Delirium

Original Editor - Lucinda hampton

Top Contributors - Lucinda hampton and Kim Jackson  

Introduction

Delirium is a clinical syndrome that typically affects elderly individuals. Delirium is caused by an underlying medical condition and is not explained by pre-existing neurocognitive disorders. Causes can include substance use, medication side effects, infections, surgery, metabolic issues, pain, or even simple conditions like constipation or urinary retention. It is characterised by:

1. Altered attention, consciousness, and cognition
2. Reduced ability to focus, sustain, or shift attention
3. Rapid onset and fluctuation throughout the day
4. Psychomotor behavioral disturbances (hyperactivity or hypoactivity)
5. Impaired sleep patterns

The condition is often missed in diagnosis, especially the hypoactive type, due to subtle symptoms. Delirium is associated with increased morbidity, mortality, and healthcare costs. It is often preventable, and efforts should focus on prevention, early diagnosis, and treating the underlying cause.

Management of delirium requires a collaborative approach from an interprofessional healthcare team to provide coordinated care and improve patient outcomes.

Diagnosis

Delirium is diagnosed based on clinical observation and assessment. Key diagnostic features include acute onset of altered mental status, fluctuating course, inattention, and disorganised thinking or altered level of consciousness. Standardized screening tools like the Confusion Assessment Method (CAM) or the 4 'A's Test (4AT) can be used to aid in diagnosis.

Prevention

Prevention strategies focus on addressing modifiable risk factors and include:

1. Maintaining proper orientation (e.g., calendars, clocks)
2. Ensuring adequate hydration and nutrition
3. Promoting normal sleep-wake cycles
4. Encouraging early mobilisation
5. Managing pain effectively
6. Minimising use of physical restraints
7. Avoiding unnecessary medications, especially those with anticholinergic effects
8. Addressing sensory impairments (providing glasses, hearing aids)
9. Encouraging family involvement in care

These non-pharmacological interventions are key to reducing the incidence of delirium, especially in high-risk patients

Management

Medical management of delirium:

1. Identify and treat underlying causes: This is the primary focus of medical management. Common causes include infections, metabolic disturbances, and medication side effects.
2. Medication review: Discontinue or modify medications that may be contributing to delirium.
3. Supportive care: Ensure proper hydration, nutrition, and oxygenation.
4. Avoid physical restraints: These can worsen confusion and agitation.
5. Pharmacological interventions: Used sparingly and only when necessary for severe agitation or distress. Low-dose antipsychotics may be considered, starting with the lowest effective dose.
6. Monitor and manage complications: Address issues like falls, pressure ulcers, or aspiration pneumonia.
7. Avoid sedatives: Especially benzodiazepines, unless managing alcohol withdrawal.
8. Correct sensory deficits: Provide glasses, hearing aids, or other assistive devices.
9. Maintain normal sleep-wake cycles: Use non-pharmacological methods to promote sleep at night and wakefulness during the day.
10. Interdisciplinary approach: Collaborate with other healthcare professionals for comprehensive care.

The goal is to address the underlying cause while providing supportive care and minimising factors that can worsen delirium

Awareness

Addressing delirium in older adults needs a proactive, multidisciplinary approach. Strategies like reducing medications and using assessment tools are needed to minimise delirium's occurrence and impact. Ponder on the below examples

• Polypharmacy in Parkinson's disease (PD): PD presents challenges, especially in older patients with polypharmacy. In the case report, there have been reports of delirium in this subset of people due to polypharmacy, highlighting the importance of careful drug management in PD.
• Intraoperative EEG monitoring: Postoperative delirium (POD) is a serious complication that can worsen patient outcomes, increasing morbidity, hospital stays, and long-term cognitive issues. See ICU delirium
• Post-stroke delirium is a serious complication affecting recovery.
• Delirium is often overlooked in the ED.
• Frailty index (FI) predicts delirium: Frailty, marked by reduced physiological reserve and higher vulnerability, increases the risk of adverse health outcomes like falls and mortality. A high score on the frailty index has a the link with delirium, underscoring the need for early frailty assessment in hospitalised patients.

Physiotherapists Role

As a physiotherapist, you play an important role in managing delirium:

1. Early mobilisation: Get patients moving as soon as possible. This helps maintain physical function and reduces confusion.
2. Orientation: During therapy, remind patients of the time, date, and where they are. Use clocks and calendars in the room.
3. Sensory aids: Ensure patients have their glasses and hearing aids to help them stay oriented.
4. Sleep promotion: Encourage normal sleep patterns by keeping patients active during the day.
5. Pain management: Use non-pharmacological techniques like positioning and gentle exercises to help manage pain.
6. Communication: Speak clearly and simply. Repeat information if needed.
7. Familiar objects: Encourage family to bring in familiar items to create a more comforting environment.
8. Consistency: Try to maintain a regular routine for therapy sessions.
9. Monitoring: Watch for changes in a patient's mental state and report any concerns to the healthcare team.
10. Education: Teach patients and families about delirium and the importance of movement in recovery.

Remember, your role in early mobilisation and maintaining physical function is key in preventing and managing delirium.