An approach to - PowerPoint Presentation

Slide1

An approach to the older patient; confusion and agitation

JMO Education

Deakin Education Room

30

th

November 2016

Ramesh Sahathevan Slide2

You are called at 1830 hrs on a weekend..This is X, nurse on 2N. I’m calling about Mrs. Y in bed 12A. She’s become drowsy and we can’t seem to wake her. We’re not sure if we should activate a MET call. She was awake half an hour ago but she was a little agitated then. We need you to come see her now. You say…

Slide3

What do you ask?What details should you request of Nurse X?What should you go assess for yourself? Slide4

From nurse XHow old is the patient?78 years old How long has the patient been

drowsy

for?

She

was fine

until about an hour ago. I think she was asleep when I came on for my shift

Why do you say she was agitated?

She was trying to climb out of her bed

What are her vital signs and general condition?

GCS 14, BP110/70 PR 98 T 37.2

Sats

95% on room air

What’s her underlying problem-why is she in hospital?

Admitted two days ago after a fall in the bathroom and has a fracture right NOF Slide5

You say….I’ll be there in 5 minutesAs you walk to 2N from the carpark (you were just going to drive and out and grab something for dinner since you last meal was at 1000 hrs), what’s running through your mind?What can I get for dinner if I can only leave the hospital at 2000 hrs?

OR

Why is this lady agitated? Slide6

Likely causes of confusion and agitationIn a 78 year-old with a fracture Rt NOF or more accurately, with any older patient admitted to hospital, the causes of confusion and agitation are myriad.

D

rugs e.g. new or increased (opiates, anticonvulsants, benzodiazepines, post-general anaesthetic) or lacking (pain relief, alcohol, recreational drugs)

E

lectrolyte imbalance e.g. sodium, potassium, calcium, phosphate

L

ow oxygen (hypoxia due to lung pathology, heart pathology, heart-lung pathology, central depression)

I

nfections e.g. lung infection, UTI, thrombophlebitis, infected surgical wound (VERY RARELY) encephalitis, meningitis

R

educed sensory input e.g. poor vision, poor hearing, lack of sleep

I

ntracranial e.g. subdural (acute/acute on chronic), extradural, ischemic or haemorrhagic stroke

U

rinary/faecal retention

M

etaboli

c e.g.,

hypoglycaemia, uraemia, liver failureSlide7

What are the possible causes?Based on the list just revealed, what are the likely causes-you haven’t arrived in 2N?78 year-old woman with fracture NOF 2 days prior. You have no idea about her background medical condition or current medications. To refresh you memory, her vitals are:

GCS

13, BP110/70mmHg

PR

98 bpm

T 37.2

Sats

95% on room

air

Possible causes? Slide8

You arrive on the wardYou have a quick look at the patient.What do you assess?POD 1You assess airway, breathing and circulation-all clear

GCS is 13-she’s drowsy and disorientated but

rouseable

; she knows who she is, thinks she’s at home and is disorientated to time

BP 135/80 mmHg, PR 100 regular, T 37.2 Sat 96% on RA

CBS 4.0

mmol

/L

Urine output-catheter in-situ

Not opened bowels since admission Slide9

What does your assessment mean?POD 1-type of surgery and type of anaesthesiaYou assess airway, breathing and circulation-all clear

GCS is 13-she’s

drowsy and disorientated

; she

knows

who she is, thinks

she’s at

home

and

is disorientated to

time-typical picture

BP 135/80

mmHg

, PR 100 regular, T 37.2 Sat 96% on

RA-

acceptable?

CBS

4.0

mmol

/L-

acceptable?

Urine output-catheter

in-situ-

good urine output and clear

Not opened bowels since

admission-

constipated?Slide10

More information78 year-old, home alone; previously wellUn-witnessed fall at home, getting out of the shower. Slipped and fell on the bathroom floor. Activated alert when she fell. Denied

feeling light-headed or

presyncopal

prior and did not lose consciousness.

