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Identifying, measuring and managing delirium
Dr Tizzy TealeSenior Clinical Lecturer and Honorary Consultant Geriatrician
University of Leeds and Bradford Teaching Hospitals NHS Trust
How common is delirium?
• Delirium is the commonest complication of hospitalisation in older people
• Large point prevalence study (Italy)
– 108 acute and 12 rehabilitation wards
– Delirium assessments with the 4AT within a pre-determined 24 hour period (“Delirium Day”)
– 1867 patients assessed
Bellelli G, Morandi A, Santo et al BMC Medicine 2016;14:106
• Overall point prevalence of delirium in hospital inpatients over 65 was 22.9%
• This estimate is consistent across prevalence studies
• Over 50% of patients with delirium have a diagnosis of dementia
Ryan DJ, O’Regan et al BMJOpen 2013;3;e001772
Poorer longer term outcomes following delirium
• Poor cognitive outcomes
– Delirium is associated with incident dementia
• OR 8.7 95%CI: 2.1-35
Davis et al Brain 2012; 135:2809-2816
– Acceleration of cognitive decline
• Two-fold increased rate in the first 12 months
Gross et al 2012; Arch Int Med;2012;172(17):1324-1331
• Institutionalisation
– OR 2.41 95%CI: 1.77-3.29 (average follow up 15 months)
• Mortality
– HR 1.95 95%CI: 1.51-2.52 (average follow up 23 months)Witlox et al JAMA 2010;304(4):443-51
People remember being delirious
• Recall of delirium experiences is common after recovery (>50%)
• Those with more severe delirium and with underlying cognitive impairment less likely to recall
– This doesn’t make their distress any less at the time
• Commonly recalled symptoms are of visual hallucinations
• Misinterpretation of real sensory experiences also common
• Source of fear and anxiety
• Delusions common (often threatening)
• Descriptions of incomprehensible situations / time distortion common
• Trying to make sense of situation
• There may be longer lasting neuropsychiatric sequelaeO’Malley et al J of Psychosomatic Res 2008;65:223-228
How often is delirium missed?
• Up to 2/3 of cases of delirium are missed or misdiagnosed by acute medical teams
Collins et al Age Ageing 2010; 39(1):131-135
Delirium is poorly coded in the UK health service
Setting Prevalence from reported studies % (range)
Delirium rate (%) from UK HES data 2006-7 (>65s)
General / geriatric medicine 23.6% (15-42) 0.39
Critical care 48 (29.8-83.3) 0.23
Emergency Department 9.8 (9.6-11.1) 0.14
Orthopaedics 44.8 (29-68.1) 0.05
Clegg A, Westby M, Young J Age Ageing 2011;40(2):283-286
Even if we diagnose it, the ‘bigger picture’ is invisible as we are not coding for delirium at hospital discharge.
Recognising delirium
• Based on DSM 5 criteria
• Diagnosis of delirium requires all DSM 5 criteria to be met
• Criteria operationalised into screening or diagnostic algorithms
• A degree of subjectivity / inconsistently applied criteria
• Delirium is a complex syndrome – features can be difficult to spot
Key features (DSM 5 criteria)
• Disturbance in attention
– Reduced ability to direct, focus, sustain and shift attention
• AND Disturbed level of awareness
– Reduced orientation to the environment
• Acute / subacute onset
– Representing a change from baseline attention and awareness
• A tendency to fluctuation
– Over hours or days
• An additional disturbance in cognition– Memory deficit, disorientation, language, visuospatial, perception
Criterion A
Criterion B
Criterion C
• Not better explained by an existing or evolving neurocognitive disorder
– Not in the context of severely reduced arousal
• e.g. coma
• Physiologically attributable to a medical condition
– History, examination, lab findings
– Substance intoxication or withdrawal
– Exposure to a toxin
– Multiple aetiologies
Criterion D
Criterion E
Key features (DSM 5 criteria)
• Disturbance in attention
– Reduced ability to direct, focus, sustain and shift attention
• AND Disturbed level of awareness
– Reduced orientation to the environment
• Acute / subacute onset
– Representing a change from baseline attention and awareness
• A tendency to fluctuation
– Over hours or days
• An additional disturbance in cognition– Memory deficit, disorientation, language, visuospatial, perception
Criterion A
Criterion B
Criterion C
Inattention
• Difficulty maintaining / shifting focus between tasks
• Easily distracted by sounds, objects, own thoughts
• Perseveration
• May be poor eye contact
• May seem vague
Detecting inattention
• Months of the year backwards (MOTYB)
–Ask to say forwards Jan to Dec.
