Guidelines for the diagnosis and

Guidelines for the diagnosis and

Management of delirium in the

Elderly

Contents Page

Grade of evidence

1

Acknowledgements

1

Definitions

2

Diagnosis

2

Abbreviated Mental Test score

3

Differential diagnosis

3

Patients at risk

3

Causes

4

History

4

Examination

4

Investigations

5

Treatment of underlying cause

6

Management of confusion

6

Sedation

7

Prevention of complications

8

Referral to Old Age Psychiatry

8

Discharge

9

Follow up

9

References

10, 11,12

Index

13

Appendix 1

Drugs causing delirium

Appendix 2

Algorithm for management

Appendix 3

Summary of Carlisle guidelines for

management of delirium

Grade of evidence:

Grade 1Based on Randomised Controlled Trial

Grade IIaBased on well designed nonrandomised controlled trial

Grade IIbBased on well designed cohort or casecontrol analytic studies

Grade IIcComparisons between times/places, with or without interventions.

Dramatic results in uncontrolled trials

Grade IIl Expert opinion, clinical experience, descriptive studies, expert committees.

Acknowledgements:

These guidelines were compiled by Dr Lesley Young and Dr Jim George with funding from the NHS central audit fund. We wish to acknowledge the support and cooperation of the following groups of people who assisted in the development of these guidelines:

Staff of the from the medical and elderly care wards and audit departments in the following hospitals:

Cumberland Infirmary, Carlisle

Newcastle General Hospital, Newcastle upon Tyne

North Tyneside General Hospital, North Shields

Royal Victoria Infirmary, Newcastle upon Tyne

St Luke's Hospital, Bradford

Bradford Royal Infirmary, Bradford

Selly Oak Hospital, Birmingham

Members of the joint working party on "Confusion in Crises", Royal College of Physicians, October 1995.

Dr Stephen Singleton, Director of Public Health, Northumberland.

1

Guidelines for the diagnosis and management of delirium

Delirium (acute confusional state) is a common condition in the elderly affecting up to 30% of all elderly medical patients. Patients who develop delirium have high mortality, institutionalisation and complication rates, and have longer lengths of stay than nondelirious patients [1]. Delirium is often not recognised by clinicians [2], and is often poorly managed. The aim of these guidelines is to aid recognition of delirium and to provide guidance on how to manage these complex and challenging patients.

Diagnosis

Delirium is characterised by a disturbance of consciousness and a change in cognition that develop over a short period of time. The disorder has a tendency to fluctuate during the course of the day, and there is evidence form the history, examination or investigations that the delirium is a direct consequence of a general medical condition, drug withdrawal or intoxication (DSM IV) [3].

In order to make a diagnosis of delirium, a patient must show each of the features 14 listed below:

1.Disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention.

2.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 or evolving dementia.

3.The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.

4.There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition, substance intoxication or substance withdrawal.

Delirium may have more than one causal factor (i.e. multiple aetiologies). A diagnosis of delirium can also be made when there is insufficient evidence to support criterion 4, if the clinical, presentation is consistent with delirium, and the clinical features can not be attributed to any other diagnosis, for example delirium due to sensory deprivation.

2

Aids to diagnosis

Cognitive testing should be carried out on all elderly patients admitted to hospital (grade llc) Use of cognitive screening tools (such as the Abbreviated Mental Test score [4] and Mini Mental State Examination [5]) may increase recognition of delirium present on admission [4, 5].

Serial measurements may help detect the new development of delirium or its resolution [6] (gradellc). However by themselves these tools cannot distinguish between delirium and other causes of cognitive impairment [4, 5].

A history from a relative or carer of the onset and course of the confusion is essential to help distinguish between delirium and dementia. (grade III).

Abbreviated Mental Test Score (AMT) (A score of less than 8/10 is abnormal)

1. Age

2.Time (to nearest hour)

3.Address for recall at end of test (42 West St)

4.Year

5.Name of hospital

6.Recognition of 2 persons (eg doctor, nurse)

7.Date of Birth

8.Year of 1st World War

9.Name of present monarch

10.Count backwards 201 (this also tests attention)

Differential diagnosis

The differential diagnosis of delirium includes:

Dementia

Depression

Hysteria

Mania

Schizophrenia

The simple screening tools, discussed earlier, are not able to distinguish between delirium and other disorders, such as dementia [4, 5]. In order to differentiate between delirium and dementia, the most helpful factor is an account of the patients preadmission state from a relative or carer. Serial measurements of cognition may help to differentiate delirium from dementia or detect its onset during a hospital admission [6] (grade Ilc).

