Guidelines for the diagnosis and management of delirium - British ...

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Guidelines for the diagnosis and


Management of delirium in the


Elderly










Contents
Page


Grade of eviden
ce




1


Acknowledgements




1


Definitions





2


Diagnosis





2


Abbreviated Mental Test score


3


Differential diagnosis



3


Patients at risk




3


Causes





4


History





4


Examination





4


Investigations




5


Treatment of underlying cause


6



Management of confusion



6



Sedation





7



Prevention of complications


8



Referral to Old Age Psychiatry


8



Discharge





9



Follow up





9



References





10, 11,12



Index






13



Appendix 1





Drugs causing delirium


Appendix
2





Algorithm for management


Appendix 3





Summary of Carlisle guidelines for

management of delirium

Grade of evidence:


Grade 1

Based on Randomised Controlled Trial


Grade IIa

Based on well designed non
-
randomised controlled trial


Grade IIb

Based on

well designed cohort or case
-
control analytic studies


Grade IIc

Comparisons between times/places, with or without interventions.

Dramatic results in uncontrolled trials


Grade IIl


Expert opinion, clinical experience, descriptive studies, expert
committe
es.



Acknowledgements:


These guidelines were compiled by Dr Lesley Young and Dr Jim George with funding
from the NHS central audit fund. We wish to acknowledge the support and co
-
operation
of the following groups of people who assisted in the development

of these guidelines:


Staff of the from the medical and elderly care wards and audit departments in the
following hospitals:


Cumberland Infirmary, Carlisle

Newcastle General Hospital, Newcastle upon Tyne

North Tyneside General Hospital, North Shields

Roy
al Victoria Infirmary, Newcastle upon Tyne

St Luke's Hospital, Bradford

Bradford Royal Infirmary, Bradford

Selly Oak Hospital, Birmingham


Members of the joint working party on "Confusion in Crises", Royal College of Physicians, October 1995.

Dr Stephen S
ingleton, Director of Public Health, Northumberland.





















1


Guidelines for the diagnosis and management of delirium


Delirium (acute confusional state) is a common condition in the elderly affecting up to
30% of all elderly medical patient
s. Patients who develop delirium have high mortality,
institutionalisation and complication rates, and have longer lengths of stay than
non
-
delirious patients [1]. Delirium is often not recognised by clinicians [2], and is often
poorly managed. The aim of
these guidelines is to aid recognition of delirium and to
provide guidance on how to manage these complex and challenging patients.


Diagnosis


Delirium is characterised by a disturbance of consciousness and a change in
cognition that develop over a short
period of time. The disorder has a tendency to
fluctuate during the course of the day, and there is evidence form the history,
examination or investigations that the delirium is a direct consequence of a
general medical condition, drug withdrawal or intoxi
cation (DSM IV) [3].


In order to make a diagnosis of delirium, a patient must show each of the features
1
-
4 listed below:


1.

Disturbance of consciousness (i.e. reduced clarity of awareness of the
environment) with reduced ability to focus, sustain or shi
ft attention.


2.

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 or evolving dementia.


3.

The disturbance develops ove
r a short period of time (usually hours to
days) and tends to fluctuate during the course of the day.


4.

There is evidence from the history, physical examination, or laboratory
findings that the disturbance is caused by the direct physiological
consequenc
es of a general medical condition, substance intoxication or
substance withdrawal.


Delirium may have more than one causal factor (i.e. multiple aetiologies). A
diagnosis of delirium can also be made when there is insufficient evidence to
support criterion

4, if the clinical, presentation is consistent with delirium, and the
clinical features can not be attributed to any other diagnosis, for example
delirium due to sensory deprivation.









2

Aids to diagnosis




Cognitive testing should be carried out on
all elderly patients
admitted to hospital (grade llc
) Use of cognitive screening tools (such
as the Abbreviated Mental Test score [4] and Mini Mental State
Examination [5]) may increase recognition of delirium present on
admission [4, 5].




Serial measureme
nts may help detect the new development of delirium or
its resolution [6] (gradellc).
However by themselves these tools cannot
distinguish between delirium and other causes of cognitive impairment [4, 5].




