Managing Acute Confusion in
The Elderly
Dr Rachel Nockels
OPALS Consultant
Why is this relevant?

GP curriculum statement 9 (care of
older people) requires GPs to be
able to manage the problems of
older people, such as confusion, in
the elderly
Causes of Acute confusion
1.
2.
3.
4.
5.
6.
7.
8.
Delirium
Worsening dementia
Depression
Alcohol withdrawal or substance
misuse
Psychotic disorder
Thyroid disease
Mania
(Schizophrenia)
Delirium - definition

A common clinical syndrome
characterised by disturbed
consciousness, cognitive function or
perception which has an acute onset
and fluctuating course
NICE delerium guideline
Definition DSM IV




disturbance of consciousness (i.e., reduced clarity of
awareness of the environment) with reduced ability to
focus, sustain, or shift attention.
a change in cognition (such as memory deficit,
disorientation, language disturbance) or the
development of a perceptual disturbance that is not
better accounted for by a pre-existing, established, or
evolving dementia.
the disturbance develops over a short period of time
(usually hours to days) and tends to fluctuate during
the course of the day.
there is evidence from the history, physical
examination, and laboratory findings that: (1) the
disturbance is caused by the direct physiological
consequences of a general medical condition, (2) the
symptoms in criteria (a) and (b) developed during
substance intoxication, or during or shortly after, a
withdrawal syndrome, or (3) the delirium has more
than one aetiology”.
Confusion Assessment Method
1.
2.
3.
4.
Acute onset and fluctuating course
Inattention
Disorganised thinking
Altered level of consciousness
A positive CAM requires presence of 1
AND 2 plus either 3 or 4
DELIRIUM
DEMENTIA
DEPRESSION
Sudden
(hours to days)
Usually gradual (over
months)
Gradual
(over weeks to months)
Alertness
Fluctuates Sleepy or agitated
Generally normal
Generally normal
Attention
Fluctuates – difficulty
concentrating,
easily distractible
Generally normal
May have difficulty
concentrating,
easily distractible
Sleep
Change in sleeping pattern
(often more confused at
night)
Can be disturbed –
night time wandering
and confusion
possible
Early morning wakening
Thinking
Disorganised - jumping
from one idea to another
Problems with
thinking and memory,
may have problems
finding right word
Slower, preoccupied with
negative thoughts of
hopelessness, helplessness
or self depreciation
Illusions, delusions and
hallucinations common.
Generally normal
Generally normal
Onset
Perception
European Delirium Association
Theories of delirium
pathophysiology
1.
2.
Cholinergic deficiency
Aberrant stress response/
neuroinflammation
Delirium – sub types




Hyperactive
Hypoactive
Mixed
(Subsyndromal)
Prevalence




Medical wards – 20-30%
Post surgery – 10-50%
Long term care – just under 20%
Community- ? Up to 1%
Who Is At Risk?






Those aged 65 years and older
Hip fracture
Cognitive impairment
Severe illness
Sensory impairment
Previous episode of delirium
Precipitating factors









Drugs
Infection
Neurological
Cardiological
Respiratory
Electrolyte imbalance
Endocrine and metabolic
Constipation
Change in environment
Think Pinch Me






Pain
INfection
Constipation
Hydration
Medication
Environment
Consequences






Dementia/Cognitive impairment
Progression of dementia
Discharge to care home (for people who
were in hospital)
Falls
Hospital admission (for people who were
in long-term care)
Post discharge care
Consequences cont.






Post traumatic stress disorder
Pressure Ulcers
Mortality
Impact on carers
Length of stay
Quality of life for patients
Management
Best management is prevention








Reorientate
Nurse in familiar surroundings
Stop all unnecessary medications
Keep lighting appropriate
Put in hearing aids and wear glasses
Keep well hydrated
Monitor nutrition
Re-align sleep wake cycle
Treatment






Identify cause(s)
Ensure effective communication
Use verbal and non verbal
techniques
Keep moves to a minimum
If a risk to themselves or others
consider short term haloperidol or
olanzapine
Continue to re evaluate
De Escalation Techniques








Approach in a calm manner
Give choices and maintain patient dignity
Speak in a low even tone
Do not maintain eye contact
Do not interrupt or argue
Allow space, do not touch patient
Empathise with their feelings
Don’t put yourself at risk
Sedation


Should be avoided
If necessary use low dose and
gradually increase
Who Needs Admitting?





Live alone
Will be left unsupervised for any duration
of time
If carers (or RH) are unprepared or
unable to continue looking after the
patient
If the cause does not become clear
despite investigation or the patient fails to
improve with treatment and/or
If the history and/or examination indicate
a cause requiring acute hospital
treatment
Conclusion





Acute confusion in the elderly is a
common problem
Delirium is often missed especially
hypoactive form
It can take months to resolve
The consequences can be
devastating
Try not to use sedation if at all
possible
Thank you
Any questions?