Delirium in the acute hospital

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Delirium in the acute hospital

• Dr Louise Allan
• Clinical Senior Lecturer and Honorary Consultant
  Geriatrician 
• British Geriatrics Society

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What is delirium?
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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

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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.

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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

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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

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Three types of delirium

• Hyperactive
• Hypoactive
• Mixed

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Why is it important?

• Its the cognitive superbug

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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

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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

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How common is it?

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

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Who gets delirium?Anyone!

• Age over 65
• Dementia
• Frailty
• Sensory impairment

• Severe illness
• Recent surgery/ fracture
• Drugs
• Alcohol

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What are the most common causes?

• Pain
• Infection
• Constipation
• Hydration
• Medication
• Environment

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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

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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

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How is it prevented?

• The environment

• Avoid

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

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

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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

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After delirium

• Frightening experience
• Post traumatic stress
• Embarrassment
• Need for reassurance
• Need for information
• Need for recognition of dementia after delirium

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What are we up against?

• Culture
• Lack of training
• Competition from other patient safety initiatives

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THINK DELIRIUM
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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?