1. Delirium in the acute hospital
Dr Louise Allan
Clinical Senior Lecturer and Honorary Consultant Geriatrician 
British Geriatrics Society

2. What is delirium?

3. What is delirium? Acute brain failure
It can be acute without previous brain failure
It can be recurrent
Acute on chronic (previous chronic brain failure aka dementia)
It can lead to chronic brain failure

4. What is delirium? DSM IV criteria
Disturbance of consciousness (ie, reduced clarity of awareness of the environment) occurs, with reduced ability to focus, sustain, or shift attention.
Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) occurs that is not better accounted for by a preexisting, established, or evolving dementia.
The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.
Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.

5. What is delirium? Change in consciousness or alertness
Change in cognition
Memory
Thinking
Perception (the senses)
Behaviour
It happens over a short period
It goes up and down
It is usually caused by a physical illness

6. Behaviours Just “more confused” Poor attention- can’t give a history
Looks around the room
Agitated, plucking at bed clothes
Hallucinating
Very quiet or drowsy
Reduced ability to care for self
Loss of mobility

7. Three types of delirium
Hyperactive
Hypoactive
Mixed

8. Why is it important?
It’s the cognitive “superbug”

9. Why is it important? It is often not diagnosed A common problem
Increased length of stay and complications
Poor outcomes- mortality, admission to care home
It often takes a long time to get better
It doesn’t always get better

10. Why is it important? It can be prevented It can be treated
If it does happen, good care will shorten the duration
Good communication reassures and also provides realistic expectations
Good practice saves money

11. How common is it? Delirium is common in acute hospitals e.g.
22% in general medicine
28% acute orthopaedics
80% medical ICU

12. Who gets delirium? Anyone!
Age over 65
Dementia
Frailty
Sensory impairment
Severe illness
Recent surgery/ fracture
Drugs
Alcohol

13. What are the most common causes?
Pain
Infection
Constipation
Hydration
Medication
Environment

14. How is it diagnosed? Short Confusion Assessment Method
1. Acute onset or fluctuating course
AND
2. Inattention
AND EITHER
3. Disorganised thinking/ incoherent speech OR
4. Altered level of consciousness

15. Other features Memory impairment
Disorientation to time, place or person
Agitation e.g. the patient is repeatedly pulling at her sheets and IV tubing
Retardation
Visual or auditory misinterpretations, illusions, or hallucinations
Change in sleep wake cycle e.g. excessive daytime sleepiness with insomnia at night

16. How is it prevented? The environment: Avoid: Hearing aids Spectacles
Orientation aids
Lighting
Encourage food and fluid intake
Encourage mobility
Maintain sleep pattern
Involve relatives and carers
Constipation
Catheters
Restraint
Sedation
Bed or Ward moves
Arguing with the patient

17. How is it treated? Treat infection Correct metabolic abnormalities
Correct hypoxia
Review medication but ensure adequate analgesia
Many episodes of delirium are multifactorial
Treat all the underlying causes

18. After delirium Frightening experience Post traumatic stress
Embarrassment
Need for reassurance
Need for information
Need for recognition of dementia after delirium

19. What are we up against? Culture Lack of training
Competition from other patient safety initiatives

20. THINK DELIRIUM

21. Table top exercise Does your group have experience of delirium?
Were you given information about it?
What can you organisation do?
What can the DAA do?