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Uh Hi guys. Can, can you hear us? Just let us know in the chat? Perfect. So um we'll just give it a couple of seconds to see to let other people join up. Amazing. Okay. So, um so welcome guys. Today's the our second webinar of the Beat Me series. Um Today we've got doctor talked with us is one of the associates specialists at Royal Sorry uh in Geriatrics. Uh The talk today is gonna be about delirium. We're just gonna be looking at sort of the types of delirium, recognizing them investigations and management. I hope you guys learn a lot and with that, I'll pass it over to doctor talk. Okay. Thank you. Bye, welcome everyone. Um This is a, this is a very common, quite unappreciated condition delirium. So I hope I can drive from a few key messages to you about diagnosing, first of all, and then hopefully also some helpful tips on how to manage the patient's who are difficult to manage. Um The ones who is in the title uh suddenly become confused and often become disruptive, although they are in a minority of delirious patient's. So without further a do um say the title was patient become confused. The confusion is actually it's not a diagnosis, it's a presentation and what we need to appreciate that a confused patient is actually having an acute brain failure, which I think in a context of how how they react to acute heart failure or react to respiratory failure. Uh It's very different to have a react to delirium. Uh I don't think we necessarily appreciate how serious that is, but that's a degree of severity can often be just the same and the patient's often have very poor outcomes if they become delirious in hospital, say what happens in acute brain failure. Uh The patient basically has an impairment of the consciousness and a change in their cognition. And this change is an acute thing that is not accounted for the previous pre existing dementia that the confusion or uh brain failure, such is a longstanding gradual thing. Patient's who have dementia is an underlying condition is are of course a much higher risk of developing uh delirium. So the main components of delirium are this fluctuating vaccine remaining mental status in attention and they had sort of disorganized thinking. So when you try to communicate with this patient, they often ramble, they don't listen, they wear off and uh in attention is probably sort of important thing just to, just to be keyed up to um maybe if I say pay attention to inattention, it's going to stick in your mind. Um to think about delirium. If the patient is not quite with you, when you uh when you're examining them, it's very common up to 10% of air daily patient's in E D will have delirium. And uh and as with many things in the early, they don't present with anything specific. Those of you who have done geriatric medicine or been in the uh admission side of the hospital. Uh We know that patient, that air daily patient's are nine out of 10 times come in. Uh they come in with a fall. Uh and it's often, you know, we look for injury, we look for uh various your BP is necessary, but the fall is just the symptom and the same with the same delirium is a symptom. You need to need to kind of look for what caused it. Is it what, what is the relevant? Think here if a patient has hearing impairment, if they have difficulty with the A D S or if they have a cognitive decline in history, uh you need to have especially heightened attention to, could this patient be delirious? Um regardless of how they behave, most patient's are hypoactive. And this is quite important because when you are busy in the hospital, the hyperactive patient's are the ones who are flying there quietly. They might look like they're having a little sleep, they don't complain, they don't press, they buzz is they cause no issues and you're going around paying attention to all the other patient's, the hyperactive patient's, you are not going to miss because they are the ones who are climbing off the bed who are pulling out their catheters, they're pulling out, they've influence and, uh, and they are the ones that are causing, causing the problem that, uh, the nurses will call you to hyperactive patient's will not be causing much problem. They are in the majority and consequently, because they don't cause any issues in terms of taking up staff time. Uh they diagnosis is often missed unless you think about it positively. So when you take a history uh of an elderly patient, whether you on call uh in the wards or on call at the front door, pay attention to uh day background, hearing idea difficulties, cognitive decline, difficulties. An idea is actually uh often marks a cognitive decline. We very often have patient's who haven't got a diagnosed dementia, but they do have dementia, they kind of been going under the radar and now they presenting either in a hyperactive manner or a hyperactive inattentive, not quite there uh manner. So you have to have positively thinking about it to diagnose it. And of course, there is mixed delirium, then the two hyperactive and hyperactive um signs uh kind of interchange vary during the day. So when you look at the symptoms, the symptoms will be affecting cognitive function, the patient's perception, the physical function and there'll be social behavior changes communication changes and there will be issues with inside. So every area of the brain is affected. And uh again, going back to the hyperactive hyperactive uh differentiation. I highlighted on this slide, the things that are easy to miss the version concentration, the slow responses, the reduced mobility, reduce movement, the changes in appetite, not eating, just, just not really. Um you're just going downhill in a non specific way, often being withdraw socially, not interested in going out. I had a lady just the other day where the family notice that she's just shutting down. Now, this lady was 94 years old, completely independent with the daughter supporting in terms of just doing her washing and a bit of cleaning. But otherwise she could look, she could dress, she could walk about. So she was in that independent in that way, but she was just slowing down. And, uh, the daughter is just said that she's getting too or she's going to die, which is, which is true further down the line. But because this was a completely new thing over the last few weeks, there are some basic things that we can check for. And when we did that, we actually found very treatable causes of this slowing down. But all she was doing, she didn't feel like eating much. She didn't want to go out for lunch with her