A history from a relative or carer of the onset an
d course of the confusion
is essential to help distinguish between delirium and dementia. (grade III).




Abbreviated Mental Test Score (AMT) (A score of less than 8/10 is
abnormal)



1.


Age


2.

Time (to nearest hour)


3.

Address for recall at end of te
st (42 West St)


4.

Year


5.

Name of hospital


6.

Recognition of 2 persons (eg doctor, nurse)


7.

Date of Birth


8.

Year of 1st World War


9.

Name of present monarch

10.

Count backwards 20
-
1 (this also tests attention)



Differential diagnosis




The differe
ntial diagnosis of delirium includes:



Dementia



Depression



Hysteria



Mania



Schizophrenia


The simple screening tools, discussed earlier, are not able to distinguish between
delirium and other disorders, such as dementia [4, 5]. In order to differentiate betw
een
delirium and dementia, the most helpful factor is an account of the patients
pre
-
admission state from a relative or carer. Serial measurements of cognition may help
to differentiate delirium from dementia or detect its onset during a hospital admission

[6]
(grade Ilc).




3

Patients at risk


Delirium is more common in those with a pre
-
existing organic brain syndrome [7] or
dementia [8
-
19], and may co
-
exist with disorders such as depression, which are also
common in the elderly [10, 20].

Delirium is more

common in patients who are:




Older [21]



Severely ill [11]



Demented [11]



Physically frail [22]



Admitted with an infection or dehydration [11, 21]



Visually impaired [11]



Polypharmacy [15, 16, 23]



Alcohol excess [12]


Early attention to possible precipitants

of delirium and adopting the approaches
detailed under "management of confusion" in those patients at increased risk of
delirium may prevent the development of delirium and improve the outcome in
those who go on to develop it [24
-
26, 44] (Grade, l).


Iden
tification of the underlying cause


Common causes of delirium include :




Infection (e.g. pneumonia, UTI)



Neurological (e.g. stroke, subdural haematoma, epilepsy)



Cardiological (eg myocardial infarction, heart failure)



Respiratory (eg pulmonary embolus, hyp
oxia)



Electrolyte imbalance (eg dehydration, renal failure)



Endocrine & metabolic (eg cachexia, thiamine deficiency, thyroid dysfunction)



Drugs ( particularly those with anticholinergic side effects, eg antidepressants,
antiparkinsonian drugs, sedatives) (
see appendix 1)



Multiple causes.


History


In addition to standard questions in the history, the following information should
be specifically sought (grade III):




Full drug history including non
-
prescribed drugs



Alcohol history



Previous intellectual functi
on (eg ability to manage household affairs, pay bills
etc.)



Functional status (eg activities of daily living)



Onset and course of confusion



Previous episodes of acute or chronic confusion


4



Symptoms suggestive of underlying cause (eg infection)



Sensory de
ficits



Aids used (eg hearing aid, glasses etc.)



Pre
-
admission social circumstances and care package



Comorbid illness


Many patients with confusional states are unable to provide an accurate history.
Where ever possible corroboration should be sought from t
he carer (grade III
).


Communication between staff from different disciplines is essential to avoid
unnecessary repetition of information gathering.


Examination


A full physical examination should be carried out including in particular the
following areas
:




Neurological examination (including assessment of speech)



Conscious level



Nutritional status



Evidence of pyrexia



Evidence of alcohol abuse or withdrawal (e.g. tremor)



Cognitive function using a standardised screening tool e.g. Abbreviated MTS or
MMSE (
grade IIc)



Attention (e.g. serial 7`s, months of year backwards)



Investigations


The following investigations are almost always indicated in patients with delirium in
order to identify

the underlying cause (grade III):




Full blood count



Calcium



Urea and
electrolytes



Liver function tests



Glucose



Thyroid function tests



Chest X
-
ray



ECG



Blood cultures



Urinalysis






5

Other investigations may be indicated according to the findings from the history and
examination.

