Welcome to the Oxford University podcast series. Today, we're going to be talking about cognitive impairment, particularly delirium.
This podcast is brought to you by Daniel Maun and Charlotte Talum,
where both speciality registrars at Oxford Deanery and we also are affiliated with Oxford University.
So, Charlotte, let's talk about delirium. Why why is delirium an important subject?
It's something which we talk about a lot in general hospitals as well as in the mental health hospitals.
And I mean, is it a common thing? What's important about delirium?
Delirium is very common and it's important because it's commonly missed.
So people can have it have the condition, but it's not recognised. And that's causes a lot of adverse consequences.
So it can increase mortality and it can increase the number of patients who end up going into care homes.
It's very important that doctors recognise it, know how to investigate it and also know how to manage it.
It's commonly missed. I presume it might be because it's quite difficult to distinguish between from from other medical presentations.
So what is delirium exactly?
Well, delirium results from an underlying organic illness, and it's a triad of acute confusion, disturbed consciousness and altered behaviour.
And the altered behaviour can be either hyperactivity where people are more active and might be quite disruptive,
hypo activity where people actually stay in bed and do less than they would usually do.
Or you can get a mixture of the two. And it's this group with hyperactivity or they're less active that are often a mess.
And it can be very difficult to identify those patients unless you're really looking for it.
So you say it's the the people who tend to present with hyperactivity, they get missed.
That's right. Are there other conditions that maybe doctors diagnose instead of it instead of diagnosing delirium?
Do you think there are other conditions that maybe take precedence in the clinicians mind?
I think there are a range of differential diagnoses for an area,
but it's more that it's just not recognised and gets most people focus on the
acute physical health problems rather than on the acute cognitive problems.
I see. So we've talk about what delirium is, what causes delirium.
I use a mnemonic to remember what causes delirium.
So the mnemonic is Delirio. So easy to remember. That's right.
So first of all, drugs. So that includes polypharmacy includes withdrawal from drugs such as alcohol or street drugs.
Second, A is eyes or ears. And by this I mean sensory deficits.
So people who don't have a hearing aid and were turned on, people who haven't got their glasses on, for example.
Al is low oxygen, and that can be a lot of causes of this, for example, myocardial infarction,
stroke or pulmonary embolism, eye infection and chest or urinary sepsis are the most common causes here.
As retention, this means your retention or constipation, they can precipitate these features.
The second day is Ekta States, then you undernutrition,
so people who are not eating properly or maybe are not well hydrated and metabolic causes and there are a range of these,
for example, diabetes, post-operative states or hyponatremia.
So you can see that there's a very broad range of causes for divorce, and actually if you're investigating somebody,
you need to think about all these different causes and what might be precipitating.
It seems that you need to be quite active in your your investigations to rule out delirium.
That's right. Although a lot of these things are just about good basic care and they are things that should be done anyway.
Thank you. So is it is it a common condition? It is.
It is actually very common. So in general, surgical wards, 10 to 15 percent of people would be expected to have delirium.
And overall, if you look at people who are in hospital and who are over 65,
about a third of people will develop delirium, which is really very high indeed is higher and specific groups.
So in intensive care settings, people who have had a stroke and people who had a hip fracture, as well as people with terminal illness.
It seems then that that delirium might be predominating in the general hospital setting.
Am I right in presuming that at all? That's right.
It predominates in a general hospital setting, but you might also find it in care homes or in the community or in psychiatric settings.
Right. And what's it like for a patient to experience delirium?
What effect does it have on the patient? There can be many different ways it affects patients,
but I think it can be very frightening to actually not understand what's going on and to lose a lot of your orientation.
So I've certainly talked to patients who recovered from delirium and said that it was a really very unsettling experience indeed.
Acutely delirium can lead to a lot of problems.
So things like self injury, people are very disturbed and it might be pulling out catheters or cannulas.
That can be a problem. And in the longer term, it does predict poor outcome.
Some studies have shown that it doubles length of stay in hospitals, which obviously puts patients at risk of acquired infections,
and that's associated with 50 percent mortality at one year and increases the risk of institutionalisation on discharge.
So these are very serious effects after people get delirium. I guess it's very difficult to say,
but could it be that the more vulnerable patients tend to have an increased risk of delirium
and that might be associated with these adverse outcomes as a chicken and egg situation?
It's difficult, maybe. So I think there's an element of that that actually people who are maybe more frail,
are more vulnerable to delirium, are more vulnerable to other things,
although some studies show that it is actually delirium is an independent risk factor for these adverse outcomes as well.
That's interesting. What would you do if you suspect delirium?
The most important thing is to recognise it, to be aware that it's a common condition and to look out for it.
And then if you suspect it's you need to identify an organic cause by taking a thorough history,
probably using enforcement history, doing a cognitive assessment, a physical examination and simple investigations.
And what investigation should you do? Investigations are designed to investigate the causes of delirium.
So first line, you need to do blood tests. This would be, say, a full blackout, looking at inflammatory markers,
using these to investigate metabolic problems, see up calcium glucose would all be helpful.
And if you're being thorough, you'd also want to look at thyroid function and he Tenex.
Because infection is a very common cause of delirium. It would be important to do your analysis, to look for signs of urinary sepsis,
to think about blood cultures and think about is there anything else you can culture, say, a sputum culture or wounds or sores?
