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Hello, everyone. Uh Welcome to this evening's talk. It'll be delirium on the acute take um with doctor, she's a specialty registrar at West Suffolk. Uh I think we've got a good amount of people here, so we'll start in just a minute. Um Hopefully at the end of the talk, I'll flash up a um feedback link which provided all goes well, will then automatically generate a certificate for you guys. So provided there's no technical difficulties, then I'll try and pop that up at the end. Um I'm gonna hand over to Doctor Keats now who hopefully is ready? Um Can you hear me? All right, ma Yeah, all good. You're good to go. Great. Ok. So um my name is Laura. I'm an ST six in Geriatric medicine currently based at West Suffolk Hospital and I'm going to talk to you this evening on delirium on the acute medical take, which I'm sure is something that we have all come across. So to begin with, because I'm a Jerrys trainee and I love Jerry's. Um And I'm always curious, I would love to know what you guys think about when you think about geriatric medicine. And so I was wondering if you could just start by doing a quick minter um, on your thoughts when you hear geriatric medicine. Um, what sort of things come to mind if you could all just pick up a few bits and pieces? That would be great. Yeah. Excellent. Yeah. So the, these are all very good. You're all being very nice. You know, it's anonymous. So you can say boring, you can say complex. Yeah, this is, oh, this is lovely guys. I like this very much important. Excellent conflicts is a really good one. Yeah, so there are a lot of conflicts within um care of the elderly and it is a real balance. Um One of the things that I love about geriatric medicine is within those conflicts. You can really employ a lot of common sense. And um actually, it's something that you guys as f ones can be doing really well from day one, you know, as a geriatric reg you don't need to be particularly senior to be able to make a real difference in this specialty. Ok. Um So that's great. Thanks guys. So um like I said, that was, that was partly for curiosity and also because I expected you to all say actually, it's a bit of a heart sink, but I hopefully will explain to you this evening why actually it's really important um how we approach medicine in older people. Um Arguably from my point of view, even more important than a lot, a lot of the other specialties. And um it's very important to know how to do this. Well, so obviously we all know that older people are making up an increasing percentage of the medical take. Um We can see that day to day in our lives and like I say, they are really complex patients. And because of that you as an individual can have a much more significant impact on the outcomes at the end of the day for these patients. So, you know, if you imagine that you go and see somebody who has a not particularly significant upper G I bleed, and you've got a standard pathway in your mind that you're going to follow. And if another person goes and sees that patient, they'll probably end up with a very similar outcome. Certainly, initially, um you know, they will all have the same kind of things put in place. But actually, when you see somebody who's an older patient who's got a lot of things going on, if you go and see them and you do a quick larking and you end up with collapsed query cause as your diagnosis, um and kind of a half budged together management plan involving antibiotics and maybe some furosemide, then actually, um you know, that's going to have a really different impact on that individual than if you've taken a really thorough history, you've assessed them fully. Ok. So you can from day one, make a big difference to these patients. OK. And so that's why it's really important that you do geriatric medicine well. And like I say, hope to address that heart sync that I know a lot of people have when it comes to geriatric medicine because it's quite, it's really interesting. The patients are really interesting. Um And it is complicated, there are complex things in conflict like somebody said, but um but actually that, that's what I find very satisfying about it. So we're gonna work through a case study. So it's um a not particularly different presentation. I mentioned to them what you guys hopefully will have seen um a lot of the time. So imagine that you are the f one doing the acute take. It is a Thursday evening. It's around nine o'clock and you've been asked by the med reg to clerk this gentleman. Ok. So he's an A&E referral, 89 year old male found lying on the floor confused. He's got some diabetes, high BP osteoarthritis. And you can see he's on tamsulosin, Ramipril, Metformin, oxybutynin and paracetamol and Amy have done some blood. He's got slightly raised white cells, 22 white blood cells, 11.8. His creatinine is a little bit higher than his last creatinine and he's got a urea of eight. They've done a CT head because he's in A&E. Um and that's fine and they've given him some IV co amox clav for a UTI because there was some mention of him having recently um had a uti diagnosed by the GP. OK. So hopefully, you know, a a not unimaginable scenario for you guys. So you go to Clark Kim and Laura, we can't see your screen anymore. It's only on one slide. What? So what's happened? Maybe it's me. No, I think is it everybody? No, it it was me. Sorry it OK. Is everybody else? Ok. Yeah, lovely. So um are we all right to carry on that? Yeah, yeah, please do. I accidentally paused the video? Ok, good. Um So you go to see this jean. Um Yeah, he is really confused. He's