SCE Geriatrics: Mastering Delirium Management Guidelines

SCE Geriatrics: Mastering Delirium Management Guidelines

Delirium is a common, serious, and often reversible neuropsychiatric syndrome that disproportionately affects older adults, especially in hospital settings. For candidates preparing for the Specialty Certificate Examination (SCE) in Geriatric Medicine, a thorough understanding of delirium – from its recognition to its nuanced management – is absolutely critical. Not only is it a frequent clinical presentation, but it’s also a high-yield topic for examination, testing your ability to apply guidelines in a practical, patient-centred manner.

Why Delirium is an SCE Hot Topic

Delirium carries significant morbidity and mortality, leading to prolonged hospital stays, increased risk of dementia, functional decline, and distress for both patients and their families. As a geriatrician, you'll be at the forefront of identifying and managing this complex condition. The SCE will test your grasp of evidence-based guidelines, your diagnostic acumen, and your ability to formulate comprehensive management plans, always prioritising the least restrictive and most effective interventions.

Key Principles for SCE Success

1. Early Recognition: Delirium is often missed, particularly the hypoactive subtype. Be vigilant!

2. Systematic Approach: Have a structured method for diagnosis and management.

3. Non-Pharmacological First: This is the cornerstone of delirium management.

4. Treat the Underlying Cause: Management is futile without addressing the precipitating factors.

5. Multidisciplinary Team (MDT) Collaboration: Essential for holistic care.

Understanding Delirium: Definitions and Diagnostic Criteria

Delirium is characterised by an acute disturbance in attention and cognition that fluctuates. It's not a disease in itself, but a manifestation of an underlying medical condition. For the SCE, be familiar with:

• Acute onset and fluctuating course: Crucial distinction from dementia.

• Inattention: Core feature (e.g., difficulty focusing, easily distracted).

• Disorganised thinking: Rambling, illogical flow of ideas.

• Altered level of consciousness: From lethargy to hyper-vigilance.

The Confusion Assessment Method (CAM) is the most widely used and validated bedside tool for diagnosing delirium. Familiarise yourself with its four features:

1. Acute onset and fluctuating course.

2. Inattention.

3. Disorganised thinking.

4. Altered level of consciousness.
   Delirium is present if features 1 and 2 are present, plus either 3 or 4.

Unravelling the Causes: Etiology (The 'DELIRIUM' Mnemonic)

The SCE often presents scenarios where you need to identify the likely cause. Think systematically using a mnemonic like DELIRIUM or I WATCH DEATH (Infection, Withdrawal, Acute metabolic, Trauma, CNS pathology, Hypoxia, Deficiencies, Endocrine, Acute vascular, Toxins/Drugs, Heavy metals).

Let's use a simpler framework for exam purposes:

• Drugs: Polypharmacy, psychoactive medications (anticholinergics, opioids, benzodiazepines), new medications, withdrawal (alcohol, benzodiazepines).

• Electrolyte imbalances: Hyponatremia, hypernatremia, hyper/hypocalcemia.

• Lack of drugs/Pain: Uncontrolled pain, constipation, urinary retention.

• Infection: Urinary tract infections (UTIs), pneumonia, sepsis, skin infections.

• Reduced sensory input: Poor vision/hearing, unfamiliar environment.

• Intracranial pathology: Stroke, haemorrhage, tumour, meningitis, encephalitis.

• Underlying medical conditions: Myocardial infarction, heart failure, renal failure, hepatic encephalopathy, anaemia, thyroid dysfunction.

• Metabolic/Other: Hypoxia, dehydration, malnutrition, sleep deprivation.

SCE Assessment & Investigations: A Practical Approach

When faced with a patient with suspected delirium in the SCE:

1. History: From patient, family/carers (onset, baseline cognition, recent changes, medications, substance use).

2. Clinical Examination: Full systemic examination to identify signs of infection, dehydration, organ dysfunction, neurological deficits.

3. Cognitive Assessment: Use CAM. Consider the 4AT (4 A's Test) as a quick screening tool, especially in acute settings.

4. Targeted Investigations: Guided by history and examination findings. Standard initial screen often includes:

   • Bloods: FBC, U&Es, LFTs, CRP, Glucose, TFTs, B12/Folate.

   • Urine: Dipstick and MC&S.

   • Imaging: CXR (for respiratory infection), head CT/MRI (if neurological signs, focal deficits, or no clear cause found).

   • ECG: To rule out cardiac causes (e.g., arrhythmia, MI).

Mastering Management: Guidelines in Practice

This is where the SCE tests your clinical judgment and adherence to best practice.

1. Treat the Underlying Cause (Primary Focus): This is paramount. If it's a UTI, treat with antibiotics. If dehydration, rehydrate. If medication-induced, review and stop/reduce offending drugs.

2. Non-Pharmacological Strategies (First-line and Continuous):

   • Environmental Modification: Quiet, well-lit room; consistent staffing; minimize noise and disruption.

   • Reorientation: Frequent verbal reorientation (person, place, time); clocks, calendars, familiar objects.

   • Sensory Aids: Ensure patient has and uses glasses, hearing aids.

   • Sleep Hygiene: Encourage normal sleep-wake cycles; minimize nocturnal disruptions.

   • Mobilisation: Early and regular mobility if appropriate.

   • Hydration & Nutrition: Adequate fluid and food intake.

   • Pain Management: Assess and treat pain effectively.

   • Communication: Calm, clear, simple communication. Involve family/carers.

   • Avoid Restraints: Physical restraints can worsen agitation and increase complications.

3. Pharmacological Management (Last Resort & Caution):

   • Only for severe agitation/distress: When non-pharmacological methods fail, and the patient poses a significant risk to themselves or others.

   • Low-dose antipsychotics: Haloperidol (0.5-1mg orally/IM) is often used, but be extremely cautious in Parkinson's disease or Lewy Body Dementia (avoid typical antipsychotics; consider Quetiapine or Olanzapine at lowest effective dose).

   • Benzodiazepines: Generally avoided as they can worsen delirium. Reserved for specific situations like alcohol or benzodiazepine withdrawal delirium.

   • Start low, go slow: Always use the lowest effective dose for the shortest possible duration.

   • Regular review: Re-evaluate the need for medication frequently.

4. Proactive Care Planning: Develop an individualised care plan with the MDT, patient, and family. Anticipate potential complications (falls, pressure ulcers, aspiration).

Navigating Challenging Scenarios for SCE

• Delirium superimposed on dementia: Common and complex. Management principles are similar, but prognosis may be poorer.

• Hyperactive vs. Hypoactive Delirium: Hypoactive is often missed due to quiet presentation; hyperactive is often agitated. Both need urgent attention.

• Ethical Considerations: Capacity assessment, best interests decisions, particularly if agitation necessitates medication against a patient's wishes.

Conclusion

Mastering delirium management for the SCE requires not just theoretical knowledge but also the ability to apply a structured, patient-centred approach. Prioritise identifying and treating the underlying cause, champion non-pharmacological interventions, and use pharmacotherapy judiciously. By adopting a comprehensive and compassionate strategy, you'll not only excel in your examination but also become a highly competent geriatrician, making a tangible difference in the lives of your elderly patients.

Good luck with your SCE preparation!