You can might be to do a culture on those. And considering whether chest X-rays indicated,
it seems like a lot of those investigators are actually baseline and well and they might be done when a patient is admitted to hospital,
but it seems as though delirium might. Sort of present itself halfway through a hospital stay,
and I think maybe you need to be active in your investigations to to continue to rule out this condition, particularly in the frail elderly.
That is that right? That's right. So if you identify a change in function, then you need to repeat these baseline investigations.
Yes, it might be that actually somebody has a delirium which is ongoing and he's done the basic investigations and still haven't found the cause.
And in that situation, there are second-line investigations that you could consider,
things like getting a brain scan, doing a lumbar puncture, doing tumour markers or even doing an EEG.
Right. And the EEG is there can sometimes differentiate between maybe some intractable phenomena or can actually diagnose delirium in itself.
That's right. That's right. Right. How do you manage delirium?
After you recognised it and investigated the causes, there are a lot of simple things you can do to manage delirium,
the most important thing is to ensure that patients are reorientated.
So you might make sure that they've got the hearing aids in and that it's turned on and that they're wearing the glasses.
Other things you can do to make sure they can see a clock and a calendar so they know what time it is,
what date it is, and to display familiar personal items and photographs.
It's very helpful to encourage visits from family and friends as well.
And if they can see a window and they can see daylight, then that can also be very useful.
The national approach is very important, and the ideal is to have consistent staffing,
nursing a patient and a quiet side room where you've got good lighting and there are minimal disruptions and transfers.
So it seems as though a large part of the management delirium is actually just
providing very good basic level of care and being aware of the fact that
the patient might be slightly confused in their surroundings and might need some reassurance from friends or family or simply by looking at a clock.
That's right. And what about the medical perspective? Is that is that just a supportive or is that sort of more active in its treatment?
That's slightly different.
So that might be about reviewing medication to see whether there's any medical triggers for the delirium prescribing analgesia,
because if somebody is in pain, they might be more likely to get delirium and showing the patient as well hydrated
and really taking a lead on investigations and treating any causes that you find.
I think they're often iatrogenic cause of delirium, aren't they? That's right, cholinergic medications, yes, can sometimes cause delirium.
And I like it's a thorough review of the patient's medication is necessary in these cases.
That's right. So would you use medication to calm someone down in delirium?
Would you think about using sedation?
It can be used, although sedative medication is rarely needed, but it's important to keep it in mind as an option.
You don't use it as a last resort. If somebody was at a risk to themselves or was posing a risk to other people through their behaviour,
and it's important to always use the lowest possible dose and preferably using oral medication rather than I am or IV medication.
The reason for all this caution is that actually the medications that you use to calm people down have problems of themselves.
So Lorazepam can be used. But some studies have shown that that actually can precipitate delirium and haloperidol can also be used.
But that can be quite risky in people with dementia, especially Lewy body dementia, because it causes extra pyramidal side effects.
So although both those things have got side effects,
they might still be needed if somebody is very disturbed in their behaviour and just for general information,
and arousal is a benzodiazepine, which is one of the common sedatives used by both general physicians and psychiatrists.
That's right. And Haloperidol is a typical antipsychotic. Yes.
With sedative effects. Yes. It's a quite different medications, but both used in the same setting.
Yeah. What happens if someone with delirium refuses treatment?
And this scenario is important to think about whether they've got capacity and by this I mean,
do they have an impairment of the brain or mind that affects their decision making ability?
The core elements of the capacity assessment involve assessing whether somebody understands the decision to be made.
So in the case of delirium, do they understand why they might need sedative medication?
Can they weigh up the pros and cons? So the side effects versus the benefits of taking it, can they retain that information?
And then can they reach a decision about whether or not they want to take it?
I have a right of it sort of captures those these four elements of capacity,
let's understand, retain way, convey sort of like a drawing that helps you remember.
It's a nice, easy way to remember it and that does capture the core elements of the capacity assessment.
Often naturally, the reason they like crusties is because of the third one, the weighing up the decision.
They can maybe understand it a little bit, but essentially retain it from weighing can be the the difficult one to do.
And they say, yeah, so what happens if they actually do the capacity that if somebody lacks capacity,
then you can consider treatment, which is in their best interests, and they should always be the least restrictive option.
So, for example, if you can avoid using medication, then you should do this.
But it does mean that if somebody is really presenting a danger to themselves or to other people and if they lack capacity,
then you can treat them in their best interests. Ideally should involve the multidisciplinary team and family members in making that decision.
But it may be that if there's an urgent situation that you actually have to to make a quite quick decision now,
it'll be under the Mental Capacity Act. That's right. Yes. That would be to bring the episode to an end as quickly as possible.
But nothing more than that. Yes. And that would be a space for use in the Mental Health Act.
We're not here now. OK, and I guess that's because actually what we're seeing here is the delirium is
caused by primary or going cause rather than it being a mental health condition.
Yes. Thank you. Well, thank you for that. So that's been a really helpful introduction to the area.
What resources would you recommend for further information if people are interested?
The two I'd recommend are the nice guidelines on delirium and also the British Geriatrics Society guidelines on Valaria.
And both of those have got further information about recognising it's investigating it and how you manage it.
Thank you. Well, thank you for listening to the Oxford Psychiatry Podcast series.
This week has been on delirium. Please listen to some more.
Thank you. Bye bye.