not answering any of your questions. So you just have to document poor historian and when you go to examine him, he is thrashing around trying to climb out of the bed um very modelled and so you just document it's moving all four limbs and um you know, you're, you're a good doctor. So you scoff at a and's diagnosis of the uti and say, oh, you know, you should really have a chest x-ray as well. Um Pat yourself on the back for getting that and that's fine. And you asked for a year in MCN S again, very pleased with yourself about that. Um And um you continue with the car and you give him a bit of fluids because of that Urea and you leave him and obviously we we all know that I'm presenting not brilliant management, but I will hold my hands up and say as an F one, I am pretty sure that I did not dissimilar management plan to this. Ok? Um And so we're gonna take a step back and have a look at how this can be done differently in a moment. But first of all, we're just gonna imagine then what could happen for this gentleman. So you've seen him in A&E and he has then moved onto the acute medical unit. And later on that night, around two in the morning, one of your colleagues is called to see him because he's been really agitated and he's ripped out his IV lines fluid everywhere. Um The nurses aren't very happy and want something given. So you the F one prescribes him some LORazepam. A few hours later, he's then moved on to the short stay unit because they need to free up beds in the AM U. And um the next morning on SSU he's drowsy still after the LORazepam, but he keeps on trying to climb out of bed. And eventually he has a fall and he fractures his neck of femur and he ends up with a very prolonged hospital admission, complicated by aspiration, pneumonia, um, other hospital acquired infections, um ongoing confusion and eventually he is discharged back to his nursing home. He's still very confused, is discharged, sorry, back to a new nursing home. Um He had to go somewhere that could meet his needs of a very agitated, confused patients. Um And he's unable to mobilize anymore. He's always transfer. So this is an extreme example in some ways, but in other ways, actually totally imaginable and realistic. Ok. So let's go back to the beginning. We've got this gentleman found lying on the floor confused. This is all the history we've been given. All right. Um We know he's got slightly raised inflammatory markers, um creatinine ever so slightly off baseline and a bit of a raised urea. So we go and see him and, um, start with a history and actually looking at his notes, it turns out this gentleman is from a residential home. So I hope that by now all of you that have done clerk jobs are aware that if somebody is in a care home, there is somebody around 24 hours a day and you will always be able to speak to somebody to get a collateral history and you should always call and get a collateral history. Ok, day or night. It is not acceptable to say that you couldn't get a history for somebody who is from a care home. All right, obviously, there are times where you can't get a collateral and if you've got somebody who's elderly who's got, you know, a wife at home in her nineties, you're not gonna call her at two in the morning to get a collateral history that can wait. Ok. Um, but it should be a priority on your management plan to call first thing in the morning. Ok. So with this gentleman, you're able to contact the residential home and you get through to a carer there that knows him very well. And she's able to tell you this that earlier in the evening he was found on the floor of his bedroom and, um, they didn't see what happened, but he's never fallen over before. He hasn't got any formal diagnosis of dementia, but he is always a little bit muddled but not very much, but he was much, much more confused than usual. Um, today, he normally gets around in the room, just furniture cruising. But when he goes longer distances, he uses a frame and he sits out every day in the day room, very interactive and engaged. Has family come and visit, watches TV, plays games, reads books. Um, very much has a good quality of life there. He doesn't have any issues with his continence. And over the last few days he's been having urinary frequency. So the GP had started him on some antibiotics for a urinary tract infection and he hasn't had his bowels open for five days. That won't be information that she will volunteer. But you do need to make sure when you call the care home, you always ask about bowels or go into that more later. So you move on to examination and again, you know, as we said before, he's very agitated it is difficult to examine him. You struggle to listen clearly to heart sounds because he's shouting and thrushing around. Um, but you are able to do a four A T which we will come back to you later and you do make sure that you manage to thoroughly assess him and comment that there is no sign of any bony injury which is really important. So, um, you know, you can, you can say that he's straight leg grazing, you can move his limbs around and make sure that there's no obvious pain. Um What you don't want is to miss that somebody has a fracture and that's happened just a few weeks ago here. Um We found that somebody had been moved to the ward who had a fractured neck of femur several days earlier. And um when that happens, obviously, patients have far, far worse outcomes, both in terms of mobility and mortality as well. Ok. Um So you've commented on that you are able to lay a hand on his abdomen and you can feel actually that although your examination is quite