Delirium_-_a_guide_for_nurses_-_Dr_Massarotto - E

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Delirium – a brief guide for
nurses
Alicia Massarotto
Geriatric Advanced Trainee
2008
What this talk will cover
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Definition
Risk factors
Causes
How to identify
How to treat
How to manage
Some pictures of Cirque du Soleil
What is Delirium?
• Rapid onset of impairment and fluctuation
in CONCENTRATION
• Altered CONSCIOUSNESS
• Impaired COGNITION
How many people get it?
• 10-24% of older adults at time of
admission to hospital
• 56% of older adults have an episode of
delirium during hospital admission
Who gets it?-risk factors
• Hx of dementia (3x)
• visual impairment(3x)
• multiple or severe
medical problems(3x)
• multiple meds
• hearing impairment
•neurological damage
•functional disability
•advanced age
•alcohol dependence
•depression
These factors multiply
rather than add to risk of
developing delirium
When do they get it? •
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acute illness
dehydration
infection
U&E disturbance
low O2, high CO2
•heart failure
•liver failure
•renal failure
•CVA
When do they get it? II
• addition of >3 new
meds
• low BSL
• pain
• restraint use
• immobilisation
• catheter
•alcohol withdrawal
•benzodiazepine
withdrawal
•cardiac surgery
•orthopaedic surgery
A special note on medications
• They contribute up to 40% of cases
• older people have decreased renal
excretion and hepatic metabolism
• drugs of concern:
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antipsychotics
anti-convulsants
corticosteroids
opiates
NSAIDS
•anticholinergics
•antiparkinsons
•benzodiazepines
•antidepressants
Why do they get it?
– Nobody really knows
– Likely chemical imbalances caused by
stress/inflammation/medications or
combination thereof.
What does it look like?
• “pre-delirium”:
irritable, bewildered,
evasive.
• Lucid periods
• evening + night
• distractible or inert
•disorientation in time
•short-term memory
loss
•rambling, incoherent
speech
•paranoid delusions
•visual hallucinations
distractible or inert?
• Hyperactive delirium
– 30%
– repetitive behaviour plucking at sheets
– wandering
– hallucinations
– aggression
• Mixed -45%
•Hypoactive delirium
–25%
–quiet + withdrawn
–looks like
depression
How do we detect it?
• 30-60% not diagnosed!
• Cognitive assessment “a vital sign”
• formal tool:
– Confusion Assessment Method (CAM)\
• Look for decreased concentration
• Seek history from family/friends of a
sudden change in behaviour
What should you assess?
• Basic observations –
– fever, hypoxia, hypotension, brady or
tachycardia
• Sensory Impairment –
– are they blind? Where are the hearing
aids?
• Are they constipated?
• Urine dipstix
• BSL
What should the doctor assess?
• Use clinical picture to guide
• Full physical exam
• Blood tests:
– FBC,U&E,Glucose,Ca,LFT’s,Trop,TFTs
• Investigations
– MSU, CXR, Head CT, (LP, EEG)
How do we treat it?
• Treat risk factors and precipitants!!!!!
How do we treat while we wait
for the definitive treatments to
work?
Non- pharmacological
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encourage adequate fluids
glasses, hearing aids
quiet rooms, well lit
re-orientation - clocks, calendars
personal items
encourage self-care and mobility
avoid frequent staffing changes
avoid catheters, iv lines
Guard/PCA/Companion
Pharmacological
• stop the baddies if possible
• only use when patient is distressed, or is a
danger to themselves or others
• use small amounts
• be acutely aware of side-effects - including
INCREASE in agitation
• dose regularly. Times should coincide with
distressing behaviour
What agents to use?
• Haloperidol
• not much postural hypotension
• lots of extrapyramidal/ or PARKINSONIAN side
effects - rigidity, tardive dyskinesia
• DON’T give to patients with hx Parkinson’s
• Atypical anti-pyschotics
• Olanzapine, Quetiapine, Risperidone
• still some EP problems, also in diabetic patients
• Benzodiazepines
• mainly for ETOH withdrawal
• often make delirium worse otherwise
How long does it last?
• Can be for a long time!
Is it really that bad?
• Doubles length of stay
• 3X relative risk of developing dementia
• increases falls, incontinence and pressure
areas
• in hospital mortality of 25-33%
• increased risk of ongoing clinical
depression
How do we prevent it?
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Identify high risk patients
Do cognitive assessment as routine
reduce bad drugs
maintain adequate analgesia
maintain U&E’s, Oxygenation, etc
try not to move patients
use the same nurse if possible
familiar things - pictures from home,
clothes, books
What you need to remember about
delirium
• Confusion with altered Concentration +
Consciousness
• Lots of Risk factors – dementia and blindness
• Look for and treat underlying causes
• Get history from family/friends
• Avoid iv lines, catheters, changing rooms
• Try familiar items, companions
• Remember sedatives can make it worse!
Oh, and this Cirque du Soleil production was called “Delirium”.
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