Acute confusion – Evening Medical Update Series at Royal College of Physicians Edinburgh 26th June

Investigating acute confusion  – Dr Luke Regan, Consultant in Emergency Medicine, Raigmore Hospital, Inverness

Luke started by making the point that there is low ratio of signal to noise in presenting complaints – and gave three examples of acute confusion where there was loads of potentially distracting information.

Percentage of delirium in presentations is 2% in GP, 12% in ED and 20-30% signal, with 60% in nursing homes.

Missing or discharging a patient with delirium is likely to cause harm, but also admitting people can cause delirium.

It’s also quite easy to think confusion is the norm but we need to remember that confusion is not a normal part of aging and it is a harbinger of significant insult.

You can use the 4AT to screen for these patients:

4AT v1_2 Oct 2014 - picture.png

Dr Regan then reminded us about the DELIRIUM mnemonic for causes:

Image result for delirium mnemonic

Then you need to think about the simple investigations to pick up causes:

  1. at the top of the list is hypoxia
  2. blood tests
  3. chest x-ray
  4. CT head
  5. looking for infection with cultures + giving abx
  6. LP
  7. end of the line attempts to find a cause – tox screen, b12/folate, thyroid function, EEG, MRI

Luke rounded his talk up with:

  1. Thinking about confusion often and early
  2. Screen effectively
  3. Identify causes with wide net but informed suite of investigations
  4. Relate any results to the physiological reserve of the actual patient

Treatment of delirium: a systematic approach – Professor Alasdair MacLullich, Professor of Geriatric Medicine, Royal Infirmary of Edinburgh

Prof MacLullich made the brilliant point that we should be using the term “delirium” both professionally and with family – to make it more technical, giving a formal diagnosis and formal treatment plan. Particularly with family, this may be more reassuring and something for them to latch on to – as opposed to a more nebulous term where it may not help them resolve the fact that their relative seems completely different to normal.

Prof went on to discuss a case of a 90 year old man who has tripped on a rug at home and fractured his hip – having just moved up to Edinburgh to be closer to his son. He’s given 10 mg IV morphine then 5mg oxycodone M/R, around 1L/day fluid / day, his BP was persistently low for around 18 hours pre-op (mostly systolic in 90s) and during the operation his BP drops to 76/34 requiring fluid boluses.

Post-op, he is seen on the ward round and is delirious – he is drowsy with 4AT of 10/12, restless, frowning, cool peripheries, RR16, sats 94% on 3L, temp37.9, hr98, bp87/54 and had crackles to his mid-zone.

Regarding state of the art delirium treatment, the content of guidelines/pathways & review articles state:

  • treat underlying cause(s)
  • agitation and distress – treat with non-pharm and pharm methods
  • variable coverage of all the points

Prof tried to make the point that treatment is complex – with massive variation in the patient population, the presentation, the environment. To try to organise this, Prof has created a Delirium 8 – a domain based approach. This is included in the new draft SIGN guideline. So, using this to think about the case discussed above:

  1. Initial check for acute, life-threatening causes (ABCDE). If delirium is suspected, treat as a medical emergency.
    • there could be possible opioid toxicity (D), or low BP (C)
  2. Identify and treat all precipitating causes
    • eg urinary retention, low glucose, pain, bladder retention, likely LRTI, AKI
  3. Optimise conditions for the brain
    • Some of this is already done in point 2, but there are others – looking to change physiological points (euvolaemia, metabolic, oxygen, temp, bowels, drugs etc) and psychological (sensory, environment, reassurance, family)
  4. Detect and treat agitation/distress
    • Ask about psychotic features, or things that are upsetting the patient
  5. Prevent complications
    • Pressure ulcers, immobility, falls, dehydration, malnourishment, aspiration pneumonia, unable to undergo rehab, inappropriate institutionalisation
  6. Communication with patients and carers
    • This nearly always causes distress in families – need to take a specific action to discuss the diagnosis with the patient & family
    • specifically giving a delirium leaflet which is very helpful
  7. Monitor for recovery/ rehabilitation
    • mobilisation is key – this is the normal state for people, don’t let them lie in bed!
    • If someone isn’t improving despite optimal treatment, then the diagnosis is persistent delirium – and further specialist thought/investigation MAY be appropriate. 1 in 5 people have some evidence of persistence symptoms…
  8. Consider whether this patient could have dementia and follow up
    • need to consider Post Traumatic Stress Disorder too

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