daughters. She didn't want to do the things that she used to enjoy until a couple of months ago. So very nonspecific symptoms just to uh add into that. So when we, when we have hallucinations and disruptive behavior, the other end of um uh delirium. So hyperactive delirium with hallucinations and the hallucinations can be a symptom of a few things in context of cognitive problem. It could be, you know, part of a delirium syndrome. It could be part of dementia with Lewy bodies and where the patient is actually various times of the day. But a lot of the times they see things that are not there, but they're not actually delirious. They just have this condition called Lewy body dementia and particular patient that comes to mind. I had a lady in a clinic who had Lewy body uh disease and she, she had sort of mild parkinsonian symptoms and then she'd come to clinic and when I asked her about whether she ever saw things that other people didn't see. She would say. Well, yes, I do. I've got those little green people sitting on the top of each fence post, but I know they're not really because I lift my walking stick and I take it through them and, you know, I can't knock them off, they just remain sitting there. So I know they are not real. And of course, as the dementia progresses, uh some of these visual hallucinations can become frightening. But uh that is, you know, for that you need a history, culture, history, normally to find out how these things progress. But this is a chronic thing, dementia with Lewy bodies. Uh Another condition is sundowning, which happens in patient's with dementia who start to have behavior problems towards uh as the sun goes down. So late afternoon, early evening, when the behavior changes so much that it's really quite difficult to manage. But again, it's not an acute delirium. It's part of the uh dementia uh condition. And of course, there are, there is a psychiatrist illness which is much more complex. The hallucinations are not just visual but often auditory hallucinations or tactile hallucinations. And again, for that, you often will have a psychiatrist underlying history. So history is very important in this patient. So how do you make the diagnosis? As I said, the most important thing is to think about it. Uh Could this patient have to liam? So if you look at what, what is the underlying functional status before they came in? How much have they needed? Have they got the hearing gauge? Do they have hearing impairment? Uh have they got a diagnosis of dementia? And then, then you start communicating with them how much attention they're paying? What are the symptoms they have. As I said, you need to get the history and then we have some screening tests that we can use and actually put it down uh and clarify the various symptoms and score uh the patient based on these symptoms to make this a bit easier. Those of you working in the UK uh and those of you who have studied UK based medicine um will have come across with the short camp, it's used in various parts of the word. Um It's basically you answer yes or no to a selection of questions. The key words again highlighted in red. Uh The key is that the disturbance in uh cognitive function. Uh The new confusion is recent. Uh it's fluctuating, there is an impaired attention which you can test by asking the patient to count backwards from 20. You can listen today speaking, you try to strike up a conversation and see how they follow your trip thought how current their speech is, whether they are sleeping lethargic or stuporous or completely the opposite. They they off in tangent and uh they're hyperactive. So any of those, if the patient score three or more delirium needs to be considered, the key is the acute onset and the short duration. So once you, once you got that, I need to figure out what's causing the problems. And again, uh with elderly patient is quite difficult because, you know, they are the ones who, who can have a heart attack without chest pain. They are the ones who can have infections without the temperature rise or a particular white cell count rise, for example, and they are the ones who want to complain about things. They might say that I can't be because uh they have a notice, they're cognitively in bed. So you have, there's a mental checklist you need to run through and have to have at least a framework in your mind. What are the things you're going to check for? So, let's say you are believed to go to one of the wards because a patient is accurately confused and uh maybe disruptive or poverty sleepy need to check. Has there been any medication changes? Yeah. New to the hospital. It's quite possible that we changed from medic medications. It could be because we haven't prescribed stuff that the patient normally is on or more often we added in some new drugs that the patient is now reacting to. So you need to look at what they came in on and what are the new drugs that were given to them once you've done that? Uh, and you know, stop some stuff that can potentially upset the patient's mental status. And I have a bit of a list later on in the presentation. Then you need to think about, is there an infection anywhere? And again, the patient might not be coughing or having the temperature. So you need to listen to their chest. You need to see what's happening with the urine. You need to see if they emptying the bladder. You need to look at their skin to uncover the patient, in particular, if the patient has been in mobile or wheelchair band prior, uh, then you need to turn the mobile, have a look at the pressure areas because they can all be source of, uh, you know, entrance for an infection. You need to have a good feel of their tummy. Uh, you could have, uh, call a cystitis, for example, without an awful lot of other symptoms, you need to look for any soft tissue swelling, um, check for neck stiffness, check if they tolerating the light and if they're diabetic, always, always remove the socks and have a look. If they've got any nasty looking ulcers under the socks or, you know, if they got dressings on various sources, they need to come off and have a look. Um, it's useful when you are in a hospital setting just to look whether they had any cultures done recently of anything at all because that will also give you an idea that this could be related to a positive blood culture, urine culture yesterday when I didn't have a result yet. And now we have one you need to do, uh, once, once you're kind of happy that you cover the infection site and then, uh, you need to do a quick neurologic exam. Now, this can be difficult because if the