Elderly Care & Frailty
Question 153 of 180
An 83 year old man is brought to the Emergency Department by your local police service. They tell you he was found in a nearby supermarket causing a disturbance. His medical records show he has been referred to the local memory clinic by his GP but has not yet been seen. The triage nurse is finding it difficult to obtain observations as the patient is so distressed. She is able to record his temperature as 38.5°C. He is distressed and is trying to leave the department. You assess his capacity to decline assessment and treatment and you feel he is lacking capacity for this decision at this time. What is the next management step for this patient?
Answer:
This man is likely to be suffering from delirium, probably on the background of dementia. He needs urgent investigation and treatment but is currently a risk to himself. NICE guidance for management of delirium only recommends pharmacological treatment if a patient presents a danger to himself or others, and verbal and non-verbal de-escalation techniques are ineffective or inappropriate. It is unlikely that this patient will take any oral medication. Low-dose haloperidol is the first line drug. Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms.Delirium
Elderly Care & Frailty
Last Updated: 12th February 2021
Delirium (sometimes called 'acute confusional state') is an acute, fluctuating syndrome of disturbed consciousness, attention, cognition and perception.
Delirium usually develops acutely over hours to days and behavioural disturbance, personality changes, and psychotic features may occur. Symptoms typically fluctuate (come and go or increase and decrease in severity). Lucid intervals usually occur during the day with the worst disturbance at night.
Delirium typically occurs in people with predisposing factors (such as advanced age or multiple comorbidities) when new precipitating factors (such as some medications or infection) are added.
Predisposing factors
Predisposing factors include:
- Older age (over 65 years)
- Cognitive impairment (such as dementia)
- Frailty/multiple comorbidities (such as stroke or heart failure)
- Significant injuries such as hip fracture
- Functional impairment (for example immobility or the use of physical restraints such as cot sides)
- Iatrogenic events (such as bladder catheterisation, polypharmacy, or surgery)
- History of, or current, alcohol excess
- Sensory impairment (such as visual impairment or hearing loss)
- Poor nutrition
- Lack of stimulation
- Terminal phase of illness
Precipitating factors
Precipitating factors include:
- Infection such as urinary tract infection, infected pressure sore, or pneumonia
- Metabolic disturbance such as hypoglycaemia, hyperglycaemia, or electrolyte abnormalities
- Cardiovascular disorders such as myocardial infarction or heart failure
- Respiratory disorders such as pulmonary embolism or exacerbation of chronic obstructive pulmonary disease
- Neurological disorders such as stroke, encephalitis, or subdural haematoma
- Endocrine disorders such as thyroid dysfunction or Cushing's syndrome
- Urological disorders such as urinary retention
- Gastrointestinal disorders such as hepatic failure, constipation (including faecal impaction), or malnutrition
- Severe uncontrolled pain
- Alcohol intoxication or withdrawal
- Medication e.g. opioids, benzodiazepines (use and withdrawal), dihydropyridines (such as amlodipine), histamine-2 receptor antagonists, anti-Parkinsonian medications, tricyclic antidepressants, lithium, antipsychotics, anticonvulsants, antiarrhythmics, antihypertensives, histamine-2 receptor antagonists, corticosteroids, and NSAIDs
- Psychosocial factors such as depression, sleep deprivation, visual or hearing impairment, emotional stress, or change of environment
Complications
The complications of delirium include:
- Increased mortality
- Increased length of stay in hospital
- Nosocomial infections
- Increased risk of admission to long-term care or re-admission to hospital
- Increased incidence of dementia
- Falls
- Pressure sores
- Continence problems
- Malnutrition
- Functional impairment
- Distress for the person, their family, and/or carers
Clinical features
Suspect delirium in people with a sudden change in behaviour that may be reported by the person, a carer, or relative. Behavioural changes may include:
- Altered cognitive function — the person may be disoriented, have memory and language impairment, worsened concentration, slow responses, and confusion. The person may not be able to recall details of their current illness, instructions, or names.
- Inattention — the person may be easily distractible and have difficulty focusing and moving attention from one thing to another, for example they are unable to maintain a conversation or follow reasonable commands.
- Disorganised thinking — the person may have disorganised, rambling, or irrelevant conversation, unclear or illogical flow of ideas, and difficulty expressing their needs and concerns.
- Altered perception — the person may experience paranoid delusions, misperceptions or, visual or auditory hallucinations which may be distressing.
- Altered physical function:
- Hyperactive delirium — the person may have increased sensitivity to their immediate surroundings with agitation, restlessness, sleep disturbance, and hypervigilance. Restlessness and wandering are common.
- Hypoactive delirium (more common) — the person may be lethargic, have reduced mobility and movement, lack interest in daily activities, have a reduced appetite, and become quiet and withdrawn.
- Mixed — the person will have a combination of signs and symptoms of hyperactive and hypoactive subtypes.
- Altered social behaviour — the person may have intermittent and labile changes in mood and/or emotions (such as fear, paranoia, anxiety, depression, irritability, apathy, anger, or euphoria). Their behaviour may be inappropriate and they may not cooperate with reasonable requests or become withdrawn.
