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Topic 4: Introduction to delirium

Learning objectives

To diagnose, prevent and manage delirium in the older patient

  • identify potential predisposing and precipitating factors for delirium
  • identify “at risk” patients for delirium
  • understand the clinical features of delirium
  • appropriately investigate delirium
  • how to appropriately prescribe medications for delirious patients.
  • formulate and communicate an appropriate management plan for an delirious older patient on the ward

Resources

  • Printed case (x12)
  • Blank progress notes (x60)
  • Medication charts (x60)

Timing 30-40 minutes x 5 groups

Briefing for the interns

Day 1

It is your first week and you are the Orthopaedic intern ward. You receive a phone call from the nursing staff asking you to come and admit a patient who has been transferred to the ward from the Emergency department.

Day 3

It is your first after hours shift. You receive a phone call from the nursing staff asking you to come to the ward as one of your patients has become confused.

Teaching style

This session will be predominantly be run as a small group, interactive discussion. Please ensure that all interns participate. To enhance the fidelity of the scenario you can ask them to write notes in the progress notes. For example, their plans to minimise the chance of developing delirium or an action plan for management once the patient develops a delirium. Similarly, ask them to chart sedative medication doses in the supplied medication charts.

Day 1

  1. What are his potential risks for developing a delirium?
  2. What are the clinical features of delirium?
  3. What strategies would you use to minimise the likelihood of him developing a delirium?
  4. Please review his medications and make changes where you feel appropriate.

Day 3

  1. What are the potential causes for his delirium?
  2. What will your approach be for:
    1. Further history – from whom, what questions would you ask?
    2. What should you look for on focused clinical examination?
    3. What investigations are needed urgently? What challenges may you face getting these? What approaches would you take to increase your chances of success?
    4. What would you do about the cannula and IDC?
  3. Write down your management strategy including location of management of patient.
  4. You receive a call later in the night from the nursing staff to say that the patient has become increasingly confused and has hit a member of staff. If you need to prescribe some sedative medication, what would you chart? Please write down your medication choice in the medication chart. What dose? PRN or regular? Ceiling dose? Route?
  5. Who should be notified about the patient’s condition?

Day 1

Details from ED admission and old notes:

  • Mr D is an 80yr old man. He has been admitted from home following a fall and a fractured left hip.
  • He is normally independently mobile with a walking stick.
  • Medical background of COPD, DM, IHD, mild short term memory loss
  • He had an elective admission last year for a TURP and his stay was compli-cated by a UTI and confusion.

Medications from charts:

  • Aspirin 100mg daily
  • Salbutamol INH
  • Spiriva INH
  • Gliclazide SR 60mg daily
  • Metformin 500mg BD
  • Isosorbide mononitrate SR 60mg daily
  • Metoprolol 25mg BD
  • Frusemide 40mg daily
  • Amitriptyline 25mg nocte

NEW medications:

  • Paracetamol 1g po QID PRN
  • Tramadol 50mg po QID PRN
  • Morphine 2.5mg sub/cut PRN 4Hr

He has been transferred to the orthopaedic ward pending surgery. He is NBM, has an IV cannula and is being nursed in bed.

On examination he is alert and orientated, but in pain.

Observations on arrival to ward are normal.

Day 3

His fracture is treated operatively with a dynamic hip screw (DHS).

There are no intra operative complications and he is now weight bearing as tolerated (WBAT).

72 hrs post admission, while you are on an overtime shift, he becomes acutely con-fused at 10pm. He is agitated and wants to leave hospital. He is wandering around the ward. He has pulled out a cannula and is pulling on his in-dwelling catheter.

Progress notes do not record any confusion until this evening

Last observations at 9pm – afebrile, pulse 80, BP 165/95, O2 sats 90% RA

Routine blood tests this morning were in normal range.

  1. BMJ: Diagnosis, Prevention and Management of Delirium: Summary of NICE guidance http://www.bmj.com/content/341/bmj.c3704
  2. BMJ “Best Practice” guideline on CIAP Assessment of delirium http://bestpractice.bmj.com.acs.hcn.com.au/best-practice/monograph/241.html
  3. Australian and New Zealand Society for Geriatric Medicine (ANZSGM) Position statement 13 Delirium in older people http://www.anzsgm.org/documents/PS13DeliriumstatementRevision2012.pdf
  4. Onthewards podcast with Dr Scott Murray http://www.onthewards.org/pods/confusion