patient is running around climbing of the bed, that's quite difficult to do a targeted neuro exam. But what you can do, you know, watch how they move, uh, if they're walking off, you can see that they're mobilizing fine. So that's great. Uh, you won't be able to check for all the reflexes, etcetera necessarily. But, but you can make quite a reasonable assessment of the overall mobility and then you look for facial asymmetry. Uh you can try to track the eye movement and then, and if you have any sort of issues that maybe, maybe this could be a neurological problem and the patient will need a brain scan, then we might have to act in a patient's best interest and bring that about on the some sedation. But that will only come uh only become an activity once you run through your whole checklist, then you need to think about any metabolic reasons. The most hospital in patient's will have recent bloods. If they don't have any recent blood, you need to get some recent blood. And I think you're looking for our major derangements in sodium Cassie. Um glucose levels, tirade function dehydration could just be a simple dehydration. So, uh you need to see that there's no acute major change from what's normal for this patient. And then cardiopulmonary checks, the vital signs ought to be checked. As I said, patient's can have silent m eyes, especially if they're diabetic at Delhi and female. It's very common. So the absolute minimum is to check their vital signs, try to get an E C G or look at recent TCG. And uh and sometimes it is, uh I put it in brackets because I don't think it's right to do troponin and D dimer on every patient who has delirium. But it is something, if you know, if you're coming to no conclusion, running down this list, it is something to consider. Sometimes stds don't show changes. Patient can have non ST elevation M eyes. And uh and then of course, there is uh going back to the drugs to some extent there is toxicity or there is withdraw and uh you know, patient's can withdraw from alcohol. We do see a reasonable number of alcoholic uh early patient's now. And uh if they don't have insight, they probably won't have admitted to using much alcohol. So if you don't have a good history, won't necessarily know that. So then you have to go after the history again. So they could be withdrawing from alcohol, they could be withdrawing from drugs even most commonly. Uh they withdrawing from some drug that they normally have and they haven't prescribed or, or they have become toxic on some drug and some, some patient's may become toxic at therapeutic drug levels. Lithium or digoxin could be one of those drugs that can cause the Librium at therapeutic levels. So it's worth bearing in mind. So those are the things that you can actually do some tests for. But there are other things, simple change of environment in a patient who uh who has an underlying dementia often coming into the hospital, middle of the night lights are on, they don't know where they are in our particular a any uh the department is so big now that if you use a large speaker system, uh communicate with colleagues and call colleagues to the main desk, that can be incredibly confusing and disturbing for patient. So if they don't know where they are, it's uh it is understandable for, you know, with the underlying conditions, they don't always complain of pain. So, pain is another thing that we need to think about and especially if the patient came in, fallen, have a good look for injuries and move everything gently and just watch for facial expression because even the patient is not crying out or not verbalizing. I do have pain in my hip when you're moving them gently and you're watching their face, you can pick this up, try to sit them up, see what happens today back, try to turn them over and while you are turning over, it's worth checking for constipation. Constipation is a very common presentation in the elderly and, and often causes union retention in ladies as well. You can't always feel a palpable bladder, especially if the patient has a bigger tummy. You won't be able to feel a power people bladder. So you have to have uh this is one of those things that you need to take off. I checked for it. I regularly do bladder scans on a post take ward round. It's very quick to do and, and gives you an answer and then you take that off if there is no significant retention and uh let's say the patient came from a care home, er, they stayed, the bowels have been working fine. You have kind of checked that off and that's okay on a, on a ward. Um, this can, of course, also happen on a ward, especially if you've given medication that cause constipation in patient's uh morphine uh derivatives, for example, uh or post operative states. Uh the patient can have delirium for a whole array of reasons. They can have a post operative. You know, there's still the effect from the anesthetic, uh frequent move of environment from war two theater to uh pasta perative recovery, uh place recovery room and then coming back, they might in pain, they might have become constipated, it might have gone into retention, they might be developing an infection, you know, a couple of days after operation. So all of these things need to be positively thought about and sometimes the patient has a primary cns infection. They don't see that very often in the elderly, but it can certainly happen. They can identify like this meningitis in black. I've got a few things that are less common and hypoxemia, hypercarbia. You would see that from uh just taking the vital signs and you know, failure is not very common, but it's, it's recognized and on the metabolic uh things if, if you really run out of ideas and going through all of this, it is something to think about. And some people present like this because they having a seizure, just a change in behavior. And, and that's how a seizure manifests. Um less frequently they may have paraneoplastic syndrome or they might have had afford that nobody knew about. And that day in a concha state and present with the actual delirium. So there's a, there's a brief list of drugs uh that can cause uh new onset confusion in patient's most common ones are opiates or nonsteroidals as well. I think opiates obviously more often um anti cholinergic drugs. We very often news drugs for blood dysfunction, oxybutynin, particularly authority and sometimes, and there's a whole array of antidepressants that can cause uh issues. And of course, many patient's are on a combination of all of these. Uh So anything that interferes with the brain, any sedatives, hypnotics, antique um