3

Patients at risk

Delirium is more common in those with a preexisting organic brain syndrome [7] or dementia [819], and may coexist with disorders such as depression, which are also common in the elderly [10, 20].

Delirium is more common in patients who are:

Older [21]

Severely ill [11]

Demented [11]

Physically frail [22]

Admitted with an infection or dehydration [11, 21]

Visually impaired [11]

Polypharmacy [15, 16, 23]

Alcohol excess [12]

Early attention to possible precipitants of delirium and adopting the approaches detailed under "management of confusion" in those patients at increased risk of delirium may prevent the development of delirium and improve the outcome in those who go on to develop it [2426, 44] (Grade, l).

Identification of the underlying cause

Common causes of delirium include :

Infection (e.g. pneumonia, UTI)

Neurological (e.g. stroke, subdural haematoma, epilepsy)

Cardiological (eg myocardial infarction, heart failure)

Respiratory (eg pulmonary embolus, hypoxia)

Electrolyte imbalance (eg dehydration, renal failure)

Endocrine & metabolic (eg cachexia, thiamine deficiency, thyroid dysfunction)

Drugs ( particularly those with anticholinergic side effects, eg antidepressants, antiparkinsonian drugs, sedatives) (see appendix 1)

Multiple causes.

History

In addition to standard questions in the history, the following information should be specifically sought (grade III):

Full drug history including nonprescribed drugs

Alcohol history

Previous intellectual function (eg ability to manage household affairs, pay bills etc.)

Functional status (eg activities of daily living)

Onset and course of confusion

Previous episodes of acute or chronic confusion

4

Symptoms suggestive of underlying cause (eg infection)

Sensory deficits

Aids used (eg hearing aid, glasses etc.)

Preadmission social circumstances and care package

Comorbid illness

Many patients with confusional states are unable to provide an accurate history. Where ever possible corroboration should be sought from the carer (grade III).

Communication between staff from different disciplines is essential to avoid unnecessary repetition of information gathering.

Examination

A full physical examination should be carried out including in particular the following areas:

Neurological examination (including assessment of speech)

Conscious level

Nutritional status

Evidence of pyrexia

Evidence of alcohol abuse or withdrawal (e.g. tremor)

Cognitive function using a standardised screening tool e.g. Abbreviated MTS or MMSE (grade IIc)

Attention (e.g. serial 7`s, months of year backwards)

Investigations

The following investigations are almost always indicated in patients with delirium in order to identify

the underlying cause (grade III):

Full blood count

Calcium

Urea and electrolytes

Liver function tests

Glucose

Thyroid function tests

Chest Xray

ECG

Blood cultures

Urinalysis

5

Other investigations may be indicated according to the findings from the history and examination.

These include:

EEG (see below)

CT head (see below)

B12 and folate

Arterial blood gases

Specific cultures eg urine, sputum

Lumbar puncture (see below)

CT Scan (grade llb)

Although many patients with delirium have an underlying dementia or structural brain lesion (eg previous stroke), CT has been shown to be unhelpful on a routine basis in identifying a cause for delirium [7] and should be reserved for those patients in whom an intracranial lesion is suspected. This might include patients with the following features (grade III):

Focal neurological signs

Confusion developing after head injury

Confusion developing after a fall

Evidence of raised intracranial pressure

EEG

Although the EEG is frequently abnormal in those with delirium [2729], showing diffuse slowing, its routine use as a diagnostic tool has not been fully evaluated. EEG may be useful where there is difficulty in the following situations (grade III):

Differentiating delirium from dementia

Differentiating delirium from nonconvulsive status epilepticus and temporal lobe epilepsy

Identifying those patients in whom the delirium is due to a focal intracranial lesion, rather than a global abnormality.

