Delirium Assessment & Management

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Delirium isย an acute, transient and reversible state of confusion, usually the result of other organic processes (infection, drugs, dehydration), the onset is acute and the cognition of the patient can be highly fluctuant over a short period of time.

One in five elderly patients on medical and surgical wards are affected by delirium at any one time.1


Clinical features

There are two main states of delirium, known as ‘hyperactive‘ and ‘hypoactivedelirium.

It is common for patients to fluctuate between these two states.

Hyperactive delirium

Hyperactive delirium is the ‘typical’ delirium presentation that most people are aware of.

Clinical features of hyperactive delirium include:

  • Agitation
  • Delusions
  • Hallucinations
  • Wandering
  • Aggression

Hypoactive delirium

Hypoactive delirium is less well known and as a result, often missed or confused with depression.

Clinical features of hypoactive delirium include:

  • Lethargy
  • Slowness with everyday tasks
  • Excessive sleeping
  • Inattention

Aetiology and risk factors

A change in environment coupled with sensory impairment (common in the elderly) increases the risk of developing delirium. These factors alone can cause delirium without any deeper organic cause, but this should only be considered as a diagnosis of exclusion.

Things that can cause or lead to delirium include pretty much anything, ever. Some of the biggies are listed below. I’m generally not a fan of acronyms for the sake of acronyms, but CHIMPS PHONED is a useful reminder that it is not just our old friend ‘UTI’ that should be considered:

  • Constipation
  • Hypoxia
  • Infection
  • Metabolic disturbance
  • Pain
  • Sleeplessness
  • Prescriptions
  • Hypothermia/pyrexia
  • Organ dysfunction (hepatic or renal impairment)
  • Nutrition
  • Environmental changes
  • Drugs (over the counter, illicit, alcohol and smoking)

Assessment of the confused patient

It is essential to perform a comprehensive assessment of all patients suspected of having delirium, given the wide range of possible causes and varying clinical features.

History

Taking a history directly from the patient may not be possible in the context of acute confusion (although you should always try):

  • Conversation can give big clues to the patient’s current mental state
  • Provide reassurance and gentle re-orientation if appropriate
  • Ask the patient what they are seeing/hearing/experiencing

Other useful sources of information include:

  • Collateral history (e.g. family, friends, nursing staff)
  • Medical notes (e.g. past medical history, current medications)

Useful information in the patient’s medical notes may include:

  • Past medical history (e.g. atherosclerosis, stroke, previous episodes of confusion, head injury, recent admissions)
  • Current medications: review for drugs that may cause or contribute to confusion (e.g. opiates)
  • Social history (e.g. how are they coping at home, excess alcohol, illicit drug use)

Cognitive assessment

The Abbreviated Mental Test Score (AMTS) is a useful screening tool for assessing cognition.

This tool can be used to objectively monitor for improvement or deterioration in cognitive function over time.

Other cognitive screening tools which provide more detailed assessment includeย MMSE and ACE-III.

Clinical examination

A thorough clinical examination (including assessment of vital signs) should be performed, looking for signs which may provide clues as to the underlying cause of confusion:

  • Vital signs (e.g. fever in infection, low SpO2 in pneumonia)
  • Level of consciousness (e.g. GCS/AVPU)
  • Evidence of head trauma
  • Sources of infection (e.g. suprapubic tenderness in urinary tract infection)
  • Asterixis (e.g. uraemia/encephalopathy)

Confusion screen

When investigating why a patient might be confused, there are a standard set of further investigations which are often referred to as a ‘confusion screen‘. This panel of investigations is useful for identifying or ruling out common causes of confusion.