persons, I talked about litum earlier and even the drugs that we give for uh improving cognitive function coordinators inhibitors uh can have a side effect of causing more confusion and and not working for that particular patient and steroids, especially at high doses. So for example, if you have a patient who presented with giants arthritis or vasculitis of some sort and uh or uh or they had a severe infection there. COPD patient and you have to stick them on 30 mg of uh cortical steroids, they can quite easily become various on the back of that. So I touched quite a bit on the investigations. I think this is just sort of checking list checklist basically. So you, you need to see what are the recent blood repeat? Anything that you're not happy with? Check the blood can't check the uh metabolic uh parameters, check for a urine and even a delirious patient can tell you whether the urine passing urine is painful or not, but uh not, not in every case. So it's useful to, to check, to check a urine and send it for culture. If the patient takes drugs where we can check the levels, it's useful to do that toxic screen, toxic screen. Sometimes appropriate blood gas will tell you quite a lot. You know, it will certainly give you a lactate. And if that's high, you, you then need to think about positively uh more of a septic and effective picture blood sugar as well. You will get from that tyrant function test. So hyper title it is uh would would make the patient obviously uh more hyperactive. The opposite is true for hypothyroidism. And then of course, cognitive function will be affected longer term by hypothyroidism and uh B 12 deficiency B deficiency will not give a patient A Q Tillery. Um E C G I mentioned and then any sort of imaging. So if you suspect uh if you suspect just infection, the patient, we need a chest X ray. They may need an abdominal ultrasound, they may need an X ray of any of any of the bones that might have broken if there was a full uh leading up to this process and more further down the line. Uh then all of the previous things have uh brought you to no conclusion. Then uh and, and the CNS infection might be possibility, then they may need an LP or sometimes they may need an E E G to see the other day actually, status epilepticus with, with a confusion picture. I think what's, what's important is not do once you find a cause not to stop there because because a lot of the presentation is non specific, I think it's very important to have this little niggling thought in your, in your head. What else can I be missing? Is there anything else going on? So, you know, if the patient is hypoxic, they're delirious, you find their saturation is 88%. They got crackles at the right base. Great. They got a chest infection. You give them some antibiotics and you move on. But that doesn't mean that that patient hasn't got retention. That doesn't mean that that patient hasn't got some new drugs that we give for whatever the initial presentation might have been. So you still have to run through this checklist. And is there anything? Yes, that, that I need to be thinking positively and do something about it. It's always helpful to sit down with a patient and be friendly not just with delirious patient's, it's good to be friendly with all other patient's now sitting down. It's a difficult one, isn't it? Because you're not really meant to sit on the hospital bed for infection control purposes. And, and I don't advocate that you do this all the time and sit down because it is, it is an issue, infection control. But sometimes, uh in order to achieve what you need to achieve with the patient, you really have to get down today I level and not communicate down to them but communicate at high level. Uh be friendly and nonthreatening, use a calm voice and then you may need to do it in stages, you get to some point and if the patient uh then shows that they really don't want any more of you and they start to become agitated, you move back and then you come again a little violator than they calm down after all of the things that I highlighted before and you haven't come to any conclusion. Uh It's useful that you go back to the drawing board, repeat the vital signs, see if anything is, is changing and reassess the patient and think of, you know, other less obvious schools. It's going down that list. Say as I said, all the patient's are, are a bit tricky because they often don't look too sick, especially if they're hyperactive. Uh often delirium is the only sign of any sort of acute e on us. So, um they might not be short of breath, that pneumonia, they might just be delirious. They might not have any urinary symptoms. They might not have any abdominal symptoms. They just, they just hyperactive or might not show any, uh might not express any pain having, let's say sustained an impacted femoral fracture, they just become delirious. Um, as I said, hyperactive is more common but uh you know, hyper hyper active patient's, they are agitated, they sleep and wake times reverse, they get irritable, they can look anxious, emotional labor, hyper, sensitive to light and sands and especially the hospital environment that that could be a difficult aggravating place. So all the symptoms don't sing in every, are not seen in every patient and they don't rule with the little in or rule delirium out. Uh And sometimes what you have to do is just describe these are the symptoms, this is a change, this is new. So I'm looking for the underlying course is um as I said, the most common presentation just being quiet, withdrawn. I like to drive from the message or delirium is actually linked to much higher rates of mortality and nursing complacent. So when I compare it to art failure and respiratory failure, brain failure is actually really severe and serious. Say I'd like to spend a little bit of time on uh scanning. So because it's brain failure, so we ought to look at the brain. But do we have to look at the brain. We don't have to scan everybody and uh we have different scans at our disposal. So we scan to use. That's also an important consideration. I would think that if a patient has been an inpatient and and you find some obvious cause is they probably don't need to be scanned if the patient, uh you know, you try to start treating that obvious cause and and obviously monitor the patient and see how things improve. And uh a city scan may not be needed at all. If this is a completely new presentation to a any and we don't know the background and there haven't been any witness, let's say a neighbor picked up this patient on the street or the police picked up