Few ill health situations

are more degrading to

people of any age than
loss of reasoning,
faculties, and personhood.
These are the unpleasant
consequences of
delirium

Delirium in older people. Young J & Inouye S. BMJ 2007; 334:842-6

What do you want to know / get

out of this session?

What do I want you to get from

this session?
1. Recognise delirium (esp hypoactive)
2. Have a method for assessment and management
3. Be able to discuss delirium with patients & families
4. Take it seriously

Early Dx & Mx better prognosis & outcomes

78 yo lady
from home
with dau.
Referred by
GP to
hospital
Recent
decline in
ability to
perform
activities of
daily living
Lives with her
daughter,
who is finding
it difficult to
provide care
for her
mother

88 yo lady
from RACF.
Usually
independent
mobility
(4WF) and
cognitively
intact.
Admitted on
Saturday with
acute onset
that morning
of confusion,
rambling
speech, and
decreased
mobility

89 yo lady,
usually from
home alone.
Presented to
ED with large
(15x15cm)
haematoma
on left leg.
In ED found
to be
confused and
mostly nonverbal.

90 yo lady home alone

in retirement
village.
Out to dinner
with son prev
evening. Well
throughout
dinner.
Activated
personal
alarm at 3am.
Confused,
agitated,
aggressive
and noncooperative
with
ambulance.

Mrs S - referral
Referred by GP to hospital
Recent decline in ability to
perform activities of daily
living

Lives with her daughter, who

is finding it difficult to provide
care for her mother

What do you think?

Mrs S - history
History from daughter who states her mother
has been confused for three days
Mrs S urinary incontinence has worsened over
the past two days she seems unable to locate
the toilet
Mrs S is eating poorly and restless at night

Mrs S - diagnosis
What is the most likely Dx?
What are the DDx?
Dementia with BPSD (behavioural and psychological
symptoms of dementia)
Depression
Other neurological conditions
Other psychiatric conditions

What else do you need to know to establish a

diagnosis?

What is delirium?
A clinical syndrome

Acute confusional state

Characterised by disturbance in:
Consciousness
Cognition (esp attention)
Perception (delusions / hallucinations)
Acute onset (hours to days)
Fluctuating course
Generally triggered by acute precipitant(s)

Mrs S - history
Daughter confirms that her mother has been
less confused in the mornings and has had
moments of clarity
Mrs S has spoken of people being in her room at
night
There has been a definite decline in cognition
over the past three days and Mrs S has tended
to drift off during conversations

Mrs S - assessment
How will you assess Mrs S?
On history (collateral)
Assume a diagnosis of delirium until proven
otherwise

What tools can you use?

CAM (Confusion Assessment Method)

Four features:
1.
2.
3.
4.

Acute onset and fluctuating course

Inattention
Disorganised thinking
Altered level of consciousness

Scoring: The diagnosis of delirium requires

the presence of:
Features 1 AND 2, and either 3 OR 4
It is scored as either positive or negative.

Mrs S - assessment
Mrs S drifts to sleep during the interview
She has difficulty following instructions and
appears to be distracted by things you cannot
see
Manages only three digits in the digit span test
She tells you that her (long deceased) husband
will come and sort you out for being so
impertinent
CAM = positive

1.
2.
3.
4.

Acute onset and fluctuating course

Inattention
Disorganised thinking
Altered level of consciousness

1. Recognise delirium

Mrs B - history
88 year old from RACF

Usually independent mobility with 4WF and

cognitively intact
Admitted on a Saturday with acute onset that
morning of confusion, very confused speech and
decreased mobility
What are your thoughts?

Mrs B - history cont

Post-take ward round..

Comments about confused and muddled speech

not making sense
Difficult to examine.
Impression:
Delirium unclear cause. ? UTI

Mrs B - history cont

And then.
During ward round on Monday morning noted to have
marked expressive dysphasia + some receptive
dysphasia + R facial, R UL and R LL weakness
Transient and all improved over 15 minutes while
examining patient
Recurred approx 1 hour later
Repeat CTB ..
Commenced Heparin infusion and transferred to
stroke unit

.back to Mrs S
What now?

Assessment and management

GOALS OF MANAGEMENT
1. Identify and address any precipitants
2. Manage the symptoms
1. Non-pharmacological providing a supportive
environment (psychological, physical and sensory support)
2.