limited, he has got a rock hard suprapubic area and you can feel a palpable bladder. And so you ask, or maybe you even do yourself for a bladder scan. Um And he's got 620 males residual in his bladder. You also with the assistance of the nurse, manage to do APR which may or may not be realistic. Um And you find that he's got solid stool, hysterectomy, you can't advance your finger. All right. So you can see we've got a lot more information now about this gentleman. Ok. Exactly the same case. Um, just a bit more effort and thought put in. All right. So now, rather than saying uti we can make this lovely diagnosis list and I, I love a list. So he's had a full secondary to delirium. He's got urinary retention. And we can say that as a result of constipation, which you know, is a leading cause of uh urinary retention, particularly in men anticholinergics. So I don't know if you remember back, but he's on oxybutynin, um which is given for urinary incontinence for urge incontinence. Um and is a horrible medication. We'll talk a bit about anticholinergics later and it wasn't listed in his past medical history, but we know he's on Tamsin. So he must have some BPH as well. You can say constipation is a big issue. And really the headline for this gentleman is that he's got a hyperactive delirium on the background of mild cognitive impairment. OK. And hopefully, you can all see how that sounds a bit better than confusion. All right, it is well thought through and it gives us some things that we can think about. So we also, I like to and you guys should all start trying to whenever you say that somebody has delirium, think about why they have delirium and so you can put list of precipitants. So this guy, I put urinary retention, constipation, pain, anticholinergic environment and possible infection. We'll talk about precipitants a bit more in a moment. All right. So um delirium. So if we go back to um the minter again. Mm Sorry. So, moving on to the next slide, could you guys try and put in what you think are the key features of delirium? OK. So I would say there there are four kind of cardinal features of delirium um with a potential fif so I'll just give you a few minutes to do that. Lovely. Yeah, probably avoid the word crazy. But um I see, I see where you're coming from. Confusion is probably a bit better word or yeah, agitation um is a safer alternative. Lovely. Yep. So, you know about hypo hyperactive, really good. Yep. Vers inattention um is good. Excellent. I'll just give you a couple more minutes. Yeah. Memory behavior. Acute. Yep. Excellent. OK. So we'll probably leave it there. So you've got a couple of the, the key features there and some really um useful things to think about. So um the key features of delirium uh that it's acute. Oh I ha I've missed, missed that one actually on the slide there, it's acute. Um there's confusion, altered cognition, it fluctuates and then the other key one is altered level of alertness um which isn't in this slide. I apologize, but they are the four main things. OK. So it's new confusion. It fluctuates rate and it's associated with a change in how alert somebody is if somebody can be um hyperactive. So somebody um mentioned before that it's hypo and hyperactive delirium, which we'll talk about in a moment that they can be more sleepy or more agitated and then they kind of optional fi is inattention. So, um I'm really impressed that somebody put that um put that up, but it is a cardinal feature of delirium is that predominantly um inattention um is something that you see far more so than in other forms of um cognitive issues. OK. So the nice definition is um that it's a common clinical syndrome characterized by disturbed consciousness. So that is the level of alertness, cognitive function or perception, which is confusion has an acute onset and a fluctuating course. OK. So those 44 key things. All right. So, oh, I'm just giving you the answer there. Um patients uh who come into the emergency department with delirium are known to have an increased risk of death. So, again, if we go back to the minter, um I'd like you to tell me if you hopefully didn't see on the slide. Um How much you think somebody's risk of death is increased in the six months after they're seen in A&E with the delirium. Let's give you a couple more minutes any more response? Lovely. OK. All right. So, no, nobody went to 20% got a couple of people at 35 a couple of people at 51 at 70. All right. So, um, back to the slides. So it is 70%. Um So these are some crazy statistics. I said these statistics to my partner who is not medical, but he, he called me out and thought that I was maybe not using the most reliable sources, but I can, I can tell you my sources as we go. This is, this is all true. So we, I don't think we'll be surprised today that it affects up to half of people over 65 in hospital. But I imagine not many of you knew that older people with delirium in hospital are 5.5 times more likely to die within the next 30 days compared to those without delirium. So it's a terrible prognostic indicator. Ok? And there are lots of factors that feed into that, but it means it's a really, really important thing to know about. Ok. And patients who present to the that sorry, I can tell you that that's from an age and aging study. And patients who present to an emergency department with delirium have a 70% increased risk of death in the first six months after their visit compared to somebody who hasn't gone in with delirium. That is crazy. OK? And um that is, that's a quite statistic in the nice guidance on how to manage delirium. All right. So it is