Lumbar puncture

Although various abnormalities have been seen in the CSF of patients with delirium [30], routine LP is not helpful [31] in identifying an underlying cause for the delirium (grade III). It should therefore be reserved for those in whom there is reason to suspect a cause such as meningitis. This might include patients with the following features:

Meningism

Headache and fever

6

Treatment of underlying cause

The most important approach to the management of delirium is the identification and treatment of the underlying cause (grade III).

Incriminated drugs should be withdrawn where ever possible (grade III).

Biochemical derangements should be corrected promptly [32] (grade IIb)

Infection is one of the most frequent precipitants of delirium. If there is a high likelihood of infection (eg abnormal urinalysis, abnormal chest examination etc.), appropriate cultures should be taken and antibiotics commenced promptly, selecting a drug to which the likely infective organism will be sensitive (grade III).

Management of confusion

In addition to treating the underlying cause, management should also be directed at the relief of the symptoms of confusion/delirium.

The patient should be nursed in a good sensory environment and with a reality orientation approach, and with involvement of the multidisciplinary team [18, 23, 25, 26, 3335] (grade I).

This includes:

Good lighting levels

Regular and repeated visible and verbal clues as to orientation (eg clocks, calendars)

Reassurance and explanation to the patient and carer of any procedures or treatment, using short simple sentences

Sensory aids should be available and working where necessary

Avoidance of inter and intraward transfers [36] (grade III)

Continuity of care from caring staff

Avoidance of physical restraints [3739] (grade IIc) (see also under Falls)

Maintenance or restoration of normal sleep patterns

Approach and handle gently

Eliminate unexpected and irritating noise (e.g. pump alarms)

Attend to bowel and bladder elimination (see continence problems)

Encouraging visits from familiar friends and relatives may help to calm an agitated patient. However communication with the relative regarding the nature of the confusion is essential.

Depending on the layout and nature of the ward, these measures may be facilitated by nursing the patient in a single room. For example, in a busy Nightingale ward, a patient with delirium may be better managed in a side room, whereas in a ward with small bays the presence of other patients may have a reassuring influence (grade III).

7

Wandering and rambling speech

Patients who wander require close observation within a safe and reasonably closed environment. It is often preferable to try distracting the agitated wandering patient rather than using restraints or sedation. Relatives could be encouraged to assist in this kind of management.

Attempts should be made to identify and remedy possible cause of agitation e.g. pain, thirst, need for toilet. Patients with delirium often exhibit confused and rambling speech, it is usually preferable not to agree with rambling talk, but to adopt one of the following strategies, depending on the circumstance (grade III) [40]:

Tactfully disagree (if the topic is not sensitive)

Change the subject

Acknowledge the feelings expressed ignore the content

Sedation

All sedatives may cause delirium, especially those with anticholinergic side effects [41] (such as thioridazine, chlorpromazine etc.). The use of sedatives and major tranquillisers should therefore be kept to a minimum (grade III). Many elderly patients with delirium have hypoactive delirium (quiet delirium) and do not require sedation [42]. Early identification of delirium and prompt treatment of the underlying cause may reduce the severity and duration of delirium [2426].

Drug sedation may be necessary in the following circumstances (grade III)

in order to carry out essential investigations or treatment

to prevent patients endangering themselves or others

to relieve distress in a highly agitated or hallucinating patient

It is preferable to use one drug only, starting at the lowest possible dose and increasing in increments if necessary after an interval of 30 minutes (grade III).

The preferred drugs are:

Haloperidol - 0.5mg3mg orally as tablets or liquid up to 4 times daily or 2.5 5 mg by

intramuscular injection (grade III) (NB the oral and IM doses of haloperidol are not equivalent)

Droperidol - 510mg orally or 5mg by intramuscular injection up to 4 times daily.

If sedatives are prescribed, the prescription should be reviewed regularly and discontinued as soon as possible.

For delirium due to alcohol withdrawal (delirium tremens) a benzodiazepine (eg diazepam or chlordiazepoxide) or chlormethiazole are preferred in a reducing course. Detailed guidelines for this condition are beyond the scope of these guidelines.