These include:




EEG (see below)



CT head (see

below)



B12 and folate



Arterial blood gases



Specific cultures eg urine, sputum



Lumbar puncture (see below)



CT Scan (grade llb)


Although many patients with delirium have an underlying dementia or structural brain
lesion (eg previous stroke), CT has been
shown to be unhelpful on a routine basis in
identifying a cause for delirium [7] and should be reserved for those patients in whom
an intracranial lesion is suspected. This might include patients with the following
features (grade III):




Focal neurological

signs



Confusion developing after head injury



Confusion developing after a fall



Evidence of raised intracranial pressure


EEG


Although the EEG is frequently abnormal in those with delirium [27
-
29], showing diffuse
slowing, its routine use as a diagnostic
tool has not been fully evaluated. EEG may be
useful where there is difficulty in the following situations (grade III):




Differentiating delirium from dementia



Differentiating delirium from non
-
convulsive status epilepticus and temporal lobe
epilepsy



Ident
ifying those patients in whom the delirium is due to a focal intracranial
lesion, rather than a global abnormality.



Lumbar puncture


Although various abnormalities have been seen in the CSF of patients with delirium
[30], routine LP is not helpful [31] i
n identifying an underlying cause for the delirium
(grade III). It should therefore be reserved for those in whom there is reason to suspect
a cause such as meningitis. This might include patients with the following features:




Meningism



Headache and fever



6

Treatment of underlying cause


The most important approach to the management of delirium is the identification and
treatment of the underlying cause (grade III).




Incriminated drugs should be withdrawn where ever possible (grade III).



Biochemical deran
gements should be corrected promptly [32] (grade IIb)



Infection is one of the most frequent precipitants of delirium. If there is a
high likelihood of infection (eg abnormal urinalysis, abnormal chest
examination etc.), appropriate cultures should be taken

and antibiotics
commenced promptly, selecting a drug to which the likely infective
organism will be sensitive (grade III).


Management of confusion


In addition to treating the underlying cause, management should also be directed at the
relief of the symp
toms of confusion/delirium.


The patient should be nursed in a good sensory environment and with a reality
orientation approach, and with involvement of the multi
-
disciplinary team [18, 23, 25, 26,

33
-
35] (grade I).


This includes:




Good lighting levels



Re
gular and repeated visible and verbal clues as to orientation (eg clocks,
calendars)



Reassurance and explanation to the patient and carer of any procedures or
treatment, using short simple sentences



Sensory aids should be available and working where necess
ary



Avoidance of inter
-

and intra
-
ward transfers [36] (grade III)



Continuity of care from caring staff



Avoidance of physical restraints [37
-
39] (grade IIc) (see also under Falls)



Maintenance or restoration of normal sleep patterns



Approach and handle gentl
y



Eliminate unexpected and irritating noise (e.g. pump alarms)



Attend to bowel and bladder elimination (see continence problems)



Encouraging visits from familiar friends and relatives may help to calm an
agitated patient. However communication with the rel
ative regarding the
nature of the confusion is essential.


Depending on the layout and nature of the ward, these measures may be facilitated by
nursing the patient in a single room. For example, in a busy Nightingale ward, a patient
with delirium may be be
tter managed in a side room, whereas in a ward with small bays
the presence of other patients may have a reassuring influence (grade III).




7

Wandering and rambling speech


Patients who wander require close observation within a safe and reasonably closed

environment. It is often preferable to try distracting the agitated wandering patient rather
than using restraints or sedation. Relatives could be encouraged to assist in this kind of
management.

Attempts should be made to identify and remedy possible cau
se of agitation
-

e.g. pain,
thirst, need for toilet. Patients with delirium often exhibit confused and rambling speech,
it is usually preferable not to agree with rambling talk, but to adopt one of the following
strategies, depending on the circumstance (
grade III) [40]:




Tactfully disagree (if the topic is not sensitive)



Change the subject



Acknowledge the feelings expressed
-

ignore the content


Sedation


All sedatives may cause delirium, especially those with anticholinergic side effects [41]
(such as th
ioridazine, chlorpromazine etc.). The use of sedatives and major
tranquillisers should therefore be kept to a minimum (grade III). Many elderly patients
with delirium have hypoactive delirium (quiet delirium) and do not require sedation [42].