really, really important to identify delirium and label it so that we can address it because it has a huge impact. And I find this absolutely fascinating. So this is a quote from a journal article um in the animal of internal medicine almost 10 years ago now. Ok. So this this also said the risk of death in patients with delirium is similar to that in patients with acute myocardial infarction, Delirium is similar to diabetes mellitus in terms of the severity of associated complications and its effects on healthcare costs. Yet, our approaches to diagnosis and monitoring are markedly different. And I think that is um yeah, so, so salient and it's such a shame that actually that was te almost 10 years ago, that study came out and I think we still have a really, really long way to go in terms of improving how we manage to do. Ok. So it's important to identify and label it. And um I hope that all of you after this talk will do the same. So we mentioned different types of delirium so that we said there could be hyperactive, hypoactive and you can also get a mixed delirium um where people kind of alternate between the two and do if you can do, try and label what sort of delirium it is, it makes you look really clever. Um People will be very impressed as an F one if you do that. Um Also do just try and put a label if you, if you can see somebody who is confused and you think they might have delirium put it down, ok? Even if you're not correct, it's good to show you're working. Ok. The nice thing about medicine is you're, you're allowed to be wrong or have different views to other people. Um, you can use very nice words like suspected or probable or even possible if you're not sure, but make sure if you're thinking about it that it's there so that um somebody is aware and can follow that up and rereview. All right, where delirium gets more difficult to diagnose is when somebody has a background of cognitive impairment and then particularly if we can't get a collateral history immediately, it can be quite difficult to cool whether this is um an acute on chronic confusion or whether this is all just the long standing confusion. But in that case again, you can just say possible delirium on the background of known chronic cognitive impairment. Um If you want, not sure. Ok, so do just please, please please do label it. Don't just put muddled. Ok. The number of times that I look through patients notes and every day it's mentioned that the patient's a bit muddled, but nobody anywhere has ever mentioned the relevance of that. They've just seen that it's an old person in bed and they've thought, well, that's normal for them. Ok? Somebody, you know, people are not just muddled, there is a reason that people are muddled and it may be that they're muddled because they have an undiagnosed dementia. In which case you can say, sounds like they've got, um, a longstanding chronic cognitive impairment, but do make sure that you're thinking about why somebody is presenting like they are. So, in terms of diagnosis, clinical diagnosis and you are mostly going to get it from history. Um, but we do have a diagnostic tool that we can use to support diagnosis. And that is the four A T. Um I don't know how many of you would have heard of this. It's not used that widely actually in day to day practice, but it is the only validated tool that we have for diagnosing delirium. Um We, some of you might have come across the confusion assessment method which is um used, there's a variation of it used in intensive care, but this, this is the validated one that we should be using. OK. So this looks at those key features that we mentioned of delirium. So it's more sensitive than the um AM TS AM TS will do a general assessment of cognition, but it doesn't help point towards whether or not this is a delirium. So this assessment takes into account the of alertness. It does still have a four question cognitive screen, but it also looks at attention specifically. So it weights that much more heavily than the AM TS. Um and you get a score for if it's an acute change or a fluctuating course. Ok. So, um yeah, it, it's really, really quick and simple to do. I have MD CALC on my phone and I just use that to do it. Um, it's only, only for um orientation questions. So the AM T four age date of birth place in year and then the attention questions. Um So in AM TS we do the um 20 to 1 but uh in four A T we do months of the year backwards. So starting with December. All right. So um now we're going to think about precipitant. So OK, back to the men. So um could you put down a few precipitants that you could think of as a cause for delirium? See somebody mentioned that the word reversible earlier, which is very important because delirium is potentially reversible. And so we have to think about what could be causing somebody's delirium. So if you could all just put down a few different causes. Oh, lovely. Yeah. Constipation. That person gets a gold star pain. Excellent. Yet another brilliant one. Yeah. Infection medications. These are all really, really good. Yeah. Changing environment. Excellent. Yeah. And so we talked about, we saw that man had had loads and loads of changes in the middle of the night that really needs to be avoided in a confused patient opioids, malnutrition. Yeah. Excellent hydration. He's really, really good. I'm very impressed. Excellent. Any anymore? Pneumonia. Yeah. So types of infection. Um Yeah. Uti Yeah. So, um, yeah, and hydration and nutrition are often kind of overlooked ones. So that's very good. Ok, excellent. Go back to the slides. So, um, in terms of precipitants, if you