized outcomes

• Reserved for delirium that causes injury to the patient or others

Benzodiazepines - alcohol and benzodiazepine withdrawal and delirium

resulting from seizures

Thiamine/Vitamin B-12 for alcohol withdrawal or Wernicke encephalopathy.

A multi-component delirium prevention

Cognition and orientation• Cognitive stimulation activities, such as reminiscing• Orientation board - names of staff and daily schedule• Talking to the patient to re-orientate themEarly mobility• Ambulation or active range-of-motion exercises• Minimising use of immobilising equipmentHearing• Amplifying devices, communication techniques• Ear wax clearing Vision• Visual aids (glasses, magnifying lenses) and adaptiveequipment (large illuminated telephone keypads, largeprint books, fluorescent tape on call bell)Daily reinforcement of their use

Sleep-wake cycle preservation• Encourage sleep: Warm milk or herbal tea, relaxation tapes or music, massage• Uninterrupted sleep: Noise reduction strategies and schedule adjustments Hydration• Encourage fluid intake• Feeding assistance and encouragement during mealsService• Education for staff• Protocols targeting specific risk factors • Review and change medication, encourage patientmobilisation, and improve patient environment

Interdisciplinary team

Thank you

Questions?