patient, we will have to scan, there's always a possibility of trauma just because we don't know about it. It might still have happened. So, um you know, nobody is supervised 24 7. So that's always a possibility. So that needs to be born in mind. And as you know, elderly patient, as we grow old, a brain shrink. So there is more space around. So you won't necessarily have a focal neurological deficit. If you got a chronic subdural, uh you might just develop a delirious state. Obviously, if there is any neurological deficit that will require a brain scan, any patient has reduced G C S that also uh goes into this, you know, it goes in the same category. And of course, if the patient is not improving, in spite of the therapy that you implemented for what you thought was the cause of the delirium. Now, it's quite difficult to do a scan in an agitated patient. We call it a normal sign. I'm sure many of you have seen brain scans where the whole thing is just entirely useless is just wash that picture because the patient was moving, moving his head. So sometimes you need to apply light sedation to allow for a CT scan to take place CT scan or MRI scan. So that's the other question. Now, an MRI is better to image the posterior oh foster area. It's better to image sub acute or acute stroke or any inflammatory lesions. But an MRI is a claustrophobic place, it's a noisy place and that's not going to improve the patient's where being definitely not going to improve data Librium unless they totally hyperactive. In which case they go in a scanner and there's no issue if they're hyperactive, that's not going to happen. So definitely will have to sedate the patient if you want to do an MRI in a short term, uh to get a basic idea of anything major a city scan is normally enough. And if the city scan is negative, you're treating anything else that might be obvious patient's not improving, then then uh you might need to go down an MRI route and sometimes you need to do that under sedation. So, treatment, I've got a few slides on treatment. I don't know how I'm doing for time. Hopefully. All right. So, questions, um, in this day and age we're very much pressed for discharging patient's as soon as possible. So, the question is, can we ever discharge a patient who has delirium? Let's say that don't up in a, any, um, they are, uh, they seen by and now they have a of acute geriatric team at the front door. I see a patient who's delirious. I have a good idea why they might be delirious. What am I going to do? Can I treat this patient at home or do I always have to admit a patient? So I have discharged a few patient's with acute delirium from the front door. It is doable but uh certain conditions have to apply and uh and it's not a simple thing to do. So home environment is always better for a patient to settle down. I think that's number one, the patient needs to be in the vital signs, need to be stable and obviously a patient cannot be left unattended. We need to nervous. The dominant course, start the treatment, give that effective treatment and with appropriate care and supervision and and supervisor, you know, being able to cope with the patient as the patient is it is possible. I remember sending home in a deli chap with the very obvious during a tract infection his daughter was looking after him. He was quite a big guy and when I saw him in a, and he, he, uh, he looked that he could be managed, but of course, the nature of delirium that it fluctuates and uh we need to be very clear with the relative or the carer that even though they're very keen to take, sometimes they're very keen to take the patient home, you know, and, and I think okay, I'm, I'm really happy to work with that. However, you need to be prepared for, you know, being awake all night. Can you cope with that? How you're going to cope with that where you be able to supervise this person and when things become really difficult, you're gonna have to call an ambulance and you need to come back to hospital. Uh, so we have to safety net it, uh effectively if you send anybody home from the front door and we need to have some kind of follow up plan. But it, it is, it is possible I had patient's who managed to stay at home because they didn't deteriorate to an extent that it was very difficult to manage. They settled better and I had patient's where they're the first presentation was what I saw. But actually they, they delirium relating to the anus got worse before it got better. And that worse point was bad enough. It's not to be able to managed to be managed at home And so that's probably um this case one, I think I probably just started to talk about how do you establish? I did establish if you see, let's say there's an 84 year old man in a any newly confused, being diagnosed with the uti. How do you establish if a patient has a uti are or if it's got anything else? And if you assume the diagnoses, right? What is it that you're going to do next? Um I've welcome any suggestions I gave you some clues. So feel free to type into the check check box. I'll give you a little time. Yes. You want to get a urine culture. It's not always easy to get a urine culture from these occasions because because it's not that easy to p on demand. So how would you get a urine culture if you can't get a urine culture if the patient is not passing water? Any suggestions? Yeah. So you check for it. Yeah, you would check for the public tenderness. Would you check? Is there anything you can do to see what's happening in the bladder? Yeah, you could do a bladder scan it in an elderly man. I would always want to do a blood scan. Uh Even if I'm quite confident that it's that the bladder is okay because often you have gas food bows overlying and it feels like that it's resonant, but actually underneath there is a full bladder. So it's really good to do a blood scan and, and try to get a urine culture. It's from an agitated patient. You probably don't want to do an I/O catheter. If the patient isn't agitated, uh that is something that could be done to get a, get a urine culture and, and try to have more targeted treatment. You start the treatment anyway, but the subsequent culture will help, especially the patient isn't improving. Subsequently on the treatment started, you know, if they have a resistant uh bug bug, especially the patient isn't improving. So uh on the treatment started, you know, if they have a resistance, I done something weird here. Uh Sorry, I think I recorded that anyway. So um okay, I'm not quite sure what happened to that. So once you, what are you going to do? Give the patient any