like a mnemonic and the British Geriatric Society has this Pinch me mnemonic, um, which I think misses out a few key things. Um, but you can use as a starting point. So, pain and we mentioned pain is really easily overlooked. And if you've got somebody who's confused and can't communicate, um you, you should always be thinking about whether or not they could be in pain infection. Um I think is one that, that I would have expected most people to get. So I think that's what we always think about when we traditionally think about delirium. I think we think about the little old lady with a uti. Um But do you remember to think more broadly as well in terms of infection? Look for other sources, don't just presume that somebody has a uti um And for God's sake, don't do a, you're in dip to diagnose a uti um nutrition really. Um like I say, is often overlooked and not assessed. And um a lot of the medical wards when you go around and do your ward round, you actually have no idea about the intake that somebody is having um nutrition when, when you go through the pinch meal, try and add hydration into nutrition because, um, no hydration isn't in pinched me. Sorry, constipation, I would add in, um, urinary retention. Um, because that's a key one that's missed, I think on pinch me. So, constipation is a really, really frequent cause of delirium. Um, and probably, I would say day to day is actually the thing that I see most, um, in terms of certainly missed precipitants for delirium. Um, and like I say, try and try and if you are using the pneumonic, try and think about bladder and bowels alongside each other and consider whether they're in retention as well. Hydration is really important and that's missed often. Um because we don't look at food and fluid charts. Medication is a really key one. really important that all people get medication review and then environment. So he said, try and avoid meeting these people in the middle of the night. I know it's not your call, but you can put, um put it in your management plan for what it's worth um unit. We know that the more people are moved, the worse their outcomes are. Um And I have often put on somebody's management plan that they should not be outlined even if they're medically stable because moving them to a different ward just because they're medically optimized, could mean that they're then become more unwell and they are no longer able to leave hospital. So I used to work on a delirium unit. So a ward that was specifically dedicated to the management of delirium and for every patient who was admitted to our ward, um we would need to reconfirm the collateral history, make sure we've got a really clear idea about what that patient's life was like day to day before they came into hospital. And you know what they were able to do what they, what they spent their day doing. Because actually if you ask, you know what somebody does with their day, you can get quite a good idea about how bad their confusion is if they've got a dementia because if they're somebody that, you know, they can't move around very much and they're a bit muddled, but actually they can still read a book and watch TV. That's very different to somebody who will sit in front of the TV, but can't actually follow anything that's going on and couldn't have a conversation about any of the plots in the TV shows they're watching. Um, everybody would get a bladder scan, every single patient. Um, because there are so many cases of missed urinary retention in delirious patients and particularly the patients that we were seeing where, um, they were being sent to our ward because people couldn't get to the bottom of why they were so confused. Um, everybody should get a medication review and, um, we'll talk about anticholinergic medications, um, in just a moment that, um, you should be familiar with some of the more common causes are some of the more commonly confusing medications. Um, stool chart, obviously, food chart and, uh, fluid chart, analgesia. Pretty much everybody who came to our delirium unit, we would give paracetamol if there was any hint of suspicion that they had pain, that they might have pain. And the other thing that we would always do, which unfortunately, it's just not really practical in most wards is monitor their sleep. So a lot of patients with delirium have severe day night reversal. And so you might see them, um, see them in the mornings and they're always sleeping. But actually that's because they're then up all night. And so they get, you know, their on calls are getting rang overnight about this very agitated patient and then you see them in the day and they're ok. Um And actually you need to try and address that and flip them back um into the, the correct sleep cycle sleep pattern because otherwise that will just make their deliver worse and less and less. And obviously, it goes without saying that an delirium unit, everything was beautifully signed posted and well lit and we had clocks and calendars everywhere. Um But again, these are things that are going to be difficult to achieve on normal general medical wards. Um, but if you can do, do what you can to try and reorientate somebody that would be great. And I've put a link here to the um, anticholinergic burden calculator. There are lots of medications that can cause confusion and we mentioned opioids, but anticholinergic medications are um a total nightmare. Um We've known now for a number of years that anticholinergics, um which are um, often prescribed for older people, often for urinary incontinence. Um They will make people feel generally unwell, dry mouth, dizziness, they