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- 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 • Severe illness
• Dementia • Recent surgery/
• Frailty fracture
• Sensory impairment • Drugs
• Alcohol
What are the most common
causes?
• Pain
• Infection
• Constipation
• Hydration
• Medication
• Environment
 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: Avoid:

• Hearing aids • Constipation

• Spectacles • Catheters
• Orientation aids • Restraint
• Lighting • Sedation
• Encourage food and fluid intake • Bed or Ward moves
• Encourage mobility • Arguing with the
• Maintain sleep pattern patient
• Involve relatives and carers
 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?