Recognising and Managing Acute Confusional State

Question 1

What is delirium?

Answer 1

• An episode of acute confusion.
  
  • Onset usually over hours/days.
• Delirium is a clinical syndrome which has disturbed:
  
  • Attention / consciousness
  • Cognitive function
  • Perception
• Fluctuates
• Due to underlying causes.
• Can be hyperactive or hypoactive.

Question 2

Describe hyperactive delirium.

Answer 2

• Causes the patient to experience:
  
  • Agitation
  • Restlessness
  • Aggression
  • Loss of concentration
  • Confusion
• May have hallucinations / delusions
• Can be difficult to manage

Question 3

Describe hypoactive delirium.

Answer 3

• Hypoactive delirium causes:
  
  • Slowing down
  • Sleepiness/lethargy
  • Reduction of consciousness
  • Reduced speech or interaction
• Higher mortality / poor prognosis
• Much harder to spot - is often just thought to be lathargia or illness.

Question 4

Describe mixed delirium.

Answer 4

A fluctuation between hyperactive and hypoactive delirium. A patient can swing from one to the other several times per day.

Question 5

Compare and contrast delirium and dementia.

Answer 5

Delirium

Dementia

Sudden onset

Gradual onset

Fluctuates

Does not usually fluctuate

Consciousness: attention reduced

Consciousness: unchanged

Perception: hallucinations common

Perception: hallucinations usually a late feature

Speech: can be incoherent / slow / rapid

Speech: repetitive

Usually reversible

Usually not reversible

Question 6

Which patients are likely to develop delirium?

Answer 6

• Anyone with a severe enough insult (regardless of age).
• Very common in ITU.
• Vulnerable and frail people develop delirium with a much smaller insult - less physiological reserve.
• Common in people with dementia - if a sudden worsening, screen for an underlying cause.

Question 7

What are the risk factors for delirium?

Answer 7

• Age >65
• Background cognitive impairment or dementia.
• Surgery, especially hip fracture - most people who have surgery for hip fracture are older and frail so it is probably the demographic which makes delirium more probable than the surgery itself.
• Comorbidities.
• Polypharmacy - 4+ medications increases risk.
• Sensory impairment.
• Functional Impairment - problems walking, needing help to go to the toilet.
• Sleep disturbance.
• Hospital admission.

Question 8

Describe the main changes in the body associated with ageing.

Answer 8

• Brain volume decreases by 5% per decade after 40.
• Vascular changes - up to 20% less blood flow.
• Reduced neurotransmitters (dopamine reduces by 10% per decade in adulthood).
• Kidney and liver function - unable to clear drugs.
• Decreased muscle mass, total body water and increased body fat - this changes how drugs are distributed through the body and this could potentially cause delirium.

Question 9

Describe frailty.

Answer 9

• Health state related to the ageing process in which multiple body systems gradually lose their in-built biological reserves.
• People lose their ability to compensate when they are medically challenged.
• Minor illnesses / insults can cause delirium and falls.

Question 10

What are the effects of delirium? Why is it important?

Answer 10

• Increased length of stay in hospital (21 vs. 9 days).
• Increased risk of dying - in hospital (11% vs. 6%) and up to 1 year later (27% vs. 15%).
• Increased risk of dementia.
• Increased risk of falls, pressure sores.
• More likely to go into 24 hour care (47% vs. 18% at 1 month).
• Can be very frightening for patient and family.
• Risk of death rises rapidly if not identified - increases by 11% with every 48 hour delay in diagnosis.
• If identified adn communicated appropriately can be followed-up and screened for dementia.

Question 11

Describe the pathophysiology of delirium.

Answer 11

• Mechanisms are not fully understood - hypothesis based on animal models.
• Changes to blood-brain barrier permeability; things which normally stay in peripheral circulation can enter the brain.
• Cerebral hemispheres or arousal mechanisms of the thalamus and brain stem reticular formation become impaired.

Question 12

Describe the pathophysiological mechanism of delirium.

Answer 12

• Increased cortisol / stress
• Increased cytokines (TNFα, IL1) / inflammation
• Increased dopamine
• Increased serotonin - stimulates the cortex.
• Increased GABA
• Decreased acetylcholine transmission (extremely important in cognition)

Question 13

What is the function of the reticular activating system?

Answer 13

• Network in the brain stem.
• Responsible for:
  
  • Arousal
  • Sleep
  • Pain
  • Muscle tone
• Ascending fibres arouse and activate the cerebral cortex.
• Controls levels of consciousness.

Question 14

Describe the process of identifying delirium.

Answer 14

• Full history - obtain collateral history.
• Key factors are acute onset, fluctuation, decreased attention.
• Review medication.
• Vital signs (NEWS scoring).
• Physical and neurological examination for signs of infection, dehydration, neurological changes.
• Consider capacity.
• Consider in any confused older person and don’t assume they have dementia (collaborative history).
• Look for plucking of bed clothes and air (carphology and floccillation).
• Use a screening tool.
• Up to 50% of cases missed by medical professionals.

Question 15

What are the screening tools used in the identification of delirium?

Answer 15

• SQiD - fo you think your relative has ben more confused recently?
• CAM - confusion assessment method.
• 4AT - recommended by Scottish Delirium Association.

Question 16

Describe the confusion assessment method (CAM).

Answer 16

Consider the diagnosis of delirium and if 1 and 2, AND either 3a or 3b is present:

1. Acute onset? Yes / no
2. Inattention? Yes / no
3. (a) Disorganised? (b) Altered consciousness? Yes / no

Question 17

Describe the 4AT.