can put people in urinary retention. But we know that there's lots of evidence that they increase confusion and increase the rate of falls in older people. And so, um, standardized scoring systems have been set up to calculate the anticholinergic burden of medications just to kind of use it as a toolkit to guide clinicians in whether they should be reconsidering, um, prescribing certain medications or using certain medications in combination. And this website is very useful tool where you can put in people's medications in combination and you can calculate what their anticholinergic burden is. Um, just to see whether actually their, all their medications are causing them issues. Ok. So we go back to our gentleman, we've got our, our diagnosis. We've said he's got this hyperactive delirium on the background of mild cognitive impairment and we've said his precipitant, he's got urinary retention, ok? Um, secondary is constipation. Um, he's also got pain with that urinary retention. He's on an anticholinergic which isn't going to help with his confusion. Um, he's been moved, uh, moved around, he's in a different place. Um, and that in itself just being in hospital is really scary. You've got a, a vulnerable brain um and he's possibly got an infection. He's got some slightly raised inflammatory markers. But this diagnosis of infection by the GP was obviously made on the basis of the fact that he was going into retention and struggling to pass urine. He had increased frequency as a result of that and was diagnosed with a uti and that is a very, very common thing that happens in the community. So, for our gentleman, now we're going to catheterize him. We, with that catheter, we can get a catheter sample sent off as well to the lab to see if he has grown any bugs going to give him glycerin suppositories. I just want to pause for a moment there because certainly, um, when I was a, an si didn't know, um, why we'd ever give suppositories. I kind of assumed that they were a milder form of enema, but actually, there is a clear indication for suppositories to this gentleman. So, an enema is a liquid medication that goes into the rectum, um, and stimulates the rectum and will help empty it and it's very effective. But a lot of the time if you've got somebody who is really, really bummed up and actually, they've just got solid stools out there at the end of verge, you can't get a liquid medication in. Ok. So there's absolutely no point in giving them a phosphate enema because it doesn't really go anywhere. And in that circumstance, what you need to do is put glycerol suppositories into that stool. All right. So, glycerol suppositories are not a medication, um, to act on the bowel, they are a medication to act on the stool and they are absorbed by the stool and will soften it up and will make it easier to pass. So, sometimes you might need to do is give suppositories and then they might need an enema later, um to clear things a bit higher up. But, um, but certainly you need to ideally be doing a rectal examination so that you know what's there or you can always ask the nurses as well if, if, if enemas failed, were they actually able to advance the enema? Could they, could they feel that there was a solid stool because they will know this gentleman is also going to get some paracetamol because, you know, he was found on the floor. He might have to get some musculoskeletal injury as well as the discomfort from having been in urary retention, but obviously stopping that oxybutynin. Um, and he's going to have an ECG and a longstanding BP because he was found on the floor. Ok. And I'm not the, it's beyond the scope of this talk to talk about falls today as well. But do remember that this is a man who was found lying on the floor. We presume he had a fall, but he may well have had a syncope or a pre syncopal episode. It was unwitnessed. He can't tell us about it. We don't know. So, you know, as a baseline, everybody needs to have an ecg underlying standing BP in that situation and then the key thing we're going to call his next of kin. Ok. It is terrifying for families when they have loved ones admitted to hospital and they are unable to get any information about what's going on because their loved one can't tell them. Ok. Um So we need to make sure that we are updating families, not waiting until they call us, we need to call them and let them know what's going on. And actually, for most of our older patients, we should be touching base with families early doors anyway, to get that collateral history, to get a bit more information. Um And particularly in the older generation, they're often really uncomfortable about asking doctors things and putting us out. Um They still, you know, some of the few people around that might still think that um doctors are these mighty beings and so they won't want to trouble us. So we need to make sure that actually we're contacting the spouses and letting them know and reassuring them and explaining what's going on. And what's really important is we need to explain delirium. Ok. So lots of people will be really, really worried when their loved one has a delirium that they're getting dementia that it's a sign that they've got dementia and they don't know what's going on. So we need to make it clear from the outset if this is not, if this is all acute that this is not dementia, OK. Delirium can unmask a dementia. So some people with delirium will have a drop in cognition and they'll never get back to quite where they were and it'll become apparent that actually it was something going on in the background already. But delirium