Pharmacological

3. Prevent complications

4. Support and educate patient & family/carers

5. Provide appropriate D/C planning and follow-up

Precipitating factors

REMEMBER there may be

multiple possible precipitants

Medications prescription and OTC

- effects, side-effects, interactions, toxicity

Drug / Alcohol
- withdrawal (or intoxication)

Neurological conditions
- stroke, bleed, seizure, infection

Medical conditions
- infection, organ failure, electrolyte & fluid disturbance, pain,
bladder & bowel dysfunction

Surgery / Anaesthetics
Environmental factors
- change in environment, sleep deprivation, medical interventions
(IDC, NGT, IV lines, O2, tubing)

1. Identify and address any precipitants

HISTORY
EXAMINATION
HOPC (esp timeline)
INVESTIGATIONS
From Pt if possible
PLUS collateral Hx (family, nurses, GP, resi care staff)

Review of systems
Review medications

Mrs S further history

Mrs S daughter tells you that her mother was
commenced on amitriptyline for her incontinence
and to help her sleep a week ago

1. Identify and address any precipitants

EXAMINATION

Thorough physical examination including:

Vital signs
CVS (inc volume status)
Respiratory system
Abdo exam (inc palpable bladder)
Neuro exam (esp looking for new signs)
Skin (esp for rashes (H. zoster), wounds, patches)
NB: To do this you need to take down all dressings

Mrs S on examination
T 382, other obs unremarkable
Dry mucous membranes, JVP 0cm
Lower abdo tenderness

1. Identify and address any precipitants

INVESTIGATIONS
A delirium screen?????

There is no such thing

B12, folate, TFTs are not useful in the work-up
for delirium they are part of a dementia workup as possibly reversible contributors to
cognitive impairment

1. Identify and address any precipitants

INVESTIGATIONS

Baseline Ix:
Pathology: FBE, EUC, LFT, Ca, CRP
FWTU (and MSU if positive for leuk or nit)
Other: BSL, ECG (plus CK and Trop if ischaemic changes or
chest pain), Post void residual bladder volume (PVRvol)
Other Ix should be considered based on clinical scenario
CXR, AXR, CTbrain, blood cultures, drug levels, TFTs,
CK & Trop, ammonia, LP, EEG,

Mrs S investigations
Urea 17, Creatinine 135 (baseline 75)
WCC 14
FWTU nitrites ++, leukocytes +++
PVRvol = 840mL
What is the cause for Mrs S delirium?
Multifactorial
Amitriptyline
Urinary retention
UTI
Dehydration
AKI

2. Have a method for

assessment
and
management

Mrs C History
89 year old lady, usually from home alone.
Presented to ED with large haematoma on left leg.

15 x 15cm haematoma

In ED found to be confused and mostly non-verbal

Mrs C History cont

4/52 of decline in function (with son staying with her)
1/52 of decline in cognition

At times not recognising family members

Non-verbal in ED and on ward
Previous cognition:
MMSE 2 months prior: 20/30

PMHx

What now?

PMHx

MEDS

Ramipril 10mg d

AF

Amlodipine 2.5mg d

HT

IHD

TIA

GTN patch 50mg d

Multiple skin cancers

Telmisartan 80mg d

PMR (on Pred)

Aspirin 100mg d

Osteoporosis

Warfarin

Bilateral cataract
surgery (with IOL)

Digoxin 62.5mcg d

Atenolol 50mg d

Rosuvastatin 10mg d
Prednisolone 1mg d
Caltrate 600mg d

Cholecalciferol 1000units d

Mrs C History cont

FBE: 118 / 6.7 / 270

(MCV 91)

EUC: 142 / 4.6 / 12.6 / 132

Digoxin 1.2
INR: 8.5
FWTU NAD

Assessment and management

GOALS OF MANAGEMENT
1. Identify and address any precipitants
2. Manage the symptoms
1. Non-pharmacological providing a supportive
environment (psychological, physical and sensory support)
2.

Pharmacological

3. Prevent complications

4. Support and educate patient & family/carers

5. Provide appropriate D/C planning and follow-up

Mrs S management
What would prompt you to use medications for
her delirium?
Which agent(s) would you choose?

