Delirium or Acute confusional State Management

Delirium Management or Acute Confusional state. Neuropsychiatric aspect of delirium

1. Managing delirium in everyday practice Dr. ayub Karim rotation PG in department of medicine unit-5 JPMC Karachi

2. Delirium An acute confusional state and fluctuating course of symptoms, including Inattention, impaired level of consciousness, Disturbance of cognition (e.g., disorientation, memory impairment, alteration in language). Supportive features include Disturbance in sleep wake cycle, perceptual disturbances (hallucinations or illusions), Delusions, Psychomotor disturbance (hypo- or hyper-activity), Inappropriate behavior, and Emotional lability .

3. Risk factors for delirium in hospital setting Patient-related • Age ≥70 years • Pre-existing cognitive impairment • Previous episode of delirium • CNS disorder • Increased blood–brain barrier permeability • Poor nutritional status • Number and severity of comorbid illnesses

4. Illness-related • Illness severity • Dehydration • Infection, e.g. urinary tract infection • Fracture • Hypothermia or fever • Hypoxia • Metabolic/electrolyte disturbances, e.g. low sodium • Pain • HIV/AIDS • Organ insufficiency • Burns • Nicotine withdrawal

5. Intervention-related • Peri-operative • Type of surgery, e.g. hip, cardiac • Duration of operation • Catheterization • Emergency procedure

6. Environment-related • Social isolation • Sensory extremes • Visual deficit • Hearing deficit • Immobility • Use of restraints • Novel environment • Stress

7. Medication-related • Polypharmacy • Drug or alcohol dependence • Benzodiazepine use • Addition of ≥3 new medications • Psychoactive drug use • Certain drugs: e.g. anticholinergics

8. Evaluation to establish the diagnosis of delirium 1 st step to establish diagnosis Clinical History from an informed observer Screening tools brief Cognitive or Delirium assessment tools or Assessment of Orientation along with an Attention task 2 nd Identify the factors contributing to its onse t Clinical history, Clinical examination Investigations a range of first-line (for all cases of delirium) and second-line (for particular cases. A collateral history clarifying baseline cognitive function should be sought as early as possible.

9. Routine screening Routine cognitive and delirium screening should be performed on all older patients admitted to hospital. ( History and screening tools ) Brief Screening tools for delirium Confusion Assessment Method (CAM) Delirium Rating Scale (DRS) Memorial Delirium Assessment Scale (MDAS) Brief cognitive assessment. Mini-cog Portable Mental Status Questionnaire Montreal Cognitive Assessment. Assessment of Orientation and attention

10. Principles of Management (1) Maintaining patient safety; (2) Searching for the causes; and its management accordingly (3) Managing delirium symptoms

11. Maintaining Patient Safety Protecting the airway preventing aspiration; Maintaining hydration and nutrition; Preventing skin breakdown; Providing safe mobility while preventing falls; Avoiding restraints and bed alarms increase risk of delirium,

12. Managing delirium symptoms Nonpharmacologic Prevention and Treatment first line management strategy Pharmacologic Prevention and Treatment Severe agitation extremely distressing psychotic symptoms

13. Nonpharmacologic Prevention and Treatment Reorientation strategies Educate patient and family/carer on delirium and prognosis Involve family/carer in hospital care routine Repeatedly reorient and reassure the patient Address sensory impairment; provide eyeglasses, hearing aids, interpreters Nurse with familiar staff in relaxed environment Normalize sleep-wake cycle Daytime: Discourage napping, encourage exposure to bright light Facilitate uninterrupted period for sleep at night Quiet room at night with low level lighting; nonpharmacologic sleep protocol

14. Maintain safe mobility Avoid use of physical restraints, tethers, and bed alarms, which can increase delirium and agitation Ambulate patient at least 3 times per day; active range-of-motion Encourage self-care and regular communication Prevent complications, e.g. falls, constipation , Ensure adequate pain relief

15. Pharmacologic Prevention and Treatment Reserve for patients with severe agitation, which will result in interruption of essential medical therapies (e.g., intubation) or severe psychotic symptoms Start low doses and titrate until effect achieved; Haloperidol 0.25–0.5 mgs. po/IM

16. Evaluation and Management of Suspected Delirium algorithm 1. 1st step to establish diagnosis Clinical 2. 2nd Identify the factors contributing to its onset Clinical and Investigation 3. Maintaining patient safety 4. Management of the underlying causes accordingly 5. Managing delirium symptoms Nonpharmacologic Prevention and Treatment Pharmacologic Prevention and Treatment Consultation liaison