DO NOT USE FOR CLINICAL PRACTICE
Please use current guidelines available on the UHNM intranet for patient treatment
Please use current guidelines available on the UHNM intranet for patient treatment
RECOGNITION AND ASSESSMENT
- Assess mental status of all elderly patients on admission
- If subsequent changes in mental function, reassess
Assessment
- History taken from patient and a relative
- On admission, medical staff complete 4AT assessment test for delirium on all elderly patients
- The six item cognitive impairment test (6 CIT) for cognitive impairment
- usually completed by nursing staff a few days after admission, especially if dementia is suspected or a referral to memory clinic is needed
- A full clinical examination, including a neurological and rectal examination (where possible)
- Basic investigations as below
High risk patients
- Dementia
- Visual impairment
- Physical frailty
- Any severe illness
- Infection
- Dehydration
- Renal impairment
- Recent surgery (e.g. fractured neck of femur)
- Alcohol excess
- Polypharmacy
Investigations
- FBC, U&E, glucose, LFT, CRP, and bone biochemistry
- Blood glucose
- Thyroid function tests
- Blood cultures
- Urinalysis
- Chest X-ray
- ECG
- Pulse oximetry
- Consider need for: lumbar puncture, blood gases, EEG, B12, folate
- Consider CT scan of head only where a brain lesion suspected (fall, head injury, focal neurological signs, evidence of raised intracranial pressure)
Differential diagnosis
- Confusion is a symptom, not a diagnosis
- Any combination of delirium, dementia or acute functional psychosis
Delirium (acute confusional state)
- Acute confusion in a previously well patient
- develops over a short period (hours to days)
- always associated with clouding of consciousness
- usually precipitated by an acute medical or surgical problem
Dementia
- Continuing confusion relatively unchanged for a month or more
Delirium superimposed on dementia
- Acute confusion in a patient with previous cognitive impairment
- suddenly much worse
IMMEDIATE TREATMENT
Environment
- Nurse in quiet environment; in a side room if possible
- appropriate lighting for time of day
- clocks and calendars to improve orientation
- hearing aids and glasses available and in good working order
- elimination of unexpected irritating noise (e.g. pump alarms)
- Avoid physical restraints
- Nursing staff carry out a risk assessment to avoid bed rails if possible
- in some cases, these do not prevent falls and can increase risk of injury
- may be preferable to nurse patient on a low bed or a mattress or protective mat on the floor
- No inter- and intra-ward transfers
Patient
- Ascertain what is worrying the patient
- often a simple cause which can be addressed
- Regular and repeated cues to improve personal orientation (at least 3 times daily)
- Continuity of care from nursing staff
- Encouragement of mobility
- Good sleep pattern (milky drinks at night, exercise during day)
- Approached and handled gently
Relatives and friends
- Encourage family and friends, who may be able to calm patient, to visit
- Ask family to complete a THIS IS ABOUT ME form
- Explain cause of confusion to relatives
- Encourage them to bring in familiar objects and pictures and to participate in rehabilitation (e.g. to help with feeding and drinking)
Clinical treatment
- Treat or remove underlying causes
- treat infection
- stop all non-essential medication
- correct hypoglycaemia/hypoxia/hypothermia
- Correct and/or maintain fluid and electrolyte balance, nutrition and vitamin supply
- In alcohol dependence or malnutrition, give Pabrinex ampoules 1 & 2, two pairs as IV infusion 8-hrly for 3 days
- For alcohol withdrawal delirium - see Alcohol withdrawal guideline
- Regular analgesia given when needed (e.g. paracetamol)
- Avoid catheters and constipation
Aggressive and violent patients
- If patient severely disturbed and a danger to self or others - see Aggressive and violent patients guideline (these are designed predominately for use in younger patients)
USE OF MEDICATION
- Try all non-pharmacological methods of management first
- medication may make the patient more confused
- only if the patient is severely distressed or poses imminent danger to self or others, consider sedation with lorazepam or haloperidol
- Use one drug only, starting at lowest possible dose
- While dose of psychotropic medication is titrated upward, ensure one-to-one nursing
- Treat underlying cause of confusion so no further anti-psychotic treatment is necessary
- try to avoid use of anti-psychotics due to increased risk of stroke
Lorazepam
- Lorazepam 500 microgram-1 mg (15 microgram/kg) 6-hrly