2. Manage the symptoms

Non-pharmacological Rx is ALWAYS 1st line
(think about what it is your are treating)

Environmental strategies

Appropriate lighting, quiet room, avoid room changes

Clinical practice strategies

Encourage family to be involved

Maintain usual routine
Regular orientation
Minimise interventions
Maintain function
1:1 nurse special

2. Manage the symptoms

PHARMACOLOGICAL Mx important points
Medications DO NOT treat the delirium
Medications may help with SOME symptoms (mainly psychotic Sx)
NOT EFFECTIVE for wandering or calling out
Consider for distressing Sx (ie; if highly agitated or hallucinating) or if
patient at risk of harm to self or others

Medications should NOT be used to sedate patients

Use lowest effective dose for shortest possible time with
regular review of efficacy and side-effects
Use oral route as first line
Use medications cautiously

2. Manage the symptoms

PHARMACOLOGICAL Mx
Haloperidol is 1st line drug of choice
- Except in patients with Parkinsons disease or Lewy Body Dementia
where Quetiapine (12.5mg) should be used carefully
- If a patient with dementia is already prescribed an antipsychotic
medication (ie; Risperidone / Olanzapine) then best to use this

Use small doses (0.25-0.5mg oral or subcut NOT IV)

Up to 3mg maximum in 24 hour period

Older patients are at higher risk of side-effects

Avoid multiple different types of medications

(NB: Olanzapine has the most anticholinergic burden of the antipsychotics)

2. Manage the symptoms

PHARMACOLOGICAL Mx
NB: Benzodiazepines (incl. Temazepam) should
generally only be used for specific causes of
delirium
Alcohol or BZD withdrawal OR Seizures
However, if a patient is on long-term BZDs then do

not cease them on admission to hospital (may

precipitate delirium)
Occasionally do need to use BZDs for sedation use
as a last resort and realise the implications

3. Prevent complications
Functional decline

Malnutrition, dehydration
Pressure injuries

Falls (and assoc injuries)

Hospital acquired infections

2. Have a method for

assessment and
management

4. Support and educate patient &

family/carers
What do you tell the family?

http://docs.health.vic.gov.au/docs/doc/Delirium---Consumer-Brochure-(Color)--June-2007

Mrs S progress
A week after treatment for her dehydration, UTI,
urinary retention and withdrawal of the
amitriptyline Mrs S improves, but is not back to
her usual self
What will you tell Mrs S daughter?

Outcomes of delirium
Delirium doesnt just stop when a patient
leaves hospital
Median duration 7 days
BUT
~96% have NOT fully resolved at D/C
~30% improve but relapse post D/C
May persist for weeks (~5% may last > 4 weeks)

Outcomes of delirium
INCREASED MORBIDITY

Length of stay
Hospital acquired complications
New admission to residential care
Permanent decline in cognition
Permanent decline in physical function
Distress

INCREASED MORTALITY (indep risk factor)

5. Provide appropriate D/C planning and

follow-up

Mrs S continued
Mrs S improves over two weeks and is
discharged home with her daughter and
additional supports
Six months later she falls and presents with a
fractured pelvis
What might you say to her and her family on
admission?

3. Be able to discuss
delirium with patients &
families

Cover shifts and ward rounds

Have a high index of suspicion for delirium
The not quite right or bit off patient
The patient with non-specific issue for review
The poor oral intake

If the family say the person is confused / not their

normal self = delirium until proven otherwise

Dont assume that all older people are confused

Get a COLLATERAL HISTORY about pre-morbid
cognition

Cover shifts and ward rounds

Check history and reason for admission
Check obs chart, bowel chart, food and fluid charts
Dont just check regular meds
Look at stat and PRN orders
Regular PRN/stat orders for BZDs or antipsychotics
at night should ring alarm bells

Cover shifts and ward rounds

Dont just give phone orders
esp for BZDs
IVT

Think and ask before you prescribe medications

Why are you treating this patient? It shouldnt just be because the
nurses ask!

Remember it is OK not to treat and to Ix and monitor

A fever in someone who is not clinically unwell with no obvious source
A noisy patient overnight who is not at risk to self or others
A one-off high BP reading (a GP wouldnt start treatment from one
reading..why should we?)

