Delirium secondary prevention
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Delirium Microchapters |
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Diagnosis |
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Treatment |
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Delirium On the Web |
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American Roentgen Ray Society Images of Delirium |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vishal Khurana, M.B.B.S., M.D. [2]
Overview
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 [37‑39]. 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, 25‑26, 33‑35] (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].
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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.