Delirium in the ED

Delirium is one of a number of geriatric syndromes and has significant associated morbidity and mortality.

3 subtypes of delirium

  1. Hyperactive – easies to spot, one we are most familiar with. Characterised by agitation/aggression/hallucinations “the non cooperative patient”
  2. Hypoactive – harder to spot. Characterised by drowsiness, less responsive, vacant, sleeping more at home
  3. Mixed

Remember there is NO SUCH THING AS A “POOR HISTORIAN” !! – Just a poor clinician! If your patient is not cooperating and can’t tell you very much then you need to find out why!!!

Diagnosis

Any patient aged over 75 who attends the ED must have a CAM score performed.  This also includes ALL patients with a diagnosis of dementia as they are at high risk of developing a delirium.   Collateral history very important, especially in context of dementia. This may be difficult but do your best to find out.

The CAM score

Investigation – Think about the cause!

  • Drugs– polypharmacy
  • Trauma – ensure CT head performed in line with NICE guidance if suspected head injury.  Do not need to routinely perform CT head in department for confusion in general unless clearly suspected intracranial cause
  • Electrolyte disturbance – ensure review of U&Es before transfer or discharge.  Remember sudden changes are more likely to produce problems than slower ones
  • Hypoxia
  • CCF/MI
  • Pain – ensure has had consideration of analgesia
  • Infection

DO NOT JUST PRESUME UTI – be #Urosceptical

  • Asymptomatic bacteruira in elderly is common.
  • Follow guidance below

Symptoms

  • Abdominal pain
  • Unexplained fever
  • Offensive urine
  • Dysuria
  • Frequency

Adapted from the RCEM silver book

 

Management

  • Document delirium as an ED diagnosis
  • Document if the CAM is POSITIVE OR NEGATIVE in your notes
  • Treat the cause if you have identified it
  • Avoid use of sedative agents if behaviour challenging unless absolutely necessary – see Acute Behavioural Disturbance / Excited Delirium

 

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