In the
previous few days we had talked about sepsis and staph aureus bacteremia, all
medical emergencies.
Delirium
is no different. Often patients get admitted "confused", a term that
has a variety of meanings to different people. We think we all have the same
understanding, but whenever someone says "the patient was
confused"... that just begs the question "what do you mean by
that"?
We
stressed the importance of calling family/the nursing home/ anyone for
collateral history, regardless of the time. We want to get a baseline, how do
they function at home in regards to their ADLs and IADLs. Doctors are poor at
recognizing delirium, however, distinguishing delirium vs dementia can often be
difficult when you are meeting a patient for the first time... SO CALL THE
FAMILY!
*note: I
will not define dementia here as if both are on the same page you will get
confused… and you should assume a patient is delirious until proven otherwise.
Dr. Naqvi
gave us a great mnemonic for remembering delirium, IADL - inattention, acute on
set (and fluctuating), disorganized thinking/speech, and level of consciousness
altered (hyper or hypoactive delirium).
This is
the CAM method, the most validated one - if positive very high likelihood that
we have delirium. MOCA/MMSE should not be done in acute delirious states, but
when a patient is at their baseline. We need I + A and then D or L.
Delirium
is associated with a higher mortality overall, hospital related complications,
and increased length of stay
Risk
factors: dementia, depression, advanced age, hearing/vision impairment, and
severe illness.
So we’ve
identified our patient is delirious, what do we do about it?
First
accept that there is often an organic cause?
DIMS:
Drugs –
intoxication/withdrawal, in hospital go through the MAR thoroughly, new benzos?
Not GETTING their benzos, graval? Opioids? SSRI withdrawal? We forget that
somepatients that get admitted get drugs they’ve never been exposed to, so call
“opioid niave”
Infection:
look for fever! This requires a head to toe assessment, be very cautious about
the positive urinalysis, or even pyuria. It makes it easy to refer to medicine
with this as a source… but be very cautious about assuming this. If a patients
vital signs are stable… realize there is know mortality and even morbidity
associated with treating a UTI. However, if patient is unable to provide a
history due to decrease LOC… one could assume they are like that from UTI…
after everything else has been considered.
Here is a
quick little article from CMAJ that demonstrates my point (or rather I
demonstrate their point)
Metabolic:
my approach for this is organ failure – hypo/hyperglycemia (easy to check),
lung failure (hypoxic/hypercapnic), liver failure, kidney failure, thyroid
failure, etc.
Electrolytes
get its own category – hypohyper natremia, calcium, magnesium
Structural:
a rare cause of delirium – look for focal deficits, if decrease LOC, you can
still see if they respond to pain, localizing, plantar responses (are they
up-going indicated UMN lesion). Seizure could also fall under here/post ictal,
this is after other things have been considered.
Miscellaneous:
a relatively newer term coined is sensory deprivation – you take away someone’s
vision, hearing, restrain their arms.. they get confused. Constipation, pain, urinary retention also fit
under here.
Preventing delirium?
This is a classic study where they focussed on 6 main
intervention in two randomized groups
6 risk factors for delirium were targeted for
intervention: cognitive impairment, sleep deprivation, immobility, visual
impairment, hearing impairment, and dehydration.
The delirium was less in the intervention group
(10% vs 15%). Those that developed it had it for less in the intervention
group.
So what we need to think about when admitted
are patients?
Firstly identify patients at risk for it!
History of dementia? Make sure they have their hearing aids, glasses, ask
nurses and family to remind patients everyday where they are and why they are
their. Ensure pain controlled, making sure they are having bowel movements, not
retaining urine, etc.
Consider geriatric consultation: this study
found benefit for delirious patients who were post op for hip fracture.
However they likely did intervention similar
to that in the study at Yale in 1999.
The FIRST step is by documenting a
patient is at risk of it in your admission note!
Finally, you figured out the cause, you
are treating it… but they are still delirious. We typically use Haldol 05 mg po
or IM, and double the dose in 30 minutes if ineffective. Getting a sitter is
better than restraints. Avoid benzos in the elderly.
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