antibiotics, you can suggest any antibiotics, you can switch it. She would normally give the patient um whatever is the hospital guideline. And in the rotisserie, we use micro guide for that. The first line depending on, depending on uh what patient you treat. Uh If patient's our uh our first on antibiotics, trimethoprim for an uncomplicated during infection, that's often fine. Uh In Adderley men, you would want to give that for at least seven days because they have uh they very often have complex urinary infections because of the enlarged prostate. So uh seven day treatment is appropriate. Nitrofurantoin is not licensed for seven for three day treatment. Sometimes in women, three day treatment is enough. But uh nitrofurantoin you would not want to give for three days because that's not licensed for that. It does need to be a seven day treatment. And another thing that we often give, if you're not totally sure, uh we often give you Amoxiclav. Uh It's not necessarily the right thing. Uh It's a, it's a broader but sometimes you have on the system, you can see previous cultures and it can give you a bit of an indication. Okay. And uh and as I'd be discussed earlier, if the daughter is happy and staying with him, we can have this discussion whether it's safe for him to go home. What are the risks? What he might be doing overnight? So she's fully aware of that and she knows what to do and she also knows how to, what to do if she's not coping. Okay. Um So you always try to treat the cause uh and don't treat totally blindly. So that's, that's a difficult one, broad spectrum antibiotics. You know, if you, if you decide on that, you really have to have a reason why theater there really is an infection. If you ever managed to get, if you don't have any culture results, at least you have try to get a urine sample. You got a blood culture that's in the making. If the patient had, let's say black ulcers, you got some swabs that are brewing. So you send all of the things off that can be cultured and, and you should have uh in the blood results. You should have supportive evidence for an info information. You should have a new CRP rise. You should have a wide say rise most of the time. Uh You may have a temperature rise. So you won't necessarily get everything in a daily patient, but completely blindly that you know CRP is normal white count, normal temperature, normal. Uh And there's just no sign of infection. I wouldn't give a patient broad spectrum antibiotics. So try to culture everything and keep on monitoring and just control the symptoms. Look at the drug chart, stop anything that's new and potentially confusing. Uh And the patient can do without uh intravenous paracetamol is quite a good uh energetic uh as opposed to, you know, move in that might have upset the patient. Uh some, yeah, we've been using quite a lot of uh morphine patches and uh I don't know how they're you are of that, but morphine patches take 48 72 hours to become fully effective. And during that time, uh we often bridge with all our morphine. So uh the confusion or a change in behavior either being hyperactive or hyperactive or a mixed picture often happens after 48 to 72 hours. So that will be the new drug. It might not have been something that you started this morning. It might be something that was started a few days ago, uh, on the top of the previous medications and often, uh, the patient's are on four or more medications. So they already have a polyp pharmacy on the top of that. Adding a new drug, especially if it's an opiate or a new antidepressant or any drug that interferes with the brain function, anticholinergic. Then that is likely to be the corporate diverse stopping now, very few drugs that the patient can't do without for a couple of days, you know, obviously antiepileptics in an inactive epileptic wouldn't want to stop. But um the patient is supervised and say there's very few things that they can't do without. If that is a potential corporate. Uh you have to make sure that there is adequate fluid and nutrition, especially in a any uh when the staff is really rushed. Uh just look what's on the desk. What's on the patient desk? Have they got a jug, have they got a cup of water? Um Have they give, have they given them the right uh cutlery to eat their food? I thought to patient just the other day in a any you were given no spoon to eat their porridge. That patient is going to remain hungry or uh they were given a very tiny spoon to eat a sandwich with which it's just completely inappropriate. And uh and I'm told, but this is the only thing we have, but that cannot be right, even need to do better than that. We do have normal. So I spoons in the canteen or wherever you need to go to the kitchen and get some proper stuff and feed the patient and make sure they get enough water as well and then need to get history and figure out just have suspicion is there are dependency in the past. And I said, if the cause is not a apparent you go back and, and look say, um there's another case I thought of uh you called your patient 86 year old lady on a surgical ward after a right hip replacement, she's fine, fallen on the floor. She's screaming, she's apparently disorientated and she's very uncooperative. So what are you going to do with this patient? In the meantime, I just have to log back in because I'm ensure myself out. So I'm sorry about that, but I will do that now. Um Yeah. So what are you going to do with 86 year old lady? Was your first step? This is quite a common occurrence. Yeah. So what are you going to do with? Look for head injury? Yes. Assess from hep two term. Yeah. So you do that. Why would she be screaming pain? Yeah, that's probably the most likely thing. She's screaming for pain. Hip replacement is quite a big thing. So, um if you were to look at the blood of this patient, uh it will probably sure really high crp, high white can't, high, everything. So that's not going to help you looking for anything. Yes. But if, if she just gone down because she's delirious from potentially, from, uh, as I was discussing earlier from the change of changes of environment, the, the medication given during the operation, she is now done. She, she might have a very prosthetic fracture, she might have some other injury and you need to really go from head to toe or gently pressing and look for any kind of deformity. Um, and there might not be any deformity at all. So you try to look, start touching from the head, moved an ac gently, see if there's any tenderness, anything showing on the face. Uh, look what she's doing with her arms. Is she moving her arms? So