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Welcome to the Oxford University podcast series. Today, we're going to be talking about cognitive impairment, particularly delirium.

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This podcast is brought to you by Daniel Maun and Charlotte Talum,

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where both speciality registrars at Oxford Deanery and we also are affiliated with Oxford University.

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So, Charlotte, let's talk about delirium. Why why is delirium an important subject?

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It's something which we talk about a lot in general hospitals as well as in the mental health hospitals.

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And I mean, is it a common thing? What's important about delirium?

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Delirium is very common and it's important because it's commonly missed.

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So people can have it have the condition, but it's not recognised. And that's causes a lot of adverse consequences.

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So it can increase mortality and it can increase the number of patients who end up going into care homes.

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It's very important that doctors recognise it, know how to investigate it and also know how to manage it.

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It's commonly missed. I presume it might be because it's quite difficult to distinguish between from from other medical presentations.

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So what is delirium exactly?

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Well, delirium results from an underlying organic illness, and it's a triad of acute confusion, disturbed consciousness and altered behaviour.

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And the altered behaviour can be either hyperactivity where people are more active and might be quite disruptive,

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hypo activity where people actually stay in bed and do less than they would usually do.

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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.

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And it can be very difficult to identify those patients unless you're really looking for it.

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So you say it's the the people who tend to present with hyperactivity, they get missed.

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That's right. Are there other conditions that maybe doctors diagnose instead of it instead of diagnosing delirium?

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Do you think there are other conditions that maybe take precedence in the clinicians mind?

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I think there are a range of differential diagnoses for an area,

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but it's more that it's just not recognised and gets most people focus on the

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acute physical health problems rather than on the acute cognitive problems.

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I see. So we've talk about what delirium is, what causes delirium.

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I use a mnemonic to remember what causes delirium.

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So the mnemonic is Delirio. So easy to remember. That's right.

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So first of all, drugs. So that includes polypharmacy includes withdrawal from drugs such as alcohol or street drugs.

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Second, A is eyes or ears. And by this I mean sensory deficits.

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So people who don't have a hearing aid and were turned on, people who haven't got their glasses on, for example.

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Al is low oxygen, and that can be a lot of causes of this, for example, myocardial infarction,

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stroke or pulmonary embolism, eye infection and chest or urinary sepsis are the most common causes here.

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As retention, this means your retention or constipation, they can precipitate these features.

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The second day is Ekta States, then you undernutrition,

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so people who are not eating properly or maybe are not well hydrated and metabolic causes and there are a range of these,

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for example, diabetes, post-operative states or hyponatremia.

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So you can see that there's a very broad range of causes for divorce, and actually if you're investigating somebody,

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you need to think about all these different causes and what might be precipitating.

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It seems that you need to be quite active in your your investigations to rule out delirium.

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That's right. Although a lot of these things are just about good basic care and they are things that should be done anyway.

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Thank you. So is it is it a common condition? It is.

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It is actually very common. So in general, surgical wards, 10 to 15 percent of people would be expected to have delirium.

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And overall, if you look at people who are in hospital and who are over 65,

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about a third of people will develop delirium, which is really very high indeed is higher and specific groups.

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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.

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It seems then that that delirium might be predominating in the general hospital setting.

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Am I right in presuming that at all? That's right.

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It predominates in a general hospital setting, but you might also find it in care homes or in the community or in psychiatric settings.

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Right. And what's it like for a patient to experience delirium?

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What effect does it have on the patient? There can be many different ways it affects patients,

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but I think it can be very frightening to actually not understand what's going on and to lose a lot of your orientation.

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So I've certainly talked to patients who recovered from delirium and said that it was a really very unsettling experience indeed.

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Acutely delirium can lead to a lot of problems.

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So things like self injury, people are very disturbed and it might be pulling out catheters or cannulas.

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That can be a problem. And in the longer term, it does predict poor outcome.

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Some studies have shown that it doubles length of stay in hospitals, which obviously puts patients at risk of acquired infections,

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and that's associated with 50 percent mortality at one year and increases the risk of institutionalisation on discharge.

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So these are very serious effects after people get delirium. I guess it's very difficult to say,

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but could it be that the more vulnerable patients tend to have an increased risk of delirium

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and that might be associated with these adverse outcomes as a chicken and egg situation?

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It's difficult, maybe. So I think there's an element of that that actually people who are maybe more frail,

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are more vulnerable to delirium, are more vulnerable to other things,

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although some studies show that it is actually delirium is an independent risk factor for these adverse outcomes as well.

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That's interesting. What would you do if you suspect delirium?

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The most important thing is to recognise it, to be aware that it's a common condition and to look out for it.

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And then if you suspect it's you need to identify an organic cause by taking a thorough history,

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probably using enforcement history, doing a cognitive assessment, a physical examination and simple investigations.

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And what investigation should you do? Investigations are designed to investigate the causes of delirium.

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So first line, you need to do blood tests. This would be, say, a full blackout, looking at inflammatory markers,

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using these to investigate metabolic problems, see up calcium glucose would all be helpful.