8

Prevention of complications

The main complications of delirium are :

Falls

Pressure sores

Nosocomial infections

Functional impairment

Continence problems

Over sedation

Restraints (including cotsides, "geriatric chairs" etc.) have not been shown to prevent falls and may increase the risk of injury [3739]. It may be preferable to nurse the patient on a low bed or place the mattress directly on the floor. Adoption of the good practices described should make the use of physical restraints unnecessary for the management of confusion (grade III).

Pressure sores

Patients should have a formal pressure sore risk assessment ( eg Norton score, or Waterlow score), and receive regular pressure area care, including special mattresses where necessary (grade III). Patients should be mobilised as soon as their illness allows.

Functional impairment

Assessment by a physiotherapist and occupational therapist to maintain and improve functional ability should be considered in all delirious patients (grade III). There is evidence that patients who are managed by a multidisciplinary team do better than those cared for in a traditional way [18, 23, 2526, 3335] (grade I, IIb).

Continence

A full continence assessment should be carried out. Regular toiletting and prompt treatment of UTI`s may prevent urinary incontinence. Catheters should be avoided where possible because of the increased risks of trauma in confused patients, and the risk of catheter associated infection (grade III).

Referral to Old Age Psychiatry services

Many patients with delirium have an underlying dementia which may be best followed up and managed by an Old Age Psychiatrist. Patients who fail to improve despite adequate treatment and resolution of the suspected cause of the delirium may benefit from referral to an Old Age Psychiatrist for further assessment (grade III) [35].

9

Discharge

As with all elderly patients discharge should be planned in conjunction with all disciplines involved in caring for the patient, both in hospital and in the community (including informal carers). Practical arrangements should be in place prior to discharge for activities such as washing, dressing, medication etc. in accordance with the joint statement of the British Geriatrics Society and the Association Directors of Social Services [43] (grade III).

Communication with all parties involved in the patients care is vital.

Prior to discharge it is useful to assess the patients cognitive and functional status ( eg using standardised tools such as AMT and Barthel Index).

Discharge summaries should be completed promptly.

Follow up

Delirium is a common first presentation of an underlying dementing process. It may also be a marker of severe illness and comorbidity. It is therefore often appropriate to refer the patient to a Geriatrician, Psychiatrist of Old Age, CPN or Social Worker for the Elderly or Consultant in Geriatric Medicine for further assessment and follow up.

10

References

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[2]Johnson JC, Kerse NM, Gottlieb G, Wanich C, Sullivan E, Chen K. Prospective versus retrospective methods of identifying patients with delirium. JAGS;1992:40:316319

[3]American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, D.C., American Psychiatric Association, 1994.

[4]Jitapunkul S, Pillay I, Ebrahim S. The abbreviated mental test: its use and validity. Age and Ageing;1991:20:332336

[5]Anthony JC, LeResche L, Niaz V, Von Korff MR, Folstein MF. Limits of the "MMSE" as a screening test for dementia and delirium among hospital patients. Psychol Med 1982;12:397408

[6]O`Keeffe ST, Lavan JN. Use of serial MMSE scores to monitor development and resolution of delirium in elderly hospital patients. Abstract to Autumn Meeting of the British Geriatrics Society, October 1995.

[7]Koponen H, Hurri L, Stenback U, Reikkinen PJ. Acute confusional states in the elderly: A radiological evaluation. Acta Psych Scand 1987;76:726731.

[8]Erkinjuntti T, Wikstrom J, Palo J, Autio L. Dementia among medical inpatients. Evaluation of 2000 consecutive admissions. Arch Int Med 1986;146:19231926

[9]Kolbeinsson HJ, Jonsson A. Delirium and dementia in acute medical admissions of elderly patients in Iceland. Acta Psych Scand 1993;87:123127.

[10]Bowler C, Boyle A, Branford M, Cooper SA, Harper R, Lindesay J. Detection of psychiatric disorders in elderly medical inpatients. Age and Ageing 1994;23:307311.

[11]Inouye S, Viscoli C, Horowitz R, Hurst L, Tinetti M. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Int Med 1993;119:474-481

[12]Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium in hospitalized older persons:outcomes and predictors. JAGS 1994;42:809815.

[13]Jitapunkul S, Pillay I, Ebrahim S. Delirium in newly admitted elderly patients: a prospective study. Quarterly Journal of Medicine 1992;83:307314.