–Then ask to recite backwards from Dec.
– If able to reach July without error, attention likely intact
• MOTYB in >69yo without dementia
– 84% sensitivity
– 90% specificity for deliriumO’Regan JNNP 2014;85:1122-1131
Detection of delirium superimposed on dementia (DSD) is particularly challenging
• Impaired attention is a key feature of delirium
• May help distinguish delirium from dementia
• But patients with dementia struggle to complete tests of attention
Rutter et al EDA Conference Abstract 2016; #13
• MOTYB in those with dementia
– Poor specificity for delirium
– Patients with dementia may struggle to complete
O’Regan JNNP 2014;85:1122-1131
• Patterns of errors may help to discriminate between delirium and dementia (more work needed)
– omissions / repetitions / self-correction Rutter et al EDA Conference Abstract 2016; #13
Duncan et al EDA Conference Abstract 2016 # 35
• Use of informant instruments can help to identify pre-existing dementia (e.g. the IQCODE-SF)
Jackson et al Age Ageing 2016;45(4):505-11
Consciousness, arousal and attention
• Altered consciousness (DSM-IV) changed to disturbance in attention and awareness in DSM-5
• Consciousness is a hierarchical construct
– Level of consciousness = arousal
– Content of consciousness = attention
• Consciousness therefore includes implicit assessment of arousal
– Removed in DSM-5
• It is important not to miss delirious patients in whom attention cannot be assessed due to alterations in arousal (e.g. too sleepy)
• Those with sudden onset of altered arousal (over, or underactive) not attributable to existing or evolving condition (e.g. stroke) should be considered to meet DSM-5 criterion A for delirium
• EDA and ADS BMC Medicine 2014; 12:141
• Hypoactive delirium– Most common subtype (39%)
– Withdrawn, quiet, sleepy, poorly rousable
– Little interest in environment, poor oral intake
– Slurred speech
– Often missed – need to consider the diagnosis
– Associated with particularly poor outcomes
• Hyperactive delirium – Less common (21%)
– Agitated, wandersome, hyper-alert
– Behavioural disturbances
Mixed delirium fluctuates between these subtypes (27%)13% have no motor symptoms
Delirium subtypes
Key features (DSM 5 criteria)
• Disturbance in attention
– Reduced ability to direct, focus, sustain and shift attention
• AND Disturbed level of awareness
– Reduced orientation to the environment
• Acute / subacute onset
– Representing a change from baseline attention and awareness
• A tendency to fluctuation
– Over hours or days
• An additional disturbance in cognition– Memory deficit, disorientation, language, visuospatial, perception
Criterion A
Criterion B
Criterion C
Acute onset and fluctuating course
• Aim to identify a change from baseline
• SQiD (single question in delirium)– “Do you think [patient] has been more confused lately”?– 80% sensitivity for delirium– 71% specificity
• Have there been fluctuations over the course of days or hours?
Sands et al. Palliat Med 2010; 24: 561-565
Key features (DSM 5 criteria)
• Disturbance in attention
– Reduced ability to direct, focus, sustain and shift attention
• AND Disturbed level of awareness
– Reduced orientation to the environment
• Acute / subacute onset
– Representing a change from baseline attention and awareness
• A tendency to fluctuation
– Over hours or days
• An additional disturbance in cognition– Memory deficit, disorientation, language, visuospatial, perception
Criterion A
Criterion B
Criterion C
Additional cognitive disturbance
• Disorganised thinking, incoherent speech, perceptual problems, disorientation
• Problems making sense of what is going on
• Misinterpreting the environment
• Asking abstract questions can help identify
• May be hallucinations or persecutory ideas
– Do you feel frightened by anything or anyone?
– Are you concerned about anything going on here?Health Improvement Scotland Delirium toolkit 2014
• Mumbling, slurred or rambling speech which may be difficult to understand
4AT (the4at.com)
• 4AT can be used in those untestable with other methods
– e.g. stupor
• Does not rely on skilled assessment of attention
• Previous validation study (Italy)
– Sensitivity 89.7%
– Specificity 84.1%Bellelli Age Ageing 2014;43(4):496-502
• Utility in non-English speaking patients
– Sensitivity 91%
– Specificity 71%De et al Int J Geriatr Psych 2016; epub ahead of print
Alertness (normal / abnormal)
AMT4 (Age, DOB, Place, Current Year)
Attention (MOTYB)
Acute change or fluctuating course (yes / no)
Who gets delirium ?