Early ident
ification of delirium and prompt treatment of the underlying cause may
reduce the severity and duration of delirium [24
-
26].


Drug sedation may be necessary in the following circumstances (grade III)




in order to carry out essential investigations or treat
ment



to prevent patients endangering themselves or others



to relieve distress in a highly agitated or hallucinating patient


It is preferable to use one drug only, starting at the lowest possible dose and increasing
in increments if necessary after an inte
rval of 30 minutes (grade III).


The preferred drugs are:




Haloperidol
-

0.5mg
-
3mg orally as tablets or liquid up to 4 times daily or 2.5
-

5
mg by

intramuscular injection (grade III) (NB the oral and IM doses of haloperidol are
not equivalen
t)




Droperidol
-

5
-
10mg orally or 5mg by intramuscular injection up to 4 times
daily.


If sedatives are prescribed, the prescription should be reviewed regularly and
discontinued as soon as possible.

For delirium due to alcohol withdrawal (delirium trem
ens) a benzodiazepine (eg
diazepam or chlordiazepoxide) or chlormethiazole are preferred in a reducing course.
Detailed guidelines for this condition are beyond the scope of these guidelines.


8

Prevention of complications


The main complications of deliri
um are :




Falls



Pressure sores



Nosocomial infections



Functional impairment



Continence problems



Over sedation



Restraints (including cotsides, "geriatric chairs" etc.) have not been shown to prevent
falls and may increase the risk of injury [37
-
39]. It may

be preferable to nurse the
patient on a low bed or place the mattress directly on the floor. Adoption of the good
practices described should make the use of physical restraints unnecessary for the
management of confusion (grade III).


Pressure sores


Pati
ents should have a formal pressure sore risk assessment ( eg Norton score, or
Waterlow score), and receive regular pressure area care, including special mattresses
where necessary (grade III). Patients should be mobilised as soon as their illness
allows.


Functional impairment


Assessment by a physiotherapist and occupational therapist to maintain and improve
functional ability should be considered in all delirious patients (grade III). There is
evidence that patients who are managed by a multidisciplinary
team do better than
those cared for in a traditional way [18, 23, 25
-
26, 33
-
35] (grade I, IIb).


Continence


A full continence assessment should be carried out. Regular toiletting and prompt
treatment of UTI`s may prevent urinary incontinence. Catheters sh
ould be avoided
where possible because of the increased risks of trauma in confused patients, and the
risk of catheter associated infection (grade III).


Referral to Old Age Psychiatry services


Many patients with delirium have an underlying dementia which

may be best followed
up and managed by an Old Age Psychiatrist. Patients who fail to improve despite
adequate treatment and resolution of the suspected cause of the delirium may benefit
from referral to an Old Age Psychiatrist for further assessment (grad
e III) [35].





9

Discharge


As with all elderly patients discharge should be planned in conjunction with all
disciplines involved in caring for the patient, both in hospital and in the community
(including informal carers). Practical arrangements should
be in place prior to discharge
for activities such as washing, dressing, medication etc. in accordance with the joint
statement of the British Geriatrics Society and the Association Directors of Social
Services [43] (grade III).




Communication with all par
ties involved in the patients care is vital.



Prior to discharge it is useful to assess the patients cognitive and
functional status ( eg using standardised tools such as AMT and Barthel
Index).



Discharge summaries should be completed promptly.


Follow up


Delirium is a common first presentation of an underlying dementing process. It may also
be a marker of severe illness and comorbidity. It is therefore often appropriate to refer
the patient to a Geriatrician, Psychiatrist of Old Age, CPN or Social Worker f
or the
Elderly or Consultant in Geriatric Medicine for further assessment and follow up.





























10

References


[1]

Levkoff S, Cleary P. Epidemiology of delirium: an overview of research issues
and findings. Int Psychogeriatrics 1991;
3(2):149
-
167


[2]

Johnson JC, Kerse NM, Gottlieb G, Wanich C, Sullivan E, Chen K. Prospective
versus retrospective methods of identifying patients with delirium.
JAGS;1992:40:316
-
319


[3]

American Psychiatric Association: Diagnostic and Statistical Manual
of Mental
Disorders, fourth edition. Washington, D.C., American Psychiatric Association,
1994.