[14]Francis J, Kapor WN. Prognosis after hospital discharge of older medical patients with delirium. JAGS 1992;40:601606.

11

[15]Schorl JD, Levkoff SE, Lipsitz LA, Reilly CH, Cleary PD, Rowe JW, Evans DA. Risk factors for delirium in hospitalized elderly. JAMA 1992;267:827831.

[16]Francis J, Martin D, Kapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990;263:10971101.

[17]Rockwood K. Acute confusion in elderly medical patients. JAGS 1989;37:150154.

[18]Williams MA, Campbell EB, Raynor WJ, Mlynarczyk SM, Ward SE. Reducing acute confusional states in elderly patients with hip fractures. Research in Nursing and Health 1985;8:329337

[19]Gustafson Y, Berggren D, Brannstrom B, Bucht G, Norberg A, Hansson LI, Winblad B. Acute confusional states in elderly patients treated for femoral neck fracture. JAGS 1988;36:525530.

[20]Feldman E, Mayou R, Hawton K, Ardern M, Smith EBO. Psychiatric disorders in medical inpatients. Quarterly Journal of Medicine 1987;63(241):405412.

[21]Levkoff SE, Safran C, Cleary PD, Gallop J, Phillips RS. Identification of factors associated with the diagnosis of delirium in elderly hospitalised patients. JAGS 1988;36:10991104.

[22]Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, Donaldson MC, Whittemore AD, Sugarbaker DJ, Poss R, Haas S, Cook EF, Orav J, Lee TH. A clinical prediction rule for delirium after elective surgery. JAMA 1994;271:134139.

[23]Williams MA, Holloway JR, Winn MC, Wolanin MO, Lawler ML, Westwick CR, Chin MH. Nursing activities and acute confusional states in elderly hipfractured patients. Nursing Research 1979;28(1):2535.

[24]Gustafson Y, Brannstron B, Berggren D, Ragnarsson JI, Sigaard J, Bucht G, Reiz S, Norberg A, Winblad B. A geriatricanesthiologic program to reduce acute confusional states in elderly patients treated with femoral neck fractures. JAGS 1991;39:655662.

[25]Landefield CS, Palmer RM, Kresevic DM, Fortinsky RH, Kowel J. A randomized trial of care in a hospital medical unit especially designed to improve the functional outcomes of acutely ill older patients. NEJM 1995;332:13381344

[26]Inouye SK, Wagner DR, Acampora D, Horowitz RI, Cooney LM, Tinetti ME. A controlled trial of a nursingcentred intervention in hospitalized elderly medical patients: the Yale Geriatric care Program. JAGS 1993;41:13531360

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[27]Brenner RP. Utility of EEG in delirium: past views and current practice. Int Psychoger. 1991;3(2):211229.

[28]Jacobsen SA, Leuchter AF, Walter DO. Conventional and quantitative EEG in the diagnosis of delirium among the elderly. J of Neurology, Neurosurgery and Psychiatry 1993;56:153158.

29]Koponen H. Electroencephalographic indices for diagnosis of delirium. Int Psychoger 1991;3(2):249251.

[30]Koponen HJ, Leinonen E, Lepola U, Reikkinen PJ. A longterm followup study of cerebrospinal fluid somatostatin in delirium. Acta Psych Scand 1994 89;329-334.

[31]Warshaw G, Tanzer F. The effectiveness of lumbar puncture in the evaluation of delirium and fever in the hospitalized elderly. Arch Family Med. 1993;2:293297.

[32]Koizumi K, Shiraishi H, Ofuku K, Suzuki T. Duration of delirium shortened by the correction electrolyte imbalance. Japanese J of Psychiatry and Neurology 1988;42(1):8188

[33]Wanich CK, SullivanMarx EM, Gottlieb GL, Johnson JC. Functional status outcomes of a nursing intervention in hospitalized elderly. Image: Journal of Nursing Scholarship 1992;24(3):201207

[34]Cole MG, Primeau FJ, Bailey RF, Bonnycastle MJ, Masciarelli F, Engelsmann F, Pepin MJ, Ducic D. Systematic intervention for elderly inpatients with delirium: a randomised trial. Can Med Ass J 1994;151(7):965970

[35]Cole MG, Fenton FR, Engelsmann F, Mansouri I. Effectiveness of Geriatric Psychiatry consultation in an acute care hospital: a randomised controlled trial. JAGS 1991;39:11831188

[36]Mattice M. Intrahospital room transfers: a potential link to delirium in the elderly.

