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?