[4]

Jitapunkul S, Pillay I, Ebrahim S. The abbreviated mental test: its use and
validity. Age and Ageing;1991:20:332
-
336


[5]

Anthony JC, LeResche L, Niaz V, Vo
n Korff MR, Folstein MF. Limits of the
"MMSE" as a screening test for dementia and delirium among hospital patients.
Psychol Med 1982;12:397
-
408


[6]

O`Keeffe ST, Lavan JN. Use of serial MMSE scores to monitor development and
resolution of delirium in elde
rly hospital patients. Abstract to Autumn Meeting of
the British Geriatrics Society, October 1995.


[7]

Koponen H, Hurri L, Stenback U, Reikkinen PJ. Acute confusional states in the
elderly: A radiological evaluation. Acta Psych Scand 1987;76:726
-
731.


[8]

Erkinjuntti T, Wikstrom J, Palo J, Autio L. Dementia among medical inpatients.
Evaluation of 2000 consecutive admissions. Arch Int Med 1986;146:1923
-
1926



[9]

Kolbeinsson HJ, Jonsson A. Delirium and dementia in acute medical admissions
of elderly pat
ients in Iceland. Acta Psych Scand 1993;87:123
-
127.


[10]

Bowler C, Boyle A, Branford M, Cooper SA, Harper R, Lindesay J. Detection of
psychiatric disorders in elderly medical inpatients. Age and Ageing
1994;23:307
-
311.



[11]

Inouye S, Viscoli C, Horo
witz R, Hurst L, Tinetti M. A predictive model for
delirium in hospitalized elderly medical patients based on admission
characteristics. Ann Int Med 1993;119:474
-
481


[12]

Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium
in hospita
lized older persons:outcomes and predictors. JAGS 1994;42:809
-
815.


[13]

Jitapunkul S, Pillay I, Ebrahim S. Delirium in newly admitted elderly patients: a
prospective study. Quarterly Journal of Medicine 1992;83:307
-
314.



[14]

Francis J, Kapor WN. Pro
gnosis after hospital discharge of older medical
patients with delirium. JAGS 1992;40:601
-
606.


11


[15]

Schorl JD, Levkoff SE, Lipsitz LA, Reilly CH, Cleary PD, Rowe JW, Evans DA.
Risk factors for delirium in hospitalized elderly. JAMA 1992;267:827
-
831.


[16]

Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized
elderly. JAMA 1990;263:1097
-
1101.



[17]

Rockwood K. Acute confusion in elderly medical patients. JAGS
1989;37:150
-
154.



[18]

Williams MA, Campbell EB, Raynor WJ, Ml
ynarczyk SM, Ward SE. Reducing
acute confusional states in elderly patients with hip fractures. Research in
Nursing and Health 1985;8:329
-
337



[19]

Gustafson Y, Berggren D, Brannstrom B, Bucht G, Norberg A, Hansson L
-
I,
Winblad B. Acute confusional states

in elderly patients treated for femoral neck
fracture. JAGS 1988;36:525
-
530.



[20]

Feldman E, Mayou R, Hawton K, Ardern M, Smith EBO. Psychiatric disorders in
medical in
-
patients. Quarterly Journal of Medicine 1987;63(241):405
-
412.


[21]

Levkoff SE,
Safran C, Cleary PD, Gallop J, Phillips RS. Identification of factors
associated with the diagnosis of delirium in elderly hospitalised patients. JAGS
1988;36:1099
-
1104.



[22]

Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer
CM, D
onaldson MC, Whittemore AD, Sugarbaker DJ, Poss R, Haas S, Cook EF,
Orav J, Lee TH. A clinical prediction rule for delirium after elective surgery. JAMA
1994;271:134
-
139.



[23]

Williams MA, Holloway JR, Winn MC, Wolanin MO, Lawler ML, Westwick CR,
Chi
n MH. Nursing activities and acute confusional states in elderly hip
-
fractured
patients. Nursing Research 1979;28(1):25
-
35.