- Altered level of consciousness — the person may have a clouding of consciousness, reduced awareness of their surroundings, and sleep-cycle disturbances (such as daytime drowsiness, night-time insomnia, disturbed sleep, or complete sleep cycle reversal). Impaired consciousness can be subtle, and may initially only be apparent as lethargy or distractibility.
Differential diagnosis
- Depression - Depression can present with similar symptoms to delirium (especially hypoactive delirium), for example mood change, anorexia, sleep disturbance, and psychomotor change.
- Dementia - Apart from Lewy-body dementia (which has fluctuation in cognition as one of its features), dementia usually has an insidious onset and is not associated with fluctuations in mental state.
- Mental illness - Late-onset mania or schizophrenia can present with features similar to hyperactive delirium.
- Anxiety - Behavioural changes associated with delirium can include anxiety.
- Thyroid disease - Hyperthyroidism and hypothyroidism can have similar features to hyperactive delirium and hypoactive delirium respectively.
- Non-convulsive epilepsy or temporal lobe epilepsy - Non-convulsive epilepsy can present with subtle behaviour or mood changes and clouding of consciousness.
- Charles Bonnet syndrome - Visual hallucinations may occur in people with severe visual impairment and can range from simple patterns of straight lines to detailed pictures of people or buildings.
Assessment
Delirium is a clinical diagnosis based on a detailed history, examination, and relevant investigations.
- Take a history from the person and an informed observer (family member or carer).
- Check vital signs including temperature, blood pressure, heart rate, capillary refill time, finger-prick blood glucose, and pulse oximetry — to identify fever, hypoperfusion, hyperglycaemia, hypoglycaemia, or hypoxia.
- Carry out a general examination to identify precipitating factors.
- Confirm a diagnosis of delirium by carrying out a cognitive assessment.
- Arrange targeted investigations based on findings from the history and examination, for example:
- Urinalysis — to identify conditions such as infection or hyperglycaemia. Arrange a mid-stream urine (MSU) if urinalysis is abnormal.
- Sputum culture — to identify chest infection.
- Full blood count — to identify infection or anaemia.
- Folate and B12 — to identify vitamin deficiency.
- Urea and electrolytes — to identify acute kidney injury and electrolyte disturbance (such as hyponatraemia or hypokalaemia).
- HbA1c — to identify hyperglycaemia.
- Calcium — to identify hypercalcaemia or hypocalcaemia.
- Liver function tests — to identify hepatic failure and rule out hepatic encephalopathy.
- Inflammatory markers (such as erythrocyte sedimentation rate and C-reactive protein) — these tests are non-discriminatory but can help to identify infection or inflammation.
- Drug levels — to identify drug toxicity, for example if the person has taken digoxin, lithium, or alcohol.
- Thyroid function tests — to identify hyperthyroidism or hypothyroidism.
- Chest X-ray — to identify conditions such as pneumonia and heart failure.
- Electrocardiogram — to identify cardiac conditions including arrhythmias.
Management
- Most people with delirium should be admitted to hospital for urgent assessment, close monitoring, and treatment. The decision as to whether to admit a person with delirium depends on the person's specific clinical and social situation, and should also take into account the views of family members or carers. If the person is deemed to not have capacity to consent, decisions should be made in the best interests of the person using the Mental Capacity Act 2005. If the person with delirium refuses admission ask carers or family (if appropriate) to help persuade the person. If this fails, consider admission under the Mental Capacity Act (2005).
- Management of a person with delirium includes:
- Correcting any precipitating factors e.g. infection, drugs, constipation, urinary retention, dehydration and electrolyte imbalance, pain
- Optimising treatment of comorbidities
- Managing behaviour change
- Trying reorientation strategies e.g. regular cues, continuity of care from carers and staff
- Maintaining safe mobility e.g. avoiding physical restraint, encouraging walking
- Normalising the sleep-wake cycle e.g. discouraging napping and encouraging uninterrupted sleep at night
- Managing challenging behaviour (such as aggression, agitation or shouting)
- Addressing any underlying causes for the behaviour (such as discomfort, thirst, or need for the toilet).
- Moving the person to a safe, low-stimulation environment (such as a quiet room).
- Using verbal and non-verbal de-escalation techniques (such as active listening, effective verbal responding, pictures, and symbols).
- Pharmacological measures
- Specialists may suggest pharmacological measures as a last resort for severe agitation or psychosis if:
- Verbal and non-verbal de-escalation techniques are inappropriate or have failed, and
- The person is a danger to themselves or others, and
- The cause of delirium is known and being treated, and
- The benefit outweighs the risk to the person, and
- There is enough care in place for the person to be continually monitored.
- The following medication may be suggested:
- Short-term (for 1 week or less) low-dose haloperidol (off-label indication).
- Low-dose lorazepam (off-label indication) as an alternative if haloperidol is contraindicated (for example in people with Parkinson's disease/parkinsonism, Lewy-body dementia, or a prolonged QT interval).
- Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms. The aim of drug treatment is to calm (not sedate) the person.
- Specialists may suggest pharmacological measures as a last resort for severe agitation or psychosis if:
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
