Which examination is most appropriate for a quick cognitive assessment?
AMT 10 (or 4AMT)
- Standardised
- Same questions every time
What can contribute towards delirium?
Pain Infection Nutrition (poor) Constipation Hydration (dehydration) Medications (polypharmacy) Environment (dark, uncomfortable, unfamiliar)
Recent surgery
Previous delirium
What are some drugs that can lead to delirium?
Ferrous sulphate - constipation
Dihydrocodeine - direct effect/constipation
Bendroflumethiazide - hyponatraemia/dehydration
What are some examples of environmental factors that can contribute to delirium?
- Dark room
- Messy environment
- Uneaten food
- Empty jug of water out of each (dehydration
- Clocks showing different types
- Untaken tablets/medications
- Absence of home comforts
How does delirium present?
- Acute onset
- Variability and fluctuation
- Personality changes
- Aggression
- Disinhibition
- Quiet
- Drowsiness
- Sleep disturbance
- Previous episode of acute confistion
- Visual or auditory hallucinations
What is the Confusion Assessment Method (CAM)?
The Confusion Assessment Method is based on the ICD 10 for delirium
To be CAM positive (and therefore have delirium) a patient must have features 1 & 2, or features 3 & 4
- Acute onset and fluctuating course
- Inattention (counting backwards or reduced attention during review)
- Disorganised thinking (incoherent disorganise speech)
- Altered level of consciousness (hyperalert, hypoalert or both)
What is the 4AT test?
The 4AT is a short version of the Abbreviated Mental Test Score (AMTS)
- Alertness
- Normal/fully alert/mild sleepiness on waking = 0
- Clearly abnormal (drowsy/hypoactive or agitated/hyperalert) = 4 - AMT4: ask the patient their age, DOB, the year, and their location
- No mistakes = 0
- 1 mistake = 1
- 2 or more mistakes/untestable = 2 - Attention: ask the patient to name the months backwards starting with December
- 7 or more correctly = 0
- Fewer than 7 or does not attempt = 1
- Untestable (drowsy/inattentive) = 2 - Acute and fluctuating course
- No = 0
- Yes = 4
Diagnosis based on score:
- 4 or above = possible delirium +/- cognitive impairment
- 1-3 = possible cognitive impairment
- 0 = delirium or cognitive impairment unlikely
What are the guidelines for using urine dipsticks in the elderly?
Urine dipsticks should not be used in patients over 65 to diagnose urinary tract infections due to the high false positive rate.
What measures should be taken for all patients with delirium?
- Reassurance and re-orientation in a calm environment
- Promote a normal sleeping pattern
- Increase nursing observation
- Encourage mobility
- Increase oral intake of food and fluids - document in carts
- Regular monitoring on AMTS
- Follow up in the community specifically regarding delirium as this increases risk of future dementia
What is the first-line management for distressed and agitated patients with delirium?
De-escalation methods with familiar staff/relatives/carers
- Calmly talk to them
- Reassure them
- Re-orientate them
- Comfort them
- Increase nursing monitoring
Conservative measures should be use initially and are effective in most patients
What are the NICE guidelines regarding pharmacological intervention of delirium?
Haloperidol (0.5mg orally or 1mg IM) or olanzapine
Given for one week or less
Haloperidol is contraindicated inParkinson’s and lewy-body dementia
- In these patients lorazepam might be considered
Ask about alcohol intake:
- Alcohol withdrawal can cause delirium
- This should be treated with oral benzodiazepines (chlordiazepoxide)
What are the overall NICE guidelines for treating someone with delirium?q
Identify and manage underling cause/combination of causes:
- Ensure effective communication and reorientation
- Consider involving family/friends/carers to help
- Ensure that people are cared for by a team of healthcare professionals familiar to them
avoid moving people within and between wards/rooms unless necessary
If symptoms do not resolve:
- Consider if the patient is distressed
- Consider if the patient is a risk to themselves or others (may be difficult to tell in hypoactive delirium)
- Use verbal and non-verbal techniques to de-escalate the situation if appropriate
If symptoms STILL do not resolve:
- Consider short term (no more than 7 days) haloperidol/olanzapine
- In patients with Parkinson’s Lewy-Body dementia use haloperidol/other antipsychotic as appropriate
If STILL no resolution:
- Re-evaluate for underlying causes
- Follow-up and assess for possible dementia
What is delirium?
Delirium: commonly referred to as ‘acute confusional state’,
- Affects 20-30% of patients on medical wards
- Affects 10-50% of patients having surgery
Acute onset (couple of days):
- Disturbed consciousness
- Reduced cognitive function/perception
- Fluctuating course
Hyperactive:
- Restlessness
- Agitation
- Heightened arousal
- Aggression
Hypoactive:
- Drowsiness
- Increases sleeping
- Quiet
- Withdrawn
- Difficult to spot
Mixed delirium is also possible
Dementia is a risk factor for delirium so it is common for patients to present with both
If in doubt, always treat as delirium initially until prove otherwise
What is the prognosis of delirium?
If found and treated, 2/3 will recover
1/3 do not completely recover: admission to a care home/death
Delirium is associated with:
- Longer hospital staus
- Increased incidence of dementia
- Increased complications such as falls/pressure ulcers
- Increased rate of admission into long-term care
- More likely to die
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How do you prevent delirium?
Prevention is better than cure
Cognitive impairment:
- Provide appropriate lighting and clear signage
- Clock with correct time (consider 24 hour clock) and calendar
- Re-orientate patient to where they are, who they are, and what your role is
- Introduce cognitively stimulating activities (ex reminiscence)
- Facilitate regular visits from family/friends
Dehydration or constipation:
- Encourage patient to drink
- Consider SC or IV fluids if necessary
- Seek advice when managing fluid balance in patients with co-morbidities (ex heart failure, chronic kidney disease)
Hypoxia:
- Assess for hypoxia and optimise oxygen saturation as required
Limited mobility;
- Encourage the patient to mobilise soon after surgery
- Walk, with aids if needed
- Encourage all patients (even if they cannot walk) to carry out active range-of-motion exercises
Infection:
- Look for and treat infection
- Avoid unnecessary catheterisation
- implement infection control procedures
Multiple medications:
- Carry out a medication review
Pain:
- Assess for pain, using non-verbal signs
- Start and review appropriate pain management
Poor nutrition:
- Follow advice in ‘Nutrition support for adults’
- Appropriate food consistencies
- Encourage favourite foods
- Ensure dentures fit properly
Sensory impairment:
- Resolve reversible causes of impairment (ex impacted earwax)
- Ensure working hearing and visual aids are available and used
- Sleep disturbance
- Avoid nursing or medical procedures during sleeping hours
- Schedule medication rounds to avoid disturbing sleep
- Reduce noise to a minimum during sleeping periods
