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.
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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You can download the show notes here.
Episode 2 Show Notes
Delirium – Supportive Measures
Presented by: Dr Jo Preston & Dr Iain Wilkinson
Core Faculty: Adam Buckler & Pam Trangmar
Broadcast Date: 2nd February 2016
- To be able to define and explain delirium
- To be able to suggest multi-component interventions for the management of delirium
- To use the 4AT and/or CAM test for the assessment of delirium
- To treat older adults with delirium as people with an acute medical problem
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.
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 It can be both HYPERactive (restless, agitated with poor concentration) and HYPOactive (withdrawn, quiet and sleepy).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.
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
- Acute onset and fluctuating course?
- Is there evidence of inattention?
AND either 3 or 4 to be present also
- Disorganised thinking?
- Altered level of consciousness?
|Alertness||0 – Normal
0 – Mildly Sleepy
4 – Clearly Abnormal
(Months of year backwards)
|0 – 7 months correctly
1 – starts but <7 named
2 – untestable
(Age, DOB, Place, Year)
|0 – No mistakes
1 – 1 mistake
2 – 2 or more mistakes
|Acute or fluctuating course||0 – No
4 – Yes
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.
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.
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.
This episode covers the following areas (n.b not all areas are covered in detail in this single episode):
|NHS Knowledge Skills Framework||Suitable to support staff at the following levels:
|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
10.4 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
|GPVTS program||Section 2.03 The GP in the Wider Professional Environment
Section 3.05 – Managing older adults
|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