Answer 17

1. Alertness
   
   • Normal = 0
   • Mild sleepiness for <10 seconds on waking = 0
   • Clearly abnormal = 4
2. AMT 4
   
   • Age, DOB, place, current year?
   • No mistakes = 0
   • 1 mistake = 1
   • ≥2 mistakes = 2
3. Attention
   
   • Ask patient to recite the months of the year backwards starting at December.
   • Achieves ≥7 correctly = 0
   • Starts but scores <7 months / refuses to start = 1
   • Untestable (cannot start because too unwell, drowsy, inattentive) = 2
4. Acute change
   
   • Evidence of significant change or fluctuation in:
     
     • Alertness
     • Cognition
     • Other mental function (hallucinations, paranoia) arising over the last 2 weeks and still evident in the last 24 hours.
   • No = 0
   • Yes = 4

Question 18

Describe the scoring of the 4AT.

Answer 18

• Total between 0 and 12
• ≥4 = possible delirium
• 1-3 = possible cognitive impairment
• 0 = delirium or significant cognitive impairment unlikely

Question 19

What are the precipitating causes of delirium?

Answer 19

• Intracranial - infarction / bleed / infection / post-ictal / medications.
• Extracranial - infection, metabolic, hypoxia, stress response, anaesthesia and surgery, any severe illness, pain.
• Environmental / iatrogenic - emotional distress, sleep deprivation, change in environment, sensory impairment, catheters, drips, urinary retention, constipation.

Question 20

What is the delirium time bundle?

Answer 20

1. Think, exclude and treat possible triggers.
2. Investigate and intervene to correct underlying causes.
3. Management plan.
4. Engage and explore

Question 21

Describe the ‘T’ in the delirium time bundle.

Answer 21

• Think, exclude and treat possible triggers.
• NEWS/FEWS - think of the sepsis 6.
• Blood glucose.
• Medication history.
• Pain review (Abbey pain scale).
• Assess for urinary retention.
• Assess for constipation.

Question 22

List the possible trigger medications for a delirium (starting or stopping).

Answer 22

• Opiates (morphine, codeine, tramadol)
• Anticholinergics (e.g. for bladder symptoms, pain killers)
• Benzodiazepines (diazepam, nitrazepam)
• Drugs used in Parkinsons
• Antipsychotics
• Antiepileptics
• Antihistamines
• Antihypertensives (if BP is too low or for low Na²⁺

Question 23

Describe the ‘I’ in the delirium time bundle.

Answer 23

• Investigate and intervene to correct the underlying cause.
• Assess hydration and start fluid balance chart.
• Blood (FBC, U&E, CRP, Ca, LFT, Mg, glucose).
• Look for symptoms/signs of infection (skin, chest, urine, CNS) and perform appropriate cultures and imagine depending on clinical assessment.
• ECG - because acute coronary syndrome can cause delirium.

Question 24

Describe the ‘M’ in the delirium time bundle.

Answer 24

• Management plan
• Initiate treatment of all underlying causes found above.

Question 25

Describe the 'E' in the delirium time bundle.

Answer 25

* **Engage and explore** * Engage with patient / family / carers - explore if this is unusual behaviour. * Explain diagnosis of delirium to the patient, family and carers (use delirium leaflet). * Document diagnosis of delirium.

Question 26

In some cases, urgent neuro-imaging will be required. What are the circumstances?

Answer 26

* If the patient is anti-coagulated. * History of fall with head injury. * New focal neurological signs.

Question 27

Describe the treatment of delirium.

Answer 27

* **Identify and treat the underlying cause.** * Reduce or remove culprit medications. * Maintain hydration and nutrition. * Reorientation strategies. * Maintain mobility. * Normalise sleep wake cycle. * Pharmacological management. **Prevention is better than cure!**

Question 28

Describe the non-pharmacological management options for deliruim.

Answer 28

* Re-orientation strategies and distraction. * Involve families / familiar people. * Use glasses / hearning aids. * Keep mobile and avoid restraints. * Promote sleep with a quiet room at night, bright light during the day and dim at night, avoid day time napping.

Question 29

Describe the appropriate communication strategies for dealing with a delirium patient.

Answer 29

* Introduce yourself and explain who you are, what you are doing and where you are - may need to repeat. * Useful to explain delirium. * Smile, make eye contact and be friendly. * Don't argue about delusions, try to persuade but if not possible use distractions. * Get help from familiar faces (family, carers). * Remember the patient may be aggressive because they are scared.

Question 30

Describe the boundaries of pharmacological treatment of delirium.

Answer 30

* No evidence for prevention of delirium with medications. * May need low dose sedation if very agitated / aggressive / hallucinating. * Start low and go slow. * Stop as soon as possible. * Alcohol withdrawl protocol.

Question 31

What are the medications which can be used in delirium?

Answer 31

* Antipsychotics (e.g. haloperidol) * May reduce duration * Increased risk of stroke * Increased risk of falls * Not in parkinson's or lewy body disease * NNH 21.9 at 1 year * Benzodiazepines (e.g. lorazepam) * May worsen / lengthen delirium * Increased falls risk

Question 32

Give exmaples of prevention strategies for delirium.

Answer 32

* Vision (glasses) * Hearing (aids) * Avoid sleep deprivation * Promote mobility (try to avoid drips and catheters) * Hydration * Orientation and activity programme - volunteers / family * Environment - lighting, clock, calendar * Avoid frequent moves (and admission if possible)

Question 33

Describe the follow-up of a delirium patient.

Answer 33

* Can take months to resolve so is often still present on discharge. * Explanation and information (If they do remember what happened during the delirium it can be terrifying so it is important to the give the patient all the information). * Repetitive cognitive testing.