Managing Acute Confusion in The Elderly Dr Rachel Nockels OPALS Consultant

Why is this relevant? GP curriculum statement 9 (care of older people) requires GPs to be able to manage the problems of older people, such as confusion, in the elderly

Causes of Acute confusion Delirium Worsening dementia Depression Alcohol withdrawal or substance misuse Psychotic disorder Thyroid disease Mania (Schizophrenia)

NICE delerium guideline Delirium - definition A common clinical syndrome characterised by disturbed consciousness, cognitive function or perception which has an acute onset and fluctuating course NICE delerium guideline

Definition DSM IV disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. a change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. the disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. there is evidence from the history, physical examination, and laboratory findings that: (1) the disturbance is caused by the direct physiological consequences of a general medical condition, (2) the symptoms in criteria (a) and (b) developed during substance intoxication, or during or shortly after, a withdrawal syndrome, or (3) the delirium has more than one aetiology”. Icd 10 has 5 criteria, dsm 4 is much more inclusive

Confusion Assessment Method Acute onset and fluctuating course Inattention Disorganised thinking Altered level of consciousness A positive CAM requires presence of 1 AND 2 plus either 3 or 4 Sensitivity 94-100% Specificity- 90—95% Strengths can be done in 5 minutes False positive rate of approx 10% Doesn’t assess severity

European Delirium Association DEMENTIA DEPRESSION Onset Sudden (hours to days) Usually gradual (over months) Gradual (over weeks to months) Alertness Fluctuates - Sleepy or agitated Generally normal Attention Fluctuates – difficulty concentrating, easily distractible May have difficulty concentrating, Sleep Change in sleeping pattern (often more confused at night) Can be disturbed –night time wandering and confusion possible Early morning wakening Thinking Disorganised - jumping from one idea to another Problems with thinking and memory, may have problems finding right word Slower, preoccupied with negative thoughts of hopelessness, helplessness or self depreciation Perception Illusions, delusions and hallucinations common. European Delirium Association

Theories of delirium pathophysiology Cholinergic deficiency Aberrant stress response/ neuroinflammation 1. Induced by anticholinergics

Delirium – sub types Hyperactive Hypoactive Mixed (Subsyndromal)

Prevalence Medical wards – 20-30% Post surgery – 10-50% Long term care – just under 20% Community- ? Up to 1% No prevalence studies

Who Is At Risk? Those aged 65 years and older Hip fracture Cognitive impairment Severe illness Sensory impairment Previous episode of delirium

Precipitating factors Drugs Infection Neurological Cardiological Respiratory Electrolyte imbalance Endocrine and metabolic Constipation Change in environment Including withdrawal

Think Pinch Me Pain INfection Constipation Hydration Medication Environment

Consequences Dementia/Cognitive impairment Progression of dementia Discharge to care home (for people who were in hospital) Falls Hospital admission (for people who were in long-term care) Post discharge care Discharge to care home at 1 month 47% vs 18%

Consequences cont. Post traumatic stress disorder Pressure Ulcers Mortality Impact on carers Length of stay Quality of life for patients LOS 21 days vs 9 In hospital mortality increases from 6 to 11% and this continues to increase at 1 month, 6 months and 1 year

Management

Best management is prevention Reorientate Nurse in familiar surroundings Stop all unnecessary medications Keep lighting appropriate Put in hearing aids and wear glasses Keep well hydrated Monitor nutrition Re-align sleep wake cycle

Treatment Identify cause(s) Ensure effective communication Use verbal and non verbal techniques Keep moves to a minimum If a risk to themselves or others consider short term haloperidol or olanzapine Continue to re evaluate Communication with family, patient, ensure hearing aids

De Escalation Techniques Approach in a calm manner Give choices and maintain patient dignity Speak in a low even tone Do not maintain eye contact Do not interrupt or argue Allow space, do not touch patient Empathise with their feelings Don’t put yourself at risk Little evidence for effectiveness

Sedation Should be avoided If necessary use low dose and gradually increase

Who Needs Admitting? Live alone Will be left unsupervised for any duration of time If carers (or RH) are unprepared or unable to continue looking after the patient If the cause does not become clear despite investigation or the patient fails to improve with treatment and/or If the history and/or examination indicate a cause requiring acute hospital treatment

Conclusion Acute confusion in the elderly is a common problem Delirium is often missed especially hypoactive form It can take months to resolve The consequences can be devastating Try not to use sedation if at all possible

Thank you Any questions?