[24]

Gustafson Y, Brannstron B, Berggren D, Ragnarsson JI, Sigaard J, Bucht G,
Reiz S, Norberg A, Winblad B. A geriatric
-
anesth
iologic program to reduce acute
confusional states in elderly patients treated with femoral neck fractures. JAGS
1991;39:655
-
662.



[25]

Landefield CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowel J. A randomized
trial of care in a hospital medical unit

especially designed to improve the
functional outcomes of acutely ill older patients. NEJM 1995;332:1338
-
1344



[26]

Inouye SK, Wagner DR, Acampora D, Horowitz RI, Cooney LM, Tinetti ME. A
controlled trial of a nursing
-
centred intervention in hospital
ized elderly medical
patients: the Yale Geriatric care Program. JAGS 1993;41:1353
-
1360




12


[27]

Brenner RP. Utility of EEG in delirium: past views and current practice. Int
Psychoger. 1991;3(2):211
-
229.



[28]

Jacobsen SA, Leuchter AF, Walter DO
. Conventional and quantitative EEG in
the diagnosis of delirium among the elderly. J of Neurology, Neurosurgery and
Psychiatry 1993;56:153
-
158.



29]

Koponen H. Electroencephalographic indices for diagnosis of delirium. Int
Psychoger 1991;3(2):249
-
251
.



[30]

Koponen HJ, Leinonen E, Lepola U, Reikkinen PJ. A long
-
term follow
-
up study
of cerebrospinal fluid somatostatin in delirium. Acta Psych Scand 1994 89;329
-
334.



[31]

Warshaw G, Tanzer F. The effectiveness of lumbar puncture in the evaluati
on of
delirium and fever in the hospitalized elderly. Arch Family Med. 1993;2:293
-
297.


[32]

Koizumi K, Shiraishi H, Ofuku K, Suzuki T. Duration of delirium shortened by the
correction electrolyte imbalance. Japanese J of Psychiatry and Neurology
1988;42(1
):81
-
88


[33]

Wanich CK, Sullivan
-
Marx EM, Gottlieb GL, Johnson JC. Functional status
outcomes of a nursing intervention in hospitalized elderly. Image: Journal of
Nursing Scholarship 1992;24(3):201
-
207



[34]

Cole MG, Primeau FJ, Bailey RF, Bonnycastl
e MJ, Masciarelli F, Engelsmann F,
Pepin MJ, Ducic D. Systematic intervention for elderly inpatients with delirium: a
randomised trial. Can Med Ass J 1994;151(7):965
-
970


[35]

Cole MG, Fenton FR, Engelsmann F, Mansouri I. Effectiveness of Geriatric
Psychi
atry consultation in an acute care hospital: a randomised controlled trial.
JAGS 1991;39:1183
-
1188



[36]

Mattice M. Intrahospital room transfers: a potential link to delirium in the elderly.

Perspectives 1989 (summer);10
-
12.



[37]

Evans LK, Strumpf NE. T
ying down the elderly. A review of the literature on
physical restraint. JAGS 1989;37:65
-
74


[38]

Sullivan
-
Marx EM. Delirium and physical restraint in the hospitalized elderly.
Image 1994;26(4):295
-
300.


[39]

Lofgren RP, MacPherson DS, Granieri R, Myllenbe
ck S, Sprafka J. Mechanical
restraints on the medical wards: are protective devices safe? Am J Public Health
1989;79(6):735
-
738.


[40]

Holden UP, Woods RT. Reality Orientation. Psychological approaches to the
"confused" elderly. 2nd edition. Churchill Livi
ngstone.



[41]

Tune L, Carr S, Hoag E, Cooper T. Anticholinergic effects of drugs commonly
prescribed for the elderly: potential means for assessing risk of delirium. Am J
Psych 1992;149:1393
-
1394



[42]

Liptzin B, Levkoff SE. An empirical study o
f delirium subtypes. B J Psych
1992;161:843
-
845.



