S1E15: Delirium - GEM
Welcome back everyone, and thanks for joining us again for April’s episode, our first Geriatric EM special! Some stellar material in here that I think you’ll find very useful - I know I have!
Orla’s back and she’s joined by Deirdre and Barry for the case.
Our Adult in the Room, Dr Vinny Ramiah of the Mater Hospital Emergency Department is there then to not only check their work, but to give an absolute masterclass in delirium in the ED.
Dr Rosa McNamara joins Barry to chat about ED in the Home (EDITH), and Mary Dawood sits down with Deirdre for a conversation about death and dying in the ED.
Lots of fantastic material, you may want to take it in a few bites this time though.
Let’s get to it!
Delirium (DSM V)
Acute confusional state characterised by:
Disturbance in attention and awareness
Acute in onset with fluctuation throughout the day
Disturbance of at least one of
Memory
Orientation
Language
Perception
Visuospatial ability
These disturbances not otherwise explained by another neurocognitive disorder
There is evidence that these disturbances are a direct physiological consequence of another medical condition, such as infection, intoxication or withdrawal
The key features of delirium³
Recent onset of fluctuating awareness
Impairment of memory and attention
Disorganised thinking
Delirium is very common in hospital. Prevalence ranges from 11-42% in older adults¹.
Patients with delirium experience
Longer inpatient stays
Higher risk of complications on both medical and surgical settings
Higher mortality
Both in hospital and up to 6 months after discharge²
As Emergency doctors, it is therefore very important that we identify and treat delirium as soon as possible
There are 3 subtypes of delirium
Hyperactive
Hypoactive
Mixed
Hypoactive delirium patients have more severe illnesses⁴, and this subtype of delirium is easily missed in the ED.
The history is key. However, your patient may not be able to give much history. Speak to family, carers, and/or the patient’s GP to gain some collateral. Try to understand the time of onset, the patient’s baseline cognition and physical function and gain a drug history.
Perform a thorough clinical exam
Perform a 4AT score⁵. Delirium is misdiagnosed, missed or diagnosed late in over 60% of cases⁶. So a simple screening tool like this may prove invaluable!
The 4AT score is excellent because it’s easy, quick, does not require any special training to perform and is applicable to all patients. It quickly allows you to identify those patients with a possible delirium.
Perform your investigations as you usually would
Vital signs
ECG
Bloods - FBC, renal profile, CRP, liver profile, blood cultures if febrile, VBG, etc
Urine dipstick
Be wary of interpretation of urine dipsticks in the older adult population
A positive dipstick is quite common, and in the absence of urinary symptoms, be slow to attribute a diagnosis of UTI based solely on a dipstick result, until you’ve outruled other potential causes
CT brain is not a routine delirium investigation! Only order if:
Confusion after fall/trauma
Focal neurological signs
Evidence of raised intracranial pressure
The same advice applies for lumbar puncture. Only do it if there is a suspicion of CNS infection. It is not a routine investigation in delirium, and hey, it’s a painful procedure to put anyone through! Let alone a confused older person who is ill.
Management of delirium starts with identifying the cause and treating the underlying condition:
Infection is most common
Electrolyte imbalances, particularly sodium
Alcohol withdrawal
Constipation
Hypoglycaemia
Hyperthyroidism
Intracranial haemorrhage/ischaemic stroke
Medications
Recent hospitalisation
Change in environment
These are just some of the potential causes. And keep in mind that the cause of delirium is often multi-factorial!
But there are also very simple measures we can do for our patients
Have appropriate lighting levels for the time of day
Regular and repeated re-orientation
Make sure the patient has their glasses or hearing aid if they use them
Encourage family members to visit (controversial at the moment as most EDs have strict no-visiting policies in place, but can be invaluable in keeping patients relaxed and oriented)
Analgesia if and as required
Prevent dehydration
Try to reduce irritating or unexpected loud noises, eg infusion pumps alarming (this is challenging, as most EDs are suffering from barely-contained chaos most of the time)
Things to avoid in delirium
Urinary catheters
Constipation
Anticholinergic drugs
Unnecessary movement around the ED or between wards
Try to avoid sedating medication if at all possible with the above measures. However, it is occasionally necessary to give a little sedation in certain circumstances
In order to perform investigations, eg bloods, IV access
To prevent the patient endangering themselves or others
To relieve distress caused by hallucinations
(Use your own hospital’s guidelines on this, but for the most part:)
The current drug of choice is haloperidol 0.5-1mg orally or IM. This can be titrated up to a max of 5-10mg. Side effects of haloperidol include extrapyramidal symptoms and therefore should be avoided in patients with Parkinson’s disease or Lewy Body Dementia. Haloperidol also prolongs the QT interval so regular monitoring with ECG is necessary.
Use lorazepam in patients with Parkinson’s disease or Lewy Body Dementia. Patients in alcohol withdrawal, or history of QT prolongation should be given lorazepam as a first line treatment if necessary. The dose of lorazepam used is 1-2mg orally or IM.
Useful resources:
RCEM Learning reference Delirium in the Elderly. https://www.rcemlearning.co.uk/reference/delirium-in-the-elderly/#1568885320474-d9d7c5c4-b825
ADEPT tool. Confusion and agitation in the elderly ED patient.
https://www.acep.org/patient-care/adept/
References
Siddiqui N, Home AO, House AO, Holmes JD. Occurrence and outcome of delirium in medical patients; a systematic literature review. Age Aging 2006;35:350-64.
American Psychiatric Association. Practice guideline for the treatment of patients with delirium. Am J Psychiatry 1999;156(5 suppl):1-20.
RCEM Learning. Delirium in the Elderly, Steve Fordham. CAP8 CC5
OKeeffe ST, Lavan JN. Clinical significance of delirium subtypes in older people. Age Ageing 1999;28:115-9.
Tieges et al. Diagnostic accuracy of the 4AT for delirium detection: systematic review and meta-analysis. Age Ageing. 2020 Nov 11:afaa224.
Collins et al. Detection of delirium in the acute hospital. Age Ageing. 2010 Jan;39(1):131-5
https://www.hse.ie/eng/about/who/cspd/ncps/acute-medicine/resources/delirium-ed-amau-pathway-march-2016.pdf