in itself, it's a separate entity to dementia, we need to explain to families that it fluctuates. So if they come in one morning and their father's much better and they're really relieved that actually, if he's then worse again the next day, they shouldn't be too disappointed. That is the nature of delirium. We need to explain that most people improve that it is a potentially reversible condition. And the earlier that we treat it, the better the outcomes are OK. So if we, if we, if you on the acute medical take pick up on it and we address it straight away, people are more likely to improve for the gentleman that we used as the example in the less well managed case who ended up going into a nursing home and was voice transferred. He had ongoing delirium and persistent confusion and that can happen. Um The longer it's gone on, the harder it is to get somebody back from a delirium. Um and we need to explain that although most people improve, some people won't get back to quite where they were before, particularly if they've already got some pre existing cognitive impairment. Um So we've said for some people, it can uncover a dementia and we can let them know what they can do to help because actually they're desperate, you know, visitors are desperate to try and do something. So just say, you know, what you can do is remind them about where they are, remind them that they're safe, reassure them, reorientate them, let them know what's going on right now. Ok. And ideally if that you have patient information, leaflets and that's a really nice thing to be able to, to give them to kind of give them a bit more information. Ok, something to go away and read about. So for our patient, he's catheterized, he has his suppositories, he opens his bowels, his urine sample doesn't show any evidence of growth. So he doesn't have any unnecessary antibiotics. Um, we make sure that he's only moved from place to place in the daytime. So that doesn't worsen his delirium and he gradually gets better on the ward, um, with support from the family once his bowels are opening, well, we take the catheter out and he's discharged back to his residential home. Um, he's got a plan for memory clinic follow up because of the preexisting memory issues. Um, but you can see compared to this he's had a completely different outcome and all of that has happened on the basis of how he was initially managed. Ok? And that's not because of something that a registrar or consultant has done that is because of the difference that you guys can make, ok, when you're Clark and when you're seeing people just gonna really, really briefly touch on this because I feel like this is something that as an f one is slightly terrifying. So just as a final thing, the acute management of agitation when you get called to see somebody on the ward. All right, it is something that unfortunately, you guys will be, um, disproportionately called about. It is something that, um, that always goes to the most junior member of the team and you'll get a call overnight from the nursing staff saying this guy is kicking off, nobody can sleep. Can you come and give him some sedation? You should really, really try and do whatever you can to avoid giving sedation to these patients because they are really, really high risk for having a fall. Um, and you are just going to increase that risk of them falling. Um, if they're drowsy and still thrushing around. Ok. So try and do what you can to do non pharmacological management first. So, you know, speak to the nursing staff say, is, you know, is, is he comfortable, is he in pain? Make sure you're addressing all those issues, um, for reversible cause of delirium. If there's nothing reversible, make sure you're doing all the environmental stuff. Make sure if he, you know, if he's a bit anxious, reassure him, get a cup of tea. Um We used to have patients, um, sat down, we'd give them folders to look through or um sheets to fold up, you know, some kind of activity if they're awake and they're struggling to get to sleep. If you really, really need to give medication, the nice guidance states that you should be giving haloperidol. And this is a really, really tricky thing because um there is not enough evidence about delirium as a whole at the moment and I'm sure over the next few years that will improve. But currently, the current guidance, um the only intervention that's really been looked at and has an evidence base is haloperidol. However, I do not know any geriatricians that would prescribe haloperidol um for an acutely confused patient, really not, not without extreme caution because of the risk of um side effects, basically of parkinsonism. Um And also because of the risk of an arrhythmia, they can end up with a prolonged QTC. So actually, in reality, most of the time, what we're gonna reach for um is a short acting benzodiazepine like LORazepam, LORazepam like is gonna be what we're going to be giving most of the time. So 0.5 mg of LORazepam um which you can give orally um or you can give intramuscularly if they're not going to be able to take an oral route that will peak two hours after you've given it. Ok. So hold off. Um, being inclined to just give more straight away. If it's a really big man who's thrashing around, then it is reasonable to start with a dose of one MG. Ok. But always, always go slow, you know, go in low and go slow. Um, you're going to get in far more trouble for over sedating somebody who then falls over than you would do for under sedating somebody. All right. And make sure if you do end up having to do that, that is not something that you should be