• Strong predictors:
– Frailty
– Dementia
– Visual impairment
– Dehydration
– Severe illness
• Modifiable vs non-modifiable risk factors
Delirium prevention strategies:
• Up to one third of delirium is preventable through multicomponent delirium prevention interventions
Siddiqi et al Cochrane Review 2016 DOI: 10.1002/14651858.CD005563.pub3
• Personalised care delivered in a ward environment geared for delirium prevention
• What don’t we know? – Which are the most important / effective components of a
multicomponent intervention and how should these best be delivered ?
Metabolic
Oxygenation
Glucose
Perfusion
Electrolytes
Infections
Environmental
Ambient noise
Signage
Re-orientation
Early mobilisation
Avoid ward moves
Attention to sleep pattern
Individual
Avoid catheters if possible
Bowel Care
Hydration
Nutrition
Treat pain
(avoid opiates if possible )
Is early discharge possible /
appropriate / safe?
Sensory
Ensure hearing aids work and
have batteries in
Specs!
(are they clean?)
Medication
Avoid deliriogenic
drugs
Simplify meds as much as
possible
Modify these factors where you can
Non-pharmacological treatment of delirium
• It is important to be aware of, and modify potential triggers in non-delirious patients, as well as targeting contributing factors in those who are delirious
• Delirium episodes shorter and less severe if occur in the context of a multicomponent delirium prevention intervention
Marcantonio JAMA 2001;49(5):516-22O’Hanlon et al JNNP 2014;85(2):207-213
• No convincing evidence that multicomponent interventions are beneficial for the treatment of established delirium
Drugs and delirium
• Drugs implicated in development of delirium
• Drugs for delirium prevention
• Drugs for delirium treatment
• Drugs for management of delirium symptoms
Drugs implicated in delirium
• In general avoid– Drugs with anticholinergic properties
• Antihistamines
• TCAD
• Treatments for OAB
– Benzodiazepines
– Opioids (but treat pain)
• Medication review is a key aspect of delirium prevention / management
• Pay attention to the number, and type of medication
Drugs to prevent delirium (outside ICU)
• Drugs investigated for prophylaxis– Antipsychotics
– Melatonin / melatonin agonists
– Acetylcholinesterase inhibitors
– Citicoline
– Gabapentinoids
• No evidence to support the use of any of these drugs for prevention of delirium
Siddiqi et al Cochrane Review 2016 DOI: 10.1002/14651858.CD005563.pub3
Pharmacological treatment of delirium
• Evidence remains limited
• No convincing benefit for pharmacological therapies for treatment or prevention of delirium in non-ICU settings
• There is a need for further trials to identify agents that are safe for older people, and that have efficacy in the treatment / prevention of delirium
Management of delirium symptoms
• Identify and manage the underlying cause
• Symptoms should be managed through verbal and non-verbal de-escalation techniques
• If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term (usually for 1 week or less) haloperidol or olanzapine
• Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms
• Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson's disease or dementia with Lewy bodies
• No drugs have a UK license for treatment or prevention of delirium https://www.nice.org.uk/guidance/cg103/chapter/1-Guidance#treating-delirium
Delirium recovery
• Persistence of delirium beyond hospital discharge is common
– Discharge 44.7% (half of these will have recovered by 3/12)
– 1 month 32.8%
– 3 months 25.6%
– 6 months 21%Cole et al Age Ageing 2009; 38:19-26
• Outcomes for people with persistent delirium are worse than for those who recover
• Those with dementia are more likely to develop persistent delirium
• 38% of people presenting with delirium have undiagnosed cognitive impairment
Jackson et al Age Ageing 2016;45(4):493-499
Follow up
• People who have had delirium are more likely to develop incident dementia
• Follow up after an episode of delirium is useful:
– For education / give the opportunity for patients to make sense of their experience if they want to
– To identify features of persistent delirium
– To identify / signpost those with incident dementia
Bradford Teaching Hospitals NHS Foundation Trust delirium patient information leaflethttp://johnscampaign.org.uk/docs/external/bradford-teaching-hospitals-delirium-prevention.pdf
• Please contact BTHFT for copyright permissions if you wish to use / adapt
Resources
NICE Delirium: Diagnosis, Prevention and Management of delirium guidelines (CG103) July 2010http://www.nice.org.uk/guidance/cg103
The 4AThttp://www.the4at.com/
The Scottish Delirium Association “Delirium Management Comprehensive Pathway” Dec 2013http://www.scottishdeliriumassociation.com
Healthcare Improvement Scotlandhttp://www.healthcareimprovementscotland.org• E-modules• Information for patients and carers• TIME delirium care bundle