| Coma management
|Acute Delirium - also see below|
- Older patient often with medical or surgical illness and existing cognitive impairment
- May be Hypo or hyperactive (think alcohol withdrawal and detox regiment)
- If agitated - calm environment, re orientate, reassure avoid disagreement
- Calm environment , involve family if overactive and behaviour issues
- Review drugs which could contribute. Exclude pain or a full bladder
- Drugs are last line when patient is at risk of harm to themselves
- Consider Haloperidol 0.5-1 mg IM/PO or Lorazepam 0.5-1 mg IM may be repeated
- Avoid IV drugs for delirium. the IM route is likely safer.
- In extreme situations staff may need to involve security
- Send off Confusion bloods (FBC. U&E, LFT, CXR, TFT) consider CT head , LP in some)
- Delirium is a clinical syndrome that may be defined by acute onset of a fluctuating course of disturbed consciousness and inattention with cognitive impairment
- It is usually temporary. Also called acute confusional state.
- Prevention and management strategies of delirium are simply good sense holistic medicine and how we should think about and improve care for all patients.
- Delirium is distressing to patients and their families. It is a marker of reduced cognitive reserve that is overwhelmed by one or more underlying causes.
- Long term prognosis is poorer for those who have had delirium with increased morbidity and mortality. Confused patients at risk of falls, infections, immobility
Diagnosis: Screen with the Confusion Assessment Method (CAM)
- Acute onset fluctuating course AND
- Inattention plus either
- Disorganised thought processes OR
- Altered level of consciousness
Consequences of Delirium
- Prolonged hospital stay (on average 8 days longer)
- Increased mortality whilst in hospital (up to 75%) in the
months following Discharge (40% 1 year mortality)
- Increased risk of developing complications such as hospital
acquired infection; pressure ulcers, incontinence and falls
- Poor physical and cognitive recovery at 6 and 12 months,
with lower scores on the Mini Mental State Examination
(MMSE) at discharge compared to controls
- Increased risk of placement in a residential home
- Increased risk of developing dementia even in patients with no
cognitive impairment at baseline
Prevalence of Delirium
- 10% of all medical admissions
- 20-30% on medical wards
- 15-53% postoperative pts
- 70-87% of those in ITU
- Age > 65, Male, Depression
- Previous stroke, Severe illness
- Cognitive impairment/Dementia
- History of falls, Current hip fracture
- Renal/Liver disease, raised urea
- Visual/Auditory impairment x 3
- Malnutrition, smokers, catheter
- Starting over 3 new medications
- Use of restraints, lack of orientation e.g. ward without windows
- Prolonged hospital stay
- Cognitive function: for example, worsened concentration*, slow responses*, confusion.
- Perception: for example, visual or auditory hallucinations.
- Physical function: for example, reduced mobility*, reduced movement*, restlessness, agitation, changes in appetite*, sleep disturbance.
- Social behaviour: for example, lack of cooperation with reasonable requests, withdrawal*, or alterations in communication, mood and/or attitude.
- Essential Features
- Acute onset often Fluctuating with Inattention
- Disorganised thinking and speech
- Clouding of consciousness and a Cognitive deficit
- Variable features
- Perceptual disturbance, Emotional disturbance
- Hyper/hypoactive and Altered sleep/wake cycle
Depression vs Delirium vs Dementia
Onset and duration
Slow and insidious onset; deterioration is progressive over time.
Sudden onset over hours or days; duration hours to less than one month, but can be longer.
Recent change in mood persisting for at least two weeks may coincide with life changes can last for months or years.
Symptoms are progressive over a long period of time; not reversible. Little fluctuation. 'Sundowning' may be evident-cognitive decline seen in the evening
Short and fluctuating; often worse at night and on waking. Usually reversible with treatment of the underlying condition.
Typically worse in the morning. Usually reversible with treatment.
Withdrawn (may be related to coexisting depression)
Hyperactive delirium: agitation, restlessness, hallucinations
Hypoactive delirium: sleepy, slow-moving
Mixed: alternating features of the above.
May include agitation
Generally normal. No effect on conscious level
Fluctuates, may be hyper-vigilant (hyperactive) through to very lethargic (hypoactive).
Impaired or fluctuates, difficulty following conversation.
May appear impaired
Depression may be present in early dementia
Fluctuating emotions for example: anger, tearful outbursts, fear
Lack of interest or pleasure in usual activities
Change in appetite (increase or decrease)
Difficulty with word-finding and abstraction
Disorganised, distorted, fragmented
Intact; themes of helplessness and hopelessness present
Misperceptions usually absent (can be present in Lewy body dementia)
Distorted illusions, hallucinations, delusions; difficulty distinguishing between reality and misperceptions
Usually intact (hallucinations and delusions only present
in severe cases)
- Dementia, depression, schizophrenia
- Dysphasia, hysteria, mania
- Non-convulsive status epilepsy.
- Indications for sedation: Get essential investigations. Prevent danger to self or other. Relieve distress. Sedation is not for staff or other patients needs. Get senior review if not settling.
- Appropriate lighting and clear signage; a clock (consider providing a 24-hour clock in critical care) and a calendar should also be easily visible to the person at risk
- Talking to the person to re-orientate them by explaining where they are, who they are, and what your role is
- Introducing cognitively stimulating activities (for example, reminiscence)
- Facilitating regular visits from family and friends.