doing routinely. Ok? You need to make sure that you document in the notes are planned for the war team. You need to highlight to them that this, this patient has required chemical restraint because that's what it is. Um And you need to make sure that they are um, make sure that the paperwork is in that they're under adults because we are significantly depriving them of their liberty, ok? And that you're making sure that the wall team have a plan to address all potential causes for that agitation and delirium that you may use your document that the wall team need to tell the family as well in the morning that they've been chemically restrained and you can put in that they may want to consider an antipsychotic. So I'm not talking to you guys tonight about antipsychotics in too much detail because they're not going to be something that you as F ones are going to be starting for delirium. But there is a place for them in the management of delirium, particularly for patients who are having um distressing, altered perceptions and hallucinations. Um And in that scenario, QUEtiapine um or OLANZapine can benefit those patients. It's not like I said, it's not a decision that you guys should be making, but it's something that you could document if somebody's repeatedly having calls made to the out of hours team that maybe they need to consider giving some kind of medication regularly, like an antipsychotic or evening sedation. So maybe they've got that day, night reversal and they're just really agitated at night. And the reason the day team aren't seeing it is because actually they sleep most of the day. Um In which case, um you need to make sure that you're suggesting that they're thinking about giving them something to help with sleep. And just on the, on the note of people that sleep all day, I forgot to mention when we mentioned um hypo and hyperactive delirium, hypoactive delirium has a far, far, far worse outcome than hyperactive delirium because it's often overlooked and you'll, you will ignore the slightly calmer sleepy patient in preference for the the patient that is kicking off. Ok. Um So do remember to look at the sleepy patient as well Alright. So this is the the last poll goes. I just want to know what you are going to take home from this talk. What is your takeaway? I put takeaway there and I imagine you're all starving. Um I'm sorry, what is your take home? Yeah. Lovely. Yeah. So investigate the delirium. That's Grand Cholac history. Yeah. Very good and manage realistically. Yeah. Excellent. Very good. Right. I will wrap it up because I'm sure that you are all tired. So we'll try to, let's make this down. Ok. So take home's key, key thing, diagnose delirium. Ok. Don't just write that they're muddled. Don't write that they're confused. Um, like I say, if it, it, you know, put it out there if you're not sure but possible, probable, but do diagnose it, label it because we need to make sure that we are addressing it because it has a huge, huge impact on mortality and morbidity. And if we ignore it, um, it has far, far worse outcomes because the longer it goes on, the harder it is to get somebody back from a delirium. Do get a collector history. Get a really good collateral history, you know, be able to say exactly what their life looks like exactly what their confusion is like. Um, what they're doing day to day, who's doing their shopping. Um, you know, whether they're getting out at all, what they enjoy doing and communicate. All right. So please try and make sure that you're updating families. It is terrifying for families when their loved one comes in with a confusion. They, everybody is really, really scared that they have dementia. Explain to them what is going on and try and keep them up to date where you can. Ok. All right. Has anybody got any questions for me? No, I'm happy for Matt to pass on my email if there's anything that you want to ask elsewhere. No, if not, then I would just do one last outfit geriatric medicine as, as a career choice. Um It's great. It is the common sense specialty. Um You get to get into real depth with and what's going on with patients. You've got lots and lots of interesting pathology. Um You get to treat everybody as an individual about, you know, thinking about what is important for that person. If you like doing complicated communication stuff, it's very good. And when you're a bit further on in your career as I am, it's really nice to think that as the consultant in that specialty, you won't be getting any calls in the middle of the night, which is great. OK. So I will end my screen sharing. Amazing. Thank you, Laura. That was really good. I really enjoyed that. Um So if there's any questions, feel free to post them in the chat. Um I don't know if you guys can turn your microphones on, but if you put them in the chart, then me and Laura will be here and we can hopefully answer them. I sent, I think I've sent a feedback link to your emails and I, I hope when this um event ends, you should get a pop up telling you to complete it, but either way it should definitely be in your emails. Um So we'll hang around otherwise. Thank you everyone for coming. Thanks to Laura for presenting. That was really, really good. Thank you. And um, yeah, we'll hang around, but you're all free to leave. That's all right. Thanks for coming. Everyone. I don't think, I don't think there's going to be any questions. Let me just see if everyone wants the um, I'm going to end the call. I don't know if we'll both get booted out, but that's great. I'll, I'll see. See you around. Thank you. Well, yeah, I might let me see what happens.