[43]

Joint statement of the Association of Directors of Social Services and the British
Geriatrics Society. Discharge to the community of elderly patients in hospital.
Guidelines, Policy Statements and

Statement of Good Practice No. 7


[44]

Inouye SK, Bogardus ST, Charpentier PA, Leo
-
Summers L, Acompora D,
Holford TR and Cooney LM. A multi
-
component intervention to prevent delirium
in hospitalised older patients. NEJM 1999; 340:669
-
676














1
3

Index


A


Abbreviated Mental Test score


3

Acknowledgements




1

Algorithm





Appendix 2

Assessment





4

B, C


Causes





3

Cognitive tests




3

Complications




8

Continence





8

CT scans





5

D


Definitions





2

Dementia





3

Depression





3

Dia
gnosis





2

Differential diagnosis



3

Aids to diagnosis



2

Diagnostic criteria



2

Discharge





9

Drugs...






causing delirium



Appendix 1

treatment of delirium


7

E


EEG






5

Examination





4

F


Falls






8

Follow
-
up





9

Functional impairment



8

G


Grade of evidence




1

H


History





4

I


Incontinence





8

Investigations




5

J, K

L


Lumbar puncture




6

M


Management of confusion



6, 7

Multidisciplinary team



6,8,9

N, O


Old age psychiatry




8

P, Q


Pressure sores




8

Prevention





3
,6

R


Reality Orientation




6

References





10

Rehabilitation




8

Restraints





6,8

Risk factors





3

S


Sedation





7

indications




7

types





7

Summary of guidelines



Appendix 3

T


Treatment





6

underlying cause



6

confusion




6,7

U, V


Unde
rlying cause




4

W


Wandering





8

X Y Z



14

Appendix 1


DRUG TYPE


EXAMPLES


RISK


COMMENTS


Benzodiazepines


Diazepam, Temazepam
Chlordiazepoxide


HIGH


Benzodiazepine withdrawal is also a common
cause of delirium


Antidepressants


Amitrip
tyline

Doxepin, Trazadone


HIGH


Risk greatest in drugs with anticholinergic and
sedative effects


Antiparkinsonian drugs


Levodopa

Bromocriptine

Selegeline

Benzhexol

Orphenadrine

Pergolide


HIGH


All have anticholinergic or dopaminergie effects,
which ca
n cause confusion


Analgesics


NSAIDs

Opiates

Aspirin


HIGH


All analgesics (except paracetamol) can cause
confusion. Of the NSAIDs indomethacin is most
likely to cause delirium. Confusion due to
aspairin is dose related. Opiates have a very
high risk
of causing confusion


Lithium




HIGH




Steroids




HIGH


Risk may be dose related


Antihypertensive
medications


Methyl Dopa

α
-
Blockers

β
-
Blockers

ACE Inhibitors

CA
-
Channel Blockers

Diuretics


HIGH

MEDIUM


LOW







Diuretics may lead to delirium by causing
electrolyte disturbances


Antiarrhythmics


Digoxin

Amiodarone

Disopyramide

Lignocaine


MEDIUM


Lignocaine has highest ris
k

Risk with digoxin is dose related


Major tranquillizers


Chlorpromazine

Thioridazine

Trifluoperazine

Haloperidol

Droperidol


MEDIUM



LOW



Sedating drugs, with anticholinergic effects (e.g.

Chlorpromazine) have higher risk than non
-
sedating drugs such
as haloperidol


Anticonvulsants


Primidone

Phenytoin

Carbamazepine

Valproate


LOW


Risk highest with primidone

Lowest risk with valproate and carbamazepine

Risk with phenytoin may be dose related


Anticholinergic drugs

Antihistamines

Antispasmodics


Chlo
rpheniramine

Atropine


MEDIUM


Drugs in this group are often bought over the
counter


Histamine blockers


Cimetidine

Ranitidine, Famotidine


LOW


Cimetidine may be more likely to cause
confusion than the other drugs in this group


Antibiotics


Benzyl Pen
icillin

Co
-
Trimoxazole

Amphotericin

Antituberculous Drugs

Rifampicin

Isoniazid

Antiparasitic Drugs

Meppacrine

Chloroquine, Quinine

Antiviral Drugs

Amantadine

Acyclovir, Zidovudine


LOW



MEDIUM


Although delirium has been attributed to most
antibiotics

Mos
t cases of confusion occurring during
antibiotic treatment are likely to be due to the
infection rather than the treatment