- ensuring adequate fluid intake to prevent dehydration by encouraging the person to drink or consider offering subcutaneous or intravenous fluids if necessary
- Taking advice if necessary when managing fluid balance in people with comorbidities (for example, heart failure or chronic kidney disease).
- Assess for hypoxia and optimise oxygen saturation if necessary, as clinically appropriate.
- Look for and treat the infection but avoid unnecessary catheterisation
- Encourage all people, including those unable to walk, to carry out active range-of-motion exercises.
- Medication review
- Ensure adequate nutrition and if people have dentures, ensuring they fit properly.
- Help sensory input - treat deafness e.g remove wax, hearing aid, treat visual impairment e.g. glasses and good lighting
- Promote good sleep patterns and sleep hygiene by avoiding nursing or medical procedures during sleeping hours, if possible, scheduling medication rounds to avoid disturbing sleep, reducing noise to a minimum during sleep periods.
Preventing Delirium in Surgery
- Lighter anaesthesia is felt to be better. Avoid intraoperative hypothermia
- Manage perioperative blood loss. Avoid intraoperative hypotension
- Control blood glucose. Early mobilise. Pain control. BP control.
- Having catheter in for more than 48 hrs is a risk
- Infection, dehydration, severe constipation, urinary retention, and pain
Causes/Aggravating factors (Spells Delirium)
- Dehydration: poor input, high glucose, calcium, diuretics
- Drugs (CNS, opiates, anticholinergics), Dehydration, Metabolic disorder
- Environment: Admission to hospital for any cause, new faces, loss of usual orientating familiar markers
- Electrolyte disturbance: hyponatraemia < 120 mmol/L
- Eating : Nutritional issues MUST score
- Level of Pain: abdomen, MI, pancreatitis
- Infection: Infection e.g. chest, urine, CNS infections. CXR, Urine/Blood Cultures, LP, CSF
- Immobility: sarcopenia
- Respiratory failure, Hypoxia, Hypercarbia, Cough
- Impacted faeces Constipation / Urine retention
- Indwelling devices: catheter related UTI
- Urinary retention, uraemia
- Miscellaneous: Surgery, Alcohol withdrawal
- Pulse oximetry, NEWS score, ABG if needed.
- FBC, U&E, CRP, TFT, Ca, Mg, B12, folate, ECG, CXR
- CT head: stroke, SDH.
- Urinalysis, Blood cultures
- Second line: LP, CT CAP, LDH, PSA, Autoimmune abs VGKC, MRI ( ? Encephalitis) will need sedation
Consider anaesthetic help in exceptional cases to sedate and paralyse and intubation in extreme agitated/violent cases with inherent risks if tests such as CT/MRI/LP felt to be critical for diagnosis and treatment. Weigh risks vs benefits. Take advice if unsure.
Avoid haloperidol if Lewy body dementia, QTC > 470 ms, Parkinsonism, Alcohol withdrawal, Epilepsy
Assessment and Management
- Manage hypoxia, Treat infection and electrolyte and other abnormalities
- Don't do pointless procedures, Avoid Catheter unless retention
- Don't argue /challenge/ confront patient
- Treat constipation, alleviate pain, manage urine retention
- Rationalise medications and drugs causing delirium (anticholinergics)
- Risks: Older patients, acute illness, cognitive impairment
- Falls risk assessment, Enable sleep in calm environment, Rehydration
- Provide hearing aids, spectacles, lighting
- Optimise nutrition, Involve friends/family/know carers
- Reduce environmental stimulation, quiet ward, good lighting, quiet music
- Re orientate, reassure, Avoid confrontation or disagreement, change subject
- Involve security if risks to self primarily and others
- Use antipsychotic drugs with caution.
- Avoid antipsychotics if Parkinson's disease or dementia with Lewy bodies and use Benzodiazepine instead
- Involve supportive family or carers or friends to lower anxieties
- Sedation see below
- Causes to consider
- Oxygen if hypoxic. Fluids oral or IV if dehydrated.
- Small doses of Naloxone 100 mcg repeated if hypoactive delirium
- Consider Non convulsive status or post ictal if hypoactive
- Urinary retention or constipation or pain or discomfort driven?
- Infection: Screen and consider antibiotics
- SDH/Tumour/Stroke/Encephalitis: CT scan + LP for CSF if encephalitis/inflammation
- Alcohol withdrawal use Lorazepam/Diazepam and give high dose IV Pabrinex
- Nicotine patches for nicotine withdrawal
Older patients in hypoactive delirum may be misdiagnosed as dying
Drugs Suggested for sedation
- Drugs always a last resort. Verbal de-escalate. Involve security or family. Calm reassuring environment. Make sure to consider risks and benefits. If oversedated and GCS < 9 consider HDU bed and anaesthetic review. Use the oral route if possible. The low dose IM route is useful. IV usage if urgent sedation needed. Go slow. Titrate doses to body mass.
- Haloperidol 0.5 mg PO/IM 1-2 hourly PRN up to 5 mg/day. Often haloperidol 0.5 mg BD + PRN dose will help until the cause treated. Titrate to clinical need. Take senior help if unsure.
- Lorazepam 0.5-1mg PO/IM up to 4mg/day if over 65 is an alternative especially if long QT or Parkinsonism or Lewy Body max 4 mg/day. Start Lorazepam 0.5 mg BD + PRN doses