Episode 1.2 Delirium

September 10, 2016

MDTea Episode 2: Delirium – Supportive Measures

Posted on 2nd February 2016

Presented by: Jo Preston & Iain Wilkinson, Geriatricians at Surrey and Sussex Healthcare NHS Trust.

Core Faculty Contributors: Adam Buckler, Pharmacist and Pam Trangmar, Physician Associate at Surrey and Sussex Healthcare NHS Trust.

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The second episode in the MDTea series concentrates on what the MDT can do to recognise and manage delirium including medication management.

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Episode 2 Show Notes

Delirium – Supportive Measures

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Presented by: Dr Jo Preston & Dr Iain Wilkinson

Core Faculty: Adam Buckler & Pam Trangmar

Broadcast Date: 2nd February 2016

 

Learning Objectives

Knowledge:

  •         To be able to define and explain delirium
  •         To be able to suggest multi-component interventions for the management of delirium

Skills:

  •         To  use the 4AT and/or CAM test for the assessment of delirium

Attitudes:

  •         To treat older adults with delirium as people with an acute medical problem

 

Definitions:

Formal / Scientific Definition:

Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1–2 days. It is a serious condition that is associated with poor outcomes. However, it can be prevented and treated if dealt with urgently.

NICE Guidance CG103

 

Practical Definition:

Any acute change in normal cognitive state for that person. It is a temporary and reversible state. It can be both HYPERactive (restless, agitated with poor concentration) and HYPOactive (withdrawn, quiet and sleepy).

 

Key Points from Discussion

 

Delirium is common with 20-30% of medical inpatients, and 50% of orthogeriatric patients post-operatively, developing delirium at some point.

 

The causes of HYPERactive and HYPOactive delirium are the same. Often people will experience both.

Stability of postoperative delirium psychomotor subtypes in individuals with hip fracture. Albrecht et al. JAGS 2015

Recognising delirium is vital to be able to manage it. Two useful tools are the short CAM and the 4AT:

 

CAM – Confusion Assessment Method

Needs both 1+2 to be present

  1. Acute onset and fluctuating course?
  2. Is there evidence of inattention?

AND either 3 or 4 to be present also

  1. Disorganised thinking?
  2. Altered level of consciousness?

 

Clarifying confusion: the confusion assessment method. Inouye et al. Annals of Internal Medicine 1990. 

The 4AT

Alertness 0 – Normal

0 – Mildly Sleepy

4 – Clearly Abnormal

Attention

(Months of year backwards)

0 – 7 months correctly

1 – starts but <7 named

2 – untestable

AMT4

(Age, DOB, Place, Year)

0 – No mistakes

1 – 1 mistake

2 – 2 or more mistakes

Acute or fluctuating course 0 – No

4 – Yes

 

http://www.the4at.com/

Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age & Ageing 2014 by Bellalli et al.

Alongside treating the underlying cause for delirium, there is evidence for the use of multicomponent interventions in reducing delirium by a third and the benefits are seen within the first couple of days.

A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. Inouye et al. NEJM 1999 

NICE Guidance CG103

By definition, multicomponent interventions require attention to many elements of care which require time and skill to deliver. A paper looking at financial modelling for ways to deliver this found that even though it took longer to deliver, it was cost effective when balanced against the benefits.

Cost effectiveness of multi-component interventions to prevent delirium in older people admitted to medical wards. Akunne, Murthy & Young. Age & Ageing 2012

Medications are commonly contribute to the development of delirium, often due to their effects on the brain. In particular, the neurotransmitter acetylcholine is affected by many medications that have anti-cholinergic properties. Some drugs do this more than others and so a drug review is essential in those presenting with confusion. The Anti-Cholinergic Burden (ACB) is a useful aid for this.

From agingbraincare.org

 

Curriculum Mapping:

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

 

Curriculum Area
NHS Knowledge Skills Framework Suitable to support staff at the following levels:

  • Personal and People Development: Levels 1-3
  • Service Improvement: Level 1 – 2
Foundation Curriculum 2012 1.3 Continuity of care

1.4 Team working

2.1 Patient as centre of care

7.9 Interactions with different specialities and other professions

10.1 Long-term conditions

10.3 Nutrition

10.4 Discharge planning

Foundation Curriculum 2016 2. Patient centred care

4. Self-directed learning

6. Interface with other healthcare professionals

7. Interaction with colleagues

9. Recognition of Acute illness

9. Assessment of the acutely unwell patient

11. Clinical management (delirium screening)

Core Medical Training Team working and patient safety

Management of long term conditions and promoting self-care

Communication with colleagues and cooperation

Evidence and guidelines

Geriatric Medicine

Confusion Acute/Delirium

GPVTS program Section 2.03 The GP in the Wider Professional Environment

  • Core Competence: Managing medical complexity

Section 3.05 – Managing older adults

  • Core Competence: Managing medical complexity
  • Core Competence: Working with colleagues and in teams
  • Core Competence: Practising holistically and promoting health
ANP (Draws from KSF) Section 4.  History taking

Section 6. Clinical examination

Section 7.1 Acute confusion/delirium

Section 9. CGA process

Section 10. CGA process

Section 20. Patient as central focus of care

Section 22. Teamworking and patient safety

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