she's fallen on her arm. Uh It's an, it's uh all the way down to her, to her toes. You look for any kind of injury and plan for an X ray or anything that might have been hurt and drug chart. Yes, you would want to review the drug chart, but before you do that, so she is on the floor, she still disorientated, uncooperative. You have examined her, you don't have to toe, you have to do something. What are you going? Are you going to give her anything before you move on to the drug chart too? For reviewing it? Because that, that's what, that's what the nurses want. You to do. And that's the, uh, exactly. So you need to, you to give her some pain relief. She can be on the floor as long as she's safe and it's, uh, you don't want to move her until you're sure that by moving her, you're not going to cause further problems. So you can examine her on the floor, put a pillow under her head, examined her carefully. Then there's a way of getting her into the bed and be happy with that, but she probably really don't algesia for it. So you can give her some analgesia, you can give her intramascular jeezy idea energies here. You can offer her liquid on algesia, liquid morphine. Um and then you can look for the causes of why she's on the floor. What made her go down because you know, there is a reason why she is she just, you know, trying to be too ambitious and uh and go to the toilet without supervision because she feels she's got a new hip now and let's get going or is she on the floor? Because she thought she was as well. She's completely confused and fell out of bed and uh we got this problem. So you still need to look for the causes of the original fall and then the effect of the fall and deal with all of it. And okay, so you do some imaging and part of that imaging might be a brain scan, I think the more important imaging uh is imaging the bit of the bone, you know, bit of the body that might have got hurt in the meantime, but if there is head injury, obviously, vehicle vehicle for uh brain scan, especially the patient is taking any uh anticoagulants, often this patient's ability of fibrillation and very many off tomorrow, neither bofferding ordered or ac most most often are on the door like nowadays. So the patient's, of course, it's not always very happy for treatment and they can be very disruptive and very difficult to deal with. And you might need to treat them in their best interest under common law and you might need to hold them in hospital. You might need to use some temporary restraint, uh gently holding down the patient's arm while administering some essential drugs. If you know, if they look like they might be hurting themselves or hurting other patient's and sometimes you have to administer drugs in a covert way. So they don't know what they are taking, what's important that you always have to document this very clearly. And the relatives need to be informed and the staff needs to be on board with this. So I've got, you might want to take a screenshot of this. Um, I've got some drug doses here of the various things that we can use and some tricks. Um, we often use a small dose of haloperidol half to 1 mg either orally if the patient's happy to take it or intervascularly. The liquid haloperidol is actually a colorless liquid. There's no smell, no color. So you can stick it in a glass of water and you can give another small dose a couple of hours later. Usually patient doesn't need more than 4 mg in a day. What you have to be aware of is that some patient's need very little and other patient's need a lot more. So start low, go slow. Uh patient can be completely flat onto milligram and another patient might need six and they still not flat. So, and you can't predict how a patient is going to uh respond. The drug has quite a long half life. So uh don't pack it in because it will take 60 hours, uh you know, for, for the patient and for the drug to reach half life in the bloodstream and that's a long time. So the effect might be several hours later. Uh The cumulative effect, obviously, if patient has a diagnosis of Louis body dementia or Parkinson's disease, uh this is not a good idea and you should stick with short acting benzodiazepine, like LORazepam, half a milligram, opportunist of 3 mg a day long acting benzodiazepine is you would use in alcohol withdraw. And uh we have a, a system of how to prescribe clot as a box side for those patients'. Atypical antipsychotics can also be used, you know, sometimes if the patient has uh an acute infection that's going on and the delirium is going on. Sometimes they need to be on, respected on for a short period of time. Half a milligram is a small amount similar in effect to Haloperidol va milligram again, it can be um can be deleted in water, black coffee or juice prochlorperazine. We don't often use block repairs in England. Uh We would normally use uh LORazepam as the first line haloperidol because because then you don't need to worry about Lee by the OPD Haloperidol and respected in a second. So prochlorperazine is not very often used and I'm conscious of the time a few more minutes. Um Let's just go through this quickly. Five o'clock on a medical ward, 88 year old man from home. He's got non dementia came home, came in after a fall. He's about to go home. He scared me is restarting and now he's causing havoc. He's wondering around he's getting into other patient's beds. He's talking to himself. He's gesticulating all over the place and he's getting more and more agitated, helping for the door. What is the thing that you're thinking about? Bear in mind that he's ready for discharge except the care is going to start tomorrow. So if he's ready for discharge, I assume he had uh he had his bloods, his bloods are fine. E C G has been fine. His ops have been fine. How do you approach this patient? What is it that you're thinking about. So thinking about the timing. Um yeah, constipation could be, I would hope that he would have been checked out for that when he first came in. So think about this is late afternoon, he's old and he's got non dementia. So this will be quite a typical presentation for sundowning. Uh And because of being in the new environment in the hospital and because we don't know, uh so he probably has sundowning at home as well, but the hospital environment would make this worse. So uh you still have to have another look at his vitals and see whether you need to repeat anything. But if he's got blood from that day and they all fine and his vitals are okay. Chances are his son dining. And uh so you might need to sedate him briefly. Uh We would, we would try