- give orally (preferably) or by slow IV injection into a large vein
- only if oral or IV routes are not possible, use IM route in the same doses as IV
- maximum of 2 mg in 24 hr
Promethazine
- As an alternative to lorazepam, consider promethazine 25-50 mg 12 hourly
Haloperidol
- Haloperidol 0.5-1 mg 8-hrly, reducing to 500 microgram oral/IM 8-hrly
- maximum dose of 3 mg in 24 hr for a maximum duration of 1 week
- Do not use haloperidol in:
- heart disease, dementia or Parkinson's disease
- known to have a prolonged QT interval
- on other drugs that prolong the QT interval
- normal range for QTc interval is up to 440 milliseconds
- QTc prolongation defined as >450 milliseconds for men and >470 milliseconds for women
Length of treatment
- If maintenance treatment required, consider haloperidol 500 microgram oral daily or 12-hrly
- Review all medication at least every 24 hr
- Stop after 1 week
- No long-term treatment should be required in patients with delirium
Side-effects
- If extrapyramidal symptoms and pyrexia occur, consider neuroleptic malignant syndrome
Risperidone
- If haloperidol is contra-indicated and lorazepam or promethazine have not been effective, consider Risperidone 250 micrograms 12 hourly
- before prescribing, seek senior advice from consultant
- see persistent aggression section below
SUBSEQUENT MANAGEMENT
Delirium
Reconditioning of patient
- Good food, adequate fluids, sufficient sleep
- Bowel regulation, pain control, avoidance of sedation
- Appearance (clothes, shoes, teeth, spectacles, hearing aids, hair and shaving)
Rehabilitation
- Start early and be comprehensive
- avoid permanent immobility, pressure sores, infections and thromboembolic disease
- Always liaise with physiotherapist, occupational therapist and nursing staff
- Where rehabilitation likely to be prolonged, refer to geriatric medicine
Monitor
- Repeat 4AT score to check whether it has reduced following treatment of the condition that induced the delirium
Slow to resolve
- Review diagnosis
- Consider vitamin B12 and folate assays, syphilis and HIV serology
Dementia
Insomnia, restlessness, wandering or difficult behaviour
- Avoid medication
- Check for sources of pain or discomfort, and treat effectively
- Keep regular behavioural charts. Check for any treatable triggers to the behaviour
- if necessary, refer to mental health liaison team
- If above does not resolve problem, give paracetamol 1 g 8-hrly (max 6-hrly)
- if weight <50 kg, reduce dose
- if not effective after 24 hr, review and consider limited trial of stepped-up pain relief
- Review every 24 hr and stop if behaviour no better
Persistent aggression
- If aggression is not modified by behavioural techniques, discuss with elderly care consultant or psycho-geriatrician
- only they can prescribe risperidone for short-term use (increased risk of stroke/death)
- starting dose: 250 microgram 12-hrly, increasing in increments of 250 microgram on alternate days
- maximum of 500 microgram 12-hrly
- Review medication weekly and stop at earliest opportunity
- Maximum treatment is 6 weeks
- Typical and atypical anti-psychotic medications (haloperidol, olanzepine) are not licensed for use in dementia
- long-term use doubles the risk of death
Monitor
- If change occurs, repeat 4AT assessment test and/or the six item cognitive impairment test (6 CIT)
- If sedation given, monitor respiratory rate, pulse and blood pressure
DISCHARGE AND FOLLOW-UP
- Many elderly patients will make a full recovery and can be discharged without referral to another agency
- Offer reassurance and support
- delirium is very unpleasant
- If community care assessment needed, refer to social services
- Consider referral to mental health liaison team
Dementia
- For patients with established dementia, give relatives or carers details of carer support agencies
- For patients with a 6 CIT >7, but not previously known to have dementia, advise GP
- patient requires review after discharge to confirm or exclude a diagnosis of dementia
- advise GP if doubt at review, refer to a memory clinic
Medication
- In patients with delirium, stop all sedatives/anti-psychotics
Anti-psychotic medication
- Long-term is not indicated for difficult behaviour or aggression
- unless patient has a psychotic illness such as schizophrenia or mania
- such use is unlicensed and increases mortality in patients with dementia
- If treatment with anti-psychotic agents is to continue past discharge, inform patient and their relatives of the unlicensed use of the drug and risk of death and stroke
- give clear plan for reducing and stopping the drug to GP, patient and family
- maximum period for prescription should be six weeks only