Delirium can be
defined as an acute confusional state caused due to medical or pharmacological
triggers. Up to 10% of all older patients
in EDs have delirium and only about one-third of them are recognized. As frontline healthcare providers, it is essential to recognize delirium
as the symptom of a life-threatening underlying medical or surgical condition. The consequences of a missed delirium can be disastrous as they can bounce back with florid sepsis, trauma, seizures. In elderly, delirium may be the only sign of an underlying infection (Pneumonia, Sepsis, ACS, Abdominal infection, Intra-cerebral event). Delirium is often multifactorial in etiology and each cause should be investigated.
DSM IV defines delirium as:
- Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
- Change in cognition that is not better accounted for by a pre-existing, established, or evolving dementia
- Development over a short period of time (usually hours to days) and disturbance tends to fluctuate during the course of the day
- There is evidence from the history, physical exam, or lab findings that the disturbance is caused by the consequences of a general medical condition
This can be remembered as:
A - Acute and fluctuating (Often reported by a family member or carers)
I - Inattention (Inattention
is a hallmark feature of delirium - Can test
with months of the years backwards, WORLD or serial 7s)
D - Disorganised thinking (incoherent, rambling, circumstantial, or vague. (irrelevant conversation, unclear or illogical flow of
ideas, or unpredictable switching from subject to subject)
A - Altered Mental Status (hyperactive, drowsy,
stuporous, comatose)
- Systemic Diseases (Infections,
ACS, Hepatic Enceph, Metabolic - Na/Glucose/Ca disturbances)
- Medications (Anticholinergic,
Antiparkinsonian, Antiemetics)
- Withdrawal (Discontinuation or
overdose of any medication, alcohol, sedative hypnotics)
- CNS Pathology (CVA, Subdural
hematoma, Meningitis, Seizures – non
convulsive, Hypertensive encephalopathy)
Infections are the most
commonly encountered cause of delirium in elderly and medications are the most common reversible causes of
geriatric delirium.
Why is Delirium
missed in ED?
We frequently assume that most older people have baseline
cognitive impairment. Collateral History and paying attention to what caregivers say is crucial. Delirium can present in hypoactive, hypoactive or mixed form. Therefore, it does not always present as restlessness or agitation, in
fact hypoactive delirium is the commonest. Using formal assessment methods is the best way to avoid such mishaps.
Managing Delirium
Most delirious patients need admission unless we find a single, reversible cause and patient has good social support and someone to observe him at home.
Non-Pharmacologic
- Manage pain and avoid unnecessary restraints including catheters and non-essential monitor leads
- Promote mobility and encourage to eat and drink
- Address bowel and bladder function
- Increase sensory stimulation (hearing aid, eye glasses)
- Enhance orientation and familiar faces (family)
- Minimize medication changes
Pharmacologic
Medications should be used if evaluation is
prevented or if the patient gets severely agitated. Haloperidol remains the
drug of choice (Not Benzodiazepines). Use BZD only in case of drug
withdrawals. Use
Haloperidol 0.5mg-1.0mg PO/IM/SC/IV every 30min to 1hr and frequently
reassess. Haloperidol is a potent anti-psychotic with limited
anti-cholinergic effects though it may cause problems in Parkinsonian
patients because of increased extra pyramidal symptom.
Preventing Delirium
ED Stay > 8 hrs itself is a
risk factor for delirium. High Risk groups include dehydrated patients,
demented and restrained patients, those who were left in the corridor
overnight, visually and hearing impaired.
Further Reading
- Altered Mental Status in Older Emergency Department Patients - Wilber, Scott T. Emergency Medicine Clinics , Volume 24 , Issue 2 , 299 - 316
- The Acutely Confused Elderly Patient
Posted by:
Lakshay Chanana
Speciality Doctor
Northwick Park Hospital
Department of Emergency Medicine
England
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