Perspectives 1989 (summer);1012.

[37]Evans LK, Strumpf NE. Tying down the elderly. A review of the literature on physical restraint. JAGS 1989;37:6574

[38]SullivanMarx EM. Delirium and physical restraint in the hospitalized elderly. Image 1994;26(4):295300.

[39]Lofgren RP, MacPherson DS, Granieri R, Myllenbeck S, Sprafka J. Mechanical restraints on the medical wards: are protective devices safe? Am J Public Health 1989;79(6):735738.

[40]Holden UP, Woods RT. Reality Orientation. Psychological approaches to the "confused" elderly. 2nd edition. Churchill Livingstone.

[41]Tune L, Carr S, Hoag E, Cooper T. Anticholinergic effects of drugs commonly prescribed for the elderly: potential means for assessing risk of delirium. Am J Psych 1992;149:13931394

[42]Liptzin B, Levkoff SE. An empirical study of delirium subtypes. B J Psych 1992;161:843845.

[43]Joint statement of the Association of Directors of Social Services and the British Geriatrics Society. Discharge to the community of elderly patients in hospital. Guidelines, Policy Statements and Statement of Good Practice No. 7

[44]Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acompora D, Holford TR and Cooney LM. A multi-component intervention to prevent delirium in hospitalised older patients. NEJM 1999; 340:669-676

13

Index

A

Abbreviated Mental Test score

3

Acknowledgements

1

Algorithm

Appendix 2

Assessment

4

B, C

Causes

3

Cognitive tests

3

Complications

8

Continence

8

CT scans

5

D

Definitions

2

Dementia

3

Depression

3

Diagnosis

2

Differential diagnosis

3

Aids to diagnosis

2

Diagnostic criteria

2

Discharge

9

Drugs...

causing delirium

Appendix 1

treatment of delirium

7

E

EEG

5

Examination

4

F

Falls

8

Follow-up

9

Functional impairment

8

G

Grade of evidence

1

H

History

4

I

Incontinence

8

Investigations

5

J, K

L

Lumbar puncture

6

M

Management of confusion

6, 7

Multidisciplinary team

6,8,9

N, O

Old age psychiatry

8

P, Q

Pressure sores

8

Prevention

3,6

R

Reality Orientation

6

References

10

Rehabilitation

8

Restraints

6,8

Risk factors

3

S

Sedation

7

indications

7

types

7

Summary of guidelines

Appendix 3

T

Treatment

6

underlying cause

6

confusion

6,7

U, V

Underlying cause

4

W

Wandering

8

X Y Z

14

Appendix 1

DRUG TYPE

EXAMPLES

RISK

COMMENTS

Benzodiazepines

Diazepam, Temazepam Chlordiazepoxide

HIGH

Benzodiazepine withdrawal is also a common cause of delirium

Antidepressants

Amitriptyline

Doxepin, Trazadone

HIGH

Risk greatest in drugs with anticholinergic and sedative effects

Antiparkinsonian drugs

Levodopa

Bromocriptine

Selegeline

Benzhexol

Orphenadrine

Pergolide

HIGH

All have anticholinergic or dopaminergie effects, which can cause confusion

Analgesics

NSAIDs

Opiates

Aspirin

HIGH

All analgesics (except paracetamol) can cause confusion. Of the NSAIDs indomethacin is most likely to cause delirium. Confusion due to aspairin is dose related. Opiates have a very high risk of causing confusion

Lithium

HIGH

Steroids

HIGH

Risk may be dose related

Antihypertensive medications

Methyl Dopa

-Blockers

-Blockers

ACE Inhibitors

CA-Channel Blockers

Diuretics

HIGH

MEDIUM

LOW

Diuretics may lead to delirium by causing electrolyte disturbances

Antiarrhythmics

Digoxin

Amiodarone

Disopyramide

Lignocaine

MEDIUM

Lignocaine has highest risk

Risk with digoxin is dose related

Major tranquillizers

Chlorpromazine

Thioridazine

Trifluoperazine

Haloperidol

Droperidol

MEDIUM

LOW

Sedating drugs, with anticholinergic effects (e.g.