Blood tests:

  • FBC (e.g. infection, anaemia, malignancy)
  • U&Es (e.g. hyponatraemia, hypernatraemia)
  • LFTs (e.g. liver failure with secondary encephalopathy)
  • Coagulation/INR (e.g. intracranial bleeding)
  • TFTs (e.g. hypothyroidism)
  • Calcium (e.g. hypercalcaemia)
  • B12 + folate/haematinics (e.g. B12/folate deficiency)
  • Glucose (e.g. hypoglycaemia/hyperglycaemia)
  • Blood culturesย (e.g. sepsis)

Urinalysis:

  • UTI is a very common cause of delirium in the elderly.
  • A positive urine dipstick without clinical signs is NOT satisfactory to diagnose urinary tract infection as a cause of delirium.2,ย 3
  • Look for other evidence supporting the diagnosis (WCCโ†‘/supra-pubic tenderness/dysuria/offensive urine/positive urine culture).

Imaging:

  • CT head: if there is concern about intracranial pathology (bleeding, ischaemic stroke, abscess)
  • Chest X-ray: may be performed if there is concern about lung pathology (e.g. pneumonia, pulmonary oedema)

Management of delirium

Definitive management

Definitive management of delirium involves identifying and treating the underlying cause.

Supportive management strategies

General supportive management strategies include:

  • Try to keep a consistent nursing and medical team, gentle re-orientation, calm and consistent care, regular introductions of yourself and your role, clear and concise communication.
  • Ensure the patient has access to aids such as glasses, hearing aids and walking sticks where appropriate.
  • Enable the patient to do what they can for themselves – independent washing, dressing, eating, toileting and other activities may still be possible with varying levels of encouragement.

Environmental adaptation management strategies include:

  • Ensure there is access to a clock and other orientation reminders for the day, date and time.
  • Have some familiar objects where possible (e.g. having photographs available, using the patient’s own clothes/washcloths).
  • Involve the family, friends and/or carers in the care of the patient.
  • Control the level of noise around the patient.
  • Ensure lighting is adequate and the temperature is ambient.

Medication

Key points include:

  • Avoid unnecessary medications wherever possible.
  • Persistent wandering and delirium are not absolute indications for sedation.
  • Aim to keep the patient safe by the least restrictive method.
  • The use of medications, particularly those for sedation, can worsen delirium.
  • Haloperidol (oral, IV or IM) is usually the first-line medical option, starting with a low dose in the elderly (0.5mg)
  • If benzodiazepines are to be used, lorazepam is first-line (0.5mg starting dose) due to its rapid onset and short half-life (see the NICE guidance for further management).6

Post-discharge

Key points include:

  • Families/carers need to be aware that delirium can continue for a period of time after the cause has been treated
  • Information should be given to those surrounding the patient on the management of any residual disorientation or inattention
  • Follow-up is advisable

Prevention

Take appropriate steps to prevent episodes of delirium:

  • Avoid drugs known to precipitate delirium (e.g. opiates and benzodiazepines)
  • Identify patients at higher risk of developing delirium and observe them closely for early signs of delirium
  • Assess other factors which may induce or exacerbate delirium (e.g. pain control, drugs etc)6
  • Employ supportive/environmental management approaches for all patients, regardless of delirium risk

References

  1. Oxford Handbook of Clinical Medicine, 8th Ed, p488
  2. Beveridge, Davey, Phillips, McMurdo (2011), Optimal Management of Urinary Tract Infections in Older People, Clin Interv Aging. 2011; 6: 173โ€“180. Available from: [LINK]ย 
  3. Woodford, George (2009) Diagnosis and Management of Urinary Tract Infection in Hospitalized Older People, J Am Geriatr Soc. 2009 Jan;57(1):107-14. Available from: [LINK]
  4. McMurdo, Gillespie (2000) Urinary tract infection in old age: over-diagnosed and over-treated. Age & Ageing (2000)29 (4):297-298
  5. SIGN (2012), 88: Management of Suspected Bacterial Urinary Tract Infection in Adults: A Clinical Guideline. Available from: [LINK]
  6. Delirium, NICE Clinical Guideline (July 2010). Available from: [LINK]

 

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