to have supervision. A Nonviolence sedation is always a resort after we try to reassure the patient, okay. It's not something that's really reached for first, but that would be an important differential diagnosis. This isn't necessarily to really delirium. This may just be sundowning. Um You need to be aware of uh doors which uh as an abbreviation in this country for deprivation of liberty and safeguarding. We use this for 80 plus old patient's who lacked capacity either due to an acute mental illness or a chronic mental illness. And shares we can use this in delirium if the patient needs treatment and we can't get it done because they will not cooperate. Uh That includes if they want to walk out or if they refuse the relevant treatment, you need to have the family on board and we need to be sure that the patient hasn't refused in advance. You know, if they haven't signed the paper to say if, if I become very confused, I want nothing to do with any medical person because you need to respect those wishes. And the treatment has to be in the best interest of the patient. The need has to be urgent and there's a limited period that you can use this for. It's only seven days. So in summary, uh just summarizing all the treatment you need, if, if we resort to actually medication, we always have to the smallest effective dose for the shortest time and slowly reducing as the patient improves because there is a risk of always uh relapse. Okay. So your patient improved, the infection is getting better. You start bringing down those little doses of risperiDONE or hollow parador LORazepam, whatever they had and just keep on monitoring and then we need to plan for discharge. You often find that the therapist can be a bit reluctant, but all the family can be reluctant because it is, it is a scary thing to have delirium. So we need to have really clear communication with the family and and with the therapies and often the patient's are much better in their own environment. So, uh that's an important thing to emphasize. Yeah, if your next time you're on a board, it's good to look around and see how orientated your patient's are. Like, have they got access to a clock on the board? Do they know? Are they near a window? Do they know if it's light or they, a lot of the times, especially in our Ianni, there are no windows, so there's no idea. The patient cannot tell, you cannot figure what time it is. Uh So that's very disorientated. Have they got their hearing gates? Have they got their glasses and on awards? It's important to have some clear signing nice bright areas that differentiate between areas you see those yellow chairs. Um And it's useful for the patient's not to be restrained and allow them to wonder about in a safe way. Sometimes it has to be supervised. But then we need to allow for that because if you restrain them, they may become very much more agitated and it's just some quite nice uh you know, signposts, you can put up like that orientate ing one that tells you what's the day today? What the season gets a share. This is, what's the food? I like the little bus stop that's painted on this particular department departments wall, but a patient can sit down and uh you know, imagine that they're waiting for the bus because as long as they can't, they are safe while you're treating them. And that's the last of my slides. I don't know if any of you like bedroom beer. There is a funny one called delirium treatment, which I thought was quite a, quite an amusing one. So, uh, don't drink too much of it is very strong and you might end up having a delirium. So, thank you for your attention. And I think we're just out of time. Uh, I don't know if our session is still active. I hope it's still active and we can wrap it up. Yep, it is active. Any, any questions from anyone or two, it'll yeah, anymore questions. Very happy to answer. So there's a head of one question here is sedation only for agitated patient at risk of hurting themselves. May I know please any other circumstances? We could give sedation. So, sedation is the way we go about it. First of all, you don't, if you have an agitated patient, it's important not to contradict them, not to increase the agitation. So if they say, I don't know, I'm being chased, I'm seeing things, I'm not uh important to be nice and calm with them and you start talking to them, you reinforce. I said, look, you are in the hospital, I'm the doctor. You come and be treating you but you don't, you don't get uh interaction and, and try to contradict the ideas because you're not going to get anywhere and we, uh we like to have enough stuff to kind of walk around with the patient. If the patient is walking about, that's, uh, that's prefer to sedation. Either patient is so agitated and we don't have enough staff and patient is about to walk out or about to decide that he's going to pick a fight with another patient in a bed. Then we will have to use sedation. The other times when you would want to use the nation is, if you think a particular uh test is really important and the patient is so uncooperative, you're not going to get it. So I said you might need to sedate for a CT scan. You might need to like to sedate to take some blood or just to examine the patient uh to get an E C G to get some vitals. If they're kicking and screaming, that's going to be very difficult. So if you give light sedation and they just get a bit calmer, then you have a better chance of examining for any injuries, any source of pain, extra, okay. Any other questions at all? I think that's, that seems to be about it. Um Thank you so much doctor for, for, for taking the time to give the talk. It was really quite insightful, given that delirium is something that's not covered quite so often. So I'm sure everyone found it quite helpful. Thank you. Thank you for listening guys. Please fill in the feedback for me. It helps, helps us improve. Uh It's sort of helpful for everyone involved. Um And you'll get your certificate of attendance as well when you um when you fill that in. Okay, thank you and have a good evening everyone. Thank you so much, doctor. Tough bye bye now. Also guys, we've got, we've also got our next session coming up on the eighth of December. It's uh it's a respiratory focused session with one of our consultants doctor or Itchy. Um It's gonna be covering uh sort of the acute presentation of a patient below saturations. So please do, please do uh sort of look into that as our and sign up if you uh if you're interested, I'll drop the link for that too. Oh, there, there we go. Thank you very much. Ok, bye now. Bye bye.