Chlorpromazine) have higher risk than non-sedating drugs such as haloperidol

Anticonvulsants

Primidone

Phenytoin

Carbamazepine

Valproate

LOW

Risk highest with primidone

Lowest risk with valproate and carbamazepine

Risk with phenytoin may be dose related

Anticholinergic drugs

Antihistamines

Antispasmodics

Chlorpheniramine

Atropine

MEDIUM

Drugs in this group are often bought over the counter

Histamine blockers

Cimetidine

Ranitidine, Famotidine

LOW

Cimetidine may be more likely to cause confusion than the other drugs in this group

Antibiotics

Benzyl Penicillin

Co-Trimoxazole

Amphotericin

Antituberculous Drugs

Rifampicin

Isoniazid

Antiparasitic Drugs

Meppacrine

Chloroquine, Quinine

Antiviral Drugs

Amantadine

Acyclovir, Zidovudine

LOW

MEDIUM

Although delirium has been attributed to most antibiotics

Most cases of confusion occurring during antibiotic treatment are likely to be due to the infection rather than the treatment

Respiratory drugs

Aminophylline

LOW

May cause dose related confusion

Oral hypoglycaemic agents

Tolbutamide

Glibenclamide

UNCERTAIN

These drugs may cause hypoglycaemia and hyponatraemia, both of which can cause delirium

Antineoplasstic drugs

Methotrexate, Vinca

Alkaloids, Fluorouracil,

Altretamine, Asparginase,

Procarbazine, Carmustine,

Dacabazine, Interferon-

UNCERTAIN

Delirium frequently occurs in malignant disease, therefore it is difficult to attribute the confusion to the drugs. However the drugs listed have been associated with confusion more often than others

Appendix 2

Guidelines for the diagnosis and management of delirium

Appendix 3

Summary of Carlisle guidelines for management of delirium

The features of delirium according to DSM IV are:

In all stages during the hospital admission, ensure good communication with

1.Disturbance of consciousness (i.e. reduced clarity of awareness of the

the patient and carer: and between professionals caring for the patient.

environment) with reduced ability to focus, sustain or shift attention.

1.Identification of delirium using established diagnostic criteria (see over).

2.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 or evolving dementia.

2.Recognition of delirium can be increased by the routine assessment of cognitive

state, e.g. using the AMT (see over). Repeated use of the AMT may help to

3.The disturbance develops over a short period of time (usually hours to days) and

determine recovery or onset of delirium in those not delirious on admission.

Tends to fluctuate during the course of the day.

3.Assessment of patients pre-admission cognitive, functional and social status.

4.

There is evidence from the history, physical examination, or laboratory

This information may need to be clarified with the carer.

findings that the disturbance is caused by the direct physiological

Consequences of a general medical condition, substance intoxication or substance withdrawal

4.Identification of risk factors such as dementia, severe illness, sensory

impairments, alcohol use.

Abbreviated Mental Test Score (AMT)

5.Identification of underlying cause (commonly infection or drugs).

1.Age

6.Treatment of underlying cause or removal of offending drugs

2.Time (to nearest hour)

7.Avoidance of physician restraints.

3.Address for recall at end of test (42 West St)

8.Avoidance of major tranquillizers, where possible, but if necessary use only one

drug and in the lowest dose possible (e.g. haloperidol 0.5mg orally up to QS).

4.Year

Review drug treatment regularly.

5.Name of hospital

9.Multi-disciplinary team involvement in treatment and discharge planning.

6.Recognition of 2 persons (e.g. doctor, nurse)

10.Create optimum environment for care (e.g. single room, good lighting).

7.Date of birth

11.Use reality orientation techniques and rehabilative care models.

8.Year of 1st World War

12.Ensure adequate discharge and follow-up to avoid unnecessary readmission

and to provide support to patient and carers.

9.Name of present monarch

10.Count 20-1

AMT

>8/10