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And if you're being thorough, you'd also want to look at thyroid function and he Tenex.

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Because infection is a very common cause of delirium. It would be important to do your analysis, to look for signs of urinary sepsis,

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to think about blood cultures and think about is there anything else you can culture, say, a sputum culture or wounds or sores?

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You can might be to do a culture on those. And considering whether chest X-rays indicated,

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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,

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but it seems as though delirium might. Sort of present itself halfway through a hospital stay,

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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.

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That is that right? That's right. So if you identify a change in function, then you need to repeat these baseline investigations.

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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.

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And in that situation, there are second-line investigations that you could consider,

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things like getting a brain scan, doing a lumbar puncture, doing tumour markers or even doing an EEG.

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Right. And the EEG is there can sometimes differentiate between maybe some intractable phenomena or can actually diagnose delirium in itself.

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That's right. That's right. Right. How do you manage delirium?

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After you recognised it and investigated the causes, there are a lot of simple things you can do to manage delirium,

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the most important thing is to ensure that patients are reorientated.

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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.

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Other things you can do to make sure they can see a clock and a calendar so they know what time it is,

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what date it is, and to display familiar personal items and photographs.

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It's very helpful to encourage visits from family and friends as well.

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And if they can see a window and they can see daylight, then that can also be very useful.

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The national approach is very important, and the ideal is to have consistent staffing,

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nursing a patient and a quiet side room where you've got good lighting and there are minimal disruptions and transfers.

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So it seems as though a large part of the management delirium is actually just

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providing very good basic level of care and being aware of the fact that

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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.

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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?

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That's slightly different.

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So that might be about reviewing medication to see whether there's any medical triggers for the delirium prescribing analgesia,

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because if somebody is in pain, they might be more likely to get delirium and showing the patient as well hydrated

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and really taking a lead on investigations and treating any causes that you find.

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I think they're often iatrogenic cause of delirium, aren't they? That's right, cholinergic medications, yes, can sometimes cause delirium.

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And I like it's a thorough review of the patient's medication is necessary in these cases.

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That's right. So would you use medication to calm someone down in delirium?

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Would you think about using sedation?

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It can be used, although sedative medication is rarely needed, but it's important to keep it in mind as an option.

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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,

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and it's important to always use the lowest possible dose and preferably using oral medication rather than I am or IV medication.

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The reason for all this caution is that actually the medications that you use to calm people down have problems of themselves.

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So Lorazepam can be used. But some studies have shown that that actually can precipitate delirium and haloperidol can also be used.

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But that can be quite risky in people with dementia, especially Lewy body dementia, because it causes extra pyramidal side effects.

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So although both those things have got side effects,

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they might still be needed if somebody is very disturbed in their behaviour and just for general information,

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and arousal is a benzodiazepine, which is one of the common sedatives used by both general physicians and psychiatrists.

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That's right. And Haloperidol is a typical antipsychotic. Yes.

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With sedative effects. Yes. It's a quite different medications, but both used in the same setting.

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Yeah. What happens if someone with delirium refuses treatment?

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And this scenario is important to think about whether they've got capacity and by this I mean,

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do they have an impairment of the brain or mind that affects their decision making ability?

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The core elements of the capacity assessment involve assessing whether somebody understands the decision to be made.

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So in the case of delirium, do they understand why they might need sedative medication?

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Can they weigh up the pros and cons? So the side effects versus the benefits of taking it, can they retain that information?

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And then can they reach a decision about whether or not they want to take it?

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I have a right of it sort of captures those these four elements of capacity,

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let's understand, retain way, convey sort of like a drawing that helps you remember.

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It's a nice, easy way to remember it and that does capture the core elements of the capacity assessment.

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Often naturally, the reason they like crusties is because of the third one, the weighing up the decision.

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They can maybe understand it a little bit, but essentially retain it from weighing can be the the difficult one to do.

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And they say, yeah, so what happens if they actually do the capacity that if somebody lacks capacity,

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then you can consider treatment, which is in their best interests, and they should always be the least restrictive option.

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So, for example, if you can avoid using medication, then you should do this.

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But it does mean that if somebody is really presenting a danger to themselves or to other people and if they lack capacity,

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then you can treat them in their best interests. Ideally should involve the multidisciplinary team and family members in making that decision.

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But it may be that if there's an urgent situation that you actually have to to make a quite quick decision now,

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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.

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But nothing more than that. Yes. And that would be a space for use in the Mental Health Act.

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We're not here now. OK, and I guess that's because actually what we're seeing here is the delirium is

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caused by primary or going cause rather than it being a mental health condition.

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Yes. Thank you. Well, thank you for that. So that's been a really helpful introduction to the area.

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What resources would you recommend for further information if people are interested?

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The two I'd recommend are the nice guidelines on delirium and also the British Geriatrics Society guidelines on Valaria.

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And both of those have got further information about recognising it's investigating it and how you manage it.

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Thank you. Well, thank you for listening to the Oxford Psychiatry Podcast series.

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This week has been on delirium. Please listen to some more.

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Thank you. Bye bye.