Medical history:

Hypertension

Type 2 DM

bilateral knee OA

Breast CA (2006-wide excision, axillary clearance, chemotherapy, radiotherapy)

Previous smoker (25 pack-years and stopped when diagnosed with CA breast) Slide11

Falls riskWas she at increased risk of falls prior to her admission?Hypertension Type 2 DMbilateral knee OA

Breast CA (2006-wide excision, axillary clearance, chemotherapy, radiotherapy)

Previous smoker (25 pack-years and stopped when diagnosed with CA breast) Slide12

Giants of Geriatrics

Term coined by Sir Bernard

Issacs

(1924-1995) to explain the role that one (or more likely more than one) of the following factors had on the morbidity of older patients

Originally four but now expanded to five; the 5 ‘I-s’ in no particular order

Instability

Incontinence

Immobility

Impaired intellect

Iatrogenesis

Slide13

Medication listExisting medicationMetformin 1gm bdGliclazide MR 30mg daily

Irbersartan

150mg daily

Aspirin 100 mg daily

Panadol

Osteo

2 capsules

bd

Risperidone 2.5mg daily

Venlafaxine 75 mg daily

Added this admission

Oxycodone

DiazepamSlide14

Medicines with clinically significant anticholinergic effects that are commonly used in older people with dementia

Antipsychotics

Antidepressants

Medicines for urinary incontinence

Antihistamines

Strong anticholinergic effects – avoid using in people with dementia

Chlorpromazine

Olanzapine

Pericyazine

Tricyclic

antidepressants

(

eg

. amitriptyline,

doxepin, imipramine)

Darifenacin

Oxybutynin

Propantheline

Solifenacin

Tolterodine

Brompheniramine

Chlorpheniramine

Cyproheptadine

Diphenhydramine

Promethazine

Moderate anticholinergic effects – use with caution in people with dementia

Haloperidol

Prochlorperazine

Quetiapine

Risperidone

Ziprasidone

Desvenlafaxine

Duloxetine

Fluoxetine

Mirtazapine

Paroxetine

Reboxetine

Venlafaxine

 Slide15

Examples of anticholinergic side effects

Confusion/hallucinations/delirium

Dry mouth

Pupil dilatation/blurred vision

Urinary retention

Constipation

Tachycardia/arrhythmiasSlide16

Clinical examination Drowsy but rouseable and disorientated; able to obey simple (one-stage) commands but appears distractible Vital signs stable

Lungs-reduced air-entry in the bases; no

crepitations

CVS-DRNM, JVP not elevated

Abdomen-soft; non-tender

CNS-grossly intact

Operation site-not swollen or tender, dressing in-situ and not soaked Slide17

What now? 78 year-old with uncomplicated fracture Rt NOF following an unwitnessed, unprovoked mechanical fallPOD 1 (general anaesthesia)Catheterised prior to surgery Possibly constipated

Borderline hypoglycaemia

Over/under-medicated for pain?

Polypharmacy-large number of medications (although most indicated) and irrational use (?) of medication Slide18

Investigations What do you want to request?Slide19

InvestigationsFBC: Hb 109 /TWBC 10.1/Platelets 220UEC Na 130/K 3.5/Urea 12.1/Creat 133Ca

2+

(corrected ) 2.4/PO

4-

1.1

Glucose 5.8

Urine analysis-normal

CXR-poor film (supine) but no obvious consolidation changes

ECG (with repeat)-sinus tachycardia, no ischemic/dynamic changes and no right ventricular strain pattern Slide20

InvestigationsFBC: Hb 109 /TWBC 10.1/Platelets 220

UEC Na 130/K 3.5/

Urea 12.1/

Creat

133

Ca

2+

(corrected ) 2.4/PO

4-

1.1

Glucose

5.8

Urine analysis-normal

CXR-poor film (supine) but no obvious consolidation changes

ECG (with repeat)-sinus tachycardia, no ischaemic/dynamic changes and no right ventricular strain pattern

CT brain-atrophy and significant deep white matter

hyperintensity

but no acute pathology-indicated?Slide21

What’s going on?What does this patient have?Delirium in the setting of recent NOF fracture (with surgery)Precipitants of delirium?Multi-factorial-fracture and surgery/GA/dehydration/constipation/hypoglycaemia/painWhat are the risk factors for delirium?

Multi-factorial-age/multiple co-morbid conditions/polypharmacy/underlying cognitive impairment? Slide22

What do you do?Identify and treat/alleviate precipitant(s)Address risk factorsUse non-pharmacological measures to help with delirium Use pharmacological means as a last resort-if the patient becomes a risk to themselves or others

Use of anti-psychotics is considered off-label but commonly practised (haloperidol; initial dose of 0.5-1.0 mg)

Use of the newer anti-psychotics is permissible although long-term use is not encouraged due to increased risk of mortality and cardiovascular events

DO NOT use benzodiazepines Slide23

In summaryOlder, hospitalised patients are at high-risk for delirium Best to identify patients at risk of delirium and take preventative measures-multifactorial Patients who develop delirium must be investigated to determine a correctable cause-multifactorial Investigations are often normal

Non-pharmacological measures come first in treating delirium

Not mentioned in this scenario-but do not forget the patient with

hypodelirium

Slide24

Thanks and questions