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Prescribing Advice on Admission – Medication for Parkinson’s Disease
Adults With Incapacity
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Delirium
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Delirium
Last updated 3rd December 2020
Introduction
- Delirium is a medical emergency that occurs in around 20-30% patients on medical wards
- If unrecognised and/or poorly treated, may lead to a number of complications including falls, pressure sores, need for long term care and even death
Who is at Risk?
- Older people – the risk increases with age.
- Older people taking multiple medicines.
- People with dementia.
- People who are dehydrated.
- People with an infection.
- Severely ill people.
- People who have had surgery, especially hip surgery.
- People who are nearing the end of their life.
- People with sight or hearing difficulties.
- People who have a temperature.
- 11. Older people with constipation or urinary retention.
Causes of Delirium
4AT Assessment Tool
- A screening instrument to be used whenever AMT4 is less than 4.
- The 4 components are Alertness, AMT4, Attention and Acute Change or fluctuating course
- Score of 4 or more suggests delirium though false positives and false negatives do occur
- Score of 1-3 suggests cognitive impairment
- Score of 0 usually means everything is ok
TIME Bundle
- If patient fulfils criteria for delirium then proceed with TIME bundle as per chart below
- TIME is an acronym for Triggers, Investigate, Manage and Engage.
- Aim to complete TIME within 2 hours if family/carer present; if absent then complete TIM within 2 hours and the whole bundle within 24 hours
Medication Review
- Review age appropriateness
- Any drugs recently started/stopped?
- Dose changes to medication?
- Compliance/concordance issues with medication?
- Carefully consider ongoing needs for: opioids / benzodiazepines / antipsychotics / antispasmodics / antiepileptics / antihistamines / antihypertensives (especially if hypotension) / corticosteroids / tricyclic antidepressants / digoxin / antiparkinsonian medication
- Avoid abrupt withdrawal of drugs with dependence potential or possible discontinuation syndrome.
Treatment of Delirium Symptoms
- Stay calm.
- Talk to patient in short, simple sentences.
- Check that they have understood you.
- Repeat things if necessary.
- Try not to agree with any unusual or incorrect ideas, but tactfully disagree or change the subject. Reassure them. Remind them of what is happening and how they are doing.
- Remind them of the time and date.
- Make sure they can see a clock or a calendar.
- Try to make sure that someone they know well is with them. This is often most important during the evening, when delirium often gets worse. Bring in some familiar objects from home.
- Make sure they have their glasses and hearing aid.
- Help them to eat and drink.
- Have a light on at night so that they can see where they are if they wake up
Medications for Unmanageable Agitation/Distress
- For use unless signs of Parkinsonism or Lewy Body Dementia
- Haloperidol 0.5-1mg orally (max 2mg/24 hours)
- Haloperidol 0.5mg IM (max 2mg/24 hours)
- If antipsychotics are contra-indicated (as above),
- Lorazepam 0.5-1mg orally (max 2mg/24 hours)
- Midazolam 2.5mg IM (max 7.5mg/24 hours)
- NB Younger patients may need higher drug doses
Indications for Referral to Psychogeriatrics
- Behavioural problems not containable in acute medical ward
- Co-existent psychiatric disease suspected e.g. depression
- Poor response to psychotropic drugs
- Guardianship or other mental health act order indicated
- Alzheimer’s disease modifying drug treatment contemplated
- Direct dial for psychogeriatrician is 34128 (Dumfries, Nithsdale, Annandale & Eskdale) or 34393 (Stewartry & Wigtownshire)
Importance of Good Communication
- This cannot be underestimated when dealing with patients suffering from dementia as difficulty in learning new information is a core symptom of the illness
- All information given to the patient, relative or carer should be recorded in case notes
Outcome
- Delirium can persist for weeks after the cause is treated
- Important to be aware that patients who look as if they may require long term nursing care may ‘recover’ several weeks after discharge from hospital
Links
- Think Delirium – Health Improvement Scotland[pdf]
- NICE CG103. Delirium – Diagnosis, Management and Prevention. July 2010
- NICE CG42. Dementia – Supporting People with Dementia and Their Carers. Nov 2006, updated Mar 2011
- Delirium Management Comprehensive Pathway from the Scottish Delirium Association