Respiratory drugs


Aminophylline


LOW


May cause dose related confusion


Oral hypoglycaemic
agents


Tolbutamide

Glibenclamide


UNC
ERTAIN


These drugs may cause hypoglycaemia and
hyponatraemia, both of which can cause
delirium


Antineoplasstic drugs


Methotrexate, Vinca

Alkaloids, Fluorouracil,

Altretamine, Asparginase,

Procarbazine,
Carmustine,

Dacabazine, Interferon
-
α


UNCERTAIN


Delirium frequently occurs in malignant disease,
therefore it is difficult to attribute the confusion to

the drugs. However the drugs listed have been
associated with confusion more often than
others



Appendix 2

Gui
delines for the diagnosis and management of delirium























































Cultures

Urinalysis

FBC,ESR

CXR

Infection

Drugs

Other

Cardiac

Endocrine, Metabolic

Review all drug
treatment

U&E

LFT,TFT,Glucose

ECG

Other tests (see guidelines
)

Empirical Treatm
ent

Discontinue likely drugs

Treat any causes found

Improving

Worsening

Con
tinue

Review

Diagnosis

Seek expert help

(See below
)

Monitor with AMT

Avoid sedatives

Avoid restraints

Use reality orientation

Avoid complications

Multidisciplinary discharge

planning

Follow up

“Expert” will depend on local availability, but may
include Consultant in Old Age Psychiatry or Geriatric
Medic
ine

Ensure good communication
with patient, carers and

other professionals

at all times

History

Examination

Investigations

Identify underlying cause (or causes)

Delirium

YES

NO

Is there a change from the usual mental
state?

Delirium unlikely

Co
nsider other diagnosis

e.g. dementia or depression

>8/10

<8/10

AMT

Possible delirium


Appendix 3










Summary of Carlisle guidelines for management of delirium




The features

of delirium according to DSM IV are:





In all stages during the hospital admission, ensure good communication with



1.

Disturbance of consciousness (i.e. reduced clarity of awareness of the

the patient and carer: and between professionals caring for th
e patient
.





environment) with reduced ability to focus, sustain or shift attention.


1.

Identification of delirium using established diagnostic criteria (see over).


2.

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 or evolving dementia.

2.

Recognition of delirium can be increased by the routine assessment of cognitive

state, e.g. using the AMT (see over). Repeated use
of the AMT may help to


3.

The disturbance develops over a short period of time (usually hours to days) and

determine recovery or onset of delirium in those not delirious on admission.



Tends to fluctuate during the course of the day.


3.

Assessment of
patients pre
-
admission cognitive, functional and social status.


4.


There is evidence from the history, physical examination, or laboratory

This information may need to be clarified with the carer
.






findings that the disturbance is caused by the direc
t physiological

Consequences of a general medical condition, substance intoxication or
substance withdrawal

4.

Identification of risk factors such as dementia, severe illness, sensory

impairments, alcohol use.














Abbreviated Mental Test Scor
e (AMT)


5.

Identification of underlying cause (commonly infection or drugs).

1.

Age

6.

Treatment of underlying cause or removal of offending drugs





2.

Time (to nearest hour)

7.

Avoidance of physician restraints
.

3.

Address for recall at end of test (42

West St)


8.

Avoidance of major tranquillizers, where possible, but if necessary use only one

drug and in the lowest dose possible (e.g. haloperidol 0.5mg orally up to Q’S).


4.

Year

Review drug treatment regularly
.

5.

Name of hospital

9.

Multi
-
disciplina
ry team involvement in treatment and discharge planning.

6.

Recognition of 2 persons (e.g. doctor, nurse)

10.

Create optimum environment for care (e.g. single room, good lighting).

7.

Date of birth

11.

Use reality orientation techniques and rehabilative ca
re models.

8.

Year of 1st World War

12.

Ensure adequate discharge and follow
-
up to avoid unnecessary readmission

and to provide support to patient and carers.






9.

Name of present monarch


10.

Count 20
-
1