Key points
Delirium:
is common
is a clinical diagnosis
is associated with increased morbidity and mortality

is often missed
You need to have a high index of suspicion and if
you think or write confused / agitated / disoriented /
wandering / then ASSUME DELIRIUM UNTIL
PROVEN OTHERWISE

3. Take it seriously

Few ill health

situations are more
degrading to people
of any age than loss
of reasoning,
faculties, and
personhood. These
are the unpleasant
consequences of
delirium
Delirium in older people. Young J & Inouye S. BMJ 2007; 334:842-6

Cases

Mrs H - history
90 yo lady from home alone in retirement village.

Out to dinner with son previous evening. Well throughout

dinner and on return to home.
Activated her personal alarm at 3am and staff attended
- Confused, agitated, c/o dysuria & headache
Ambulance called and non-cooperative with MAS staff
finally agreed to come to hospital.

Thoughts?

Mrs H - history cont

In ambulance:

T 381
HR: 103
BSL: 9.9
GCS 15
Headache 4/10
In ED:
Drowsy GCS 13
Febrile
BP: 180/90
FWTU: leucs 3+ and blood 2+

Mrs H - history cont

On ward:

Urinary frequency and new incontinence

Urinary retention IDC inserted
Marked agitation (and appeared terrified)
Ongoing high fevers (396)
Hypoxic (SaO2 88% RA)
Sinus tachycardia (HR 120)

Mrs H O/E
O/E:

-R basal crackles on chest auscultation

-Abdo NAD
-Skin NAD
-No joint or spinal tenderness / no neck stiffness
-Normal left fundus (unable to visualise right)
MSU WCC 60
CXR possible minor bibasal changes
WCC normal

CRP -30
CT brain reported as NAD but impression of subtle oedema

Mrs H ????
DDx??

Working diagnosis:

Severe community acquired pneumonia

Ceftriaxone 1g BD + Azithromycin 500mg daily

Next day on post-take ward round - concern

about cerebral irritation and DDx of meningitis /
encephalitis
Aciclovir 500mg BD + Benzylpenicillin 1.8g QID

Mrs H ..
Over next 48 hours.
- worsening agitation
- facial droop
- 3rd nerve palsy
- deteriorating conscious state
Blood cultures:

1st set: negative

2nd set (12 hrs later): Listeria monocytogenes

Mrs L
90 year old lady with known diagnosis of vascular dementia
admitted with delirium.

Previously living alone at home but had moved in with

daughter a few months prior as not managing being alone.
Admitted with confusion, agitation and halllucinations that had
come on over period of 1-2 days.

Mrs L
PMHx

Medications

Vascular dementia

Aspirin 100mg dialy

Type 2 DM (diet controlled)

Candesartan 8mg daily

AF (not on Warfarin due to

frequent falls)

Metoprolol 50mg bd

Osteoporosis
HT
GORD
Recurrent UTIs
Urinary incontinence
DVT (below knee in May 2010)

Frusemide 40mg daily

Digoxin 62.5microg daily

Pantoprazole 40mg daily

Fentanyl patch 12microg/hour
Risperidone 0.25mg nocte

Paracetamol 1gram tds

Refresh tears
Coloxyl and senna PRN

Mrs L
Over past few months since living with daughter

- Recurrent falls, most recent 1 week prior with headstrike

- Worsening nocturnal behaviours with some agitation
Behaviours markedly changed 2 nights prior to admission:
- Increasing confusion, agitation, disorientation and visual
hallucinations
- Not unwell, no symptoms to suggest infection
- Obs stable
- Bloods fairly unremarkable / FWTU NAD

Mrs L
Working diagnosis on admission:
Delirium on background dementia cause unclear

Further history on post-take ward round

Commenced Risperidone night prior to behaviours worsening. Prescribed by
LMO to assist with BPSD

New working diagnosis

Delirium due to paradoxical reaction to Risperidone with background of
dementia with BPSD
Risperidone ceased delirium settled and Pt D/C home with support and
education for daughter around BPSD and its Mx

Few ill health situations

are more degrading to
people of any age than
loss of reasoning,
faculties, and personhood.
These are the unpleasant
consequences of
delirium

Delirium in older people. Young J & Inouye S. BMJ 2007; 334:842-6