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Summary

This on-demand teaching session hosted by Medical Registar, Mr. A Cash, will be discussing delirium, an issue medical professionals often face. We will be joined by Daniel Tyler from the BMA who will be discussing the services they offer medical students and professionals in the UK. The BMA will also be offering members a 10 lb discount and a free digital support pack. Topics covered in this session include an introduction to delirium, how to assess and diagnose it and the management involved in delirium. Join us to gain insight into this important and relevant topic!

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Learning objectives

Learning Objectives:

  1. Understand the importance of delirium, including the prevalence and risk of life-threatening causes.
  2. Learn to assess delirious patients, interpret vital signs and lab tests associated with delirium.
  3. Identify the different types of delirium and the symptoms associated with each type.
  4. Identify the appropriate investigation and management strategies for delirium.
  5. Understand why indemnity is important for medical professionals and learn about the products and services available from the BMA to support this.
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Computer generated transcript

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The following transcript was generated automatically from the content and has not been checked or corrected manually.

um, so Hi, everyone. My name is a cash, um, the medical history who has kind of coordinating this webinar series that we have happening every week on Wednesdays? Our topic today is on delirium, But just before we get into that, we've got Daniel Tyler, who's from the BMA who's just going to who? It's just going to say a few words were very much thankful for the b m a sponsoring these webinars and I will send it over to Daniel Tyler. Thanks. So yeah. So you've seen the post a few things in the chat and there's also a thing on the screen. Um, so if you use that QR code, we'll send you a report back, so it doesn't mean you're signing up to the membership. It just means we're sending you sort of digital support back, regardless of whether you're a member or not. So it's free to everyone doesn't mean you're signing up. Um, usually we give you a truckload of pens and the different freeways at you. But we can't do that. Can't be there. We just want to give you something anyway, so, yeah, QR code will be in the top corner throughout the presentation as well. So you haven't done it yet. As I'm moving on, you can do it while I'm talking hundreds. So Yeah, so I'm done. I'm just going to talk about being a membership. I'm sure your members or you've been a member at some point. So you know, a bit about, um, what we do and what you sort of get as a member. So true. This is a bit of pressure, and I'm hoping you might also find out something new. So obviously the trade union and, uh, professional association doctor's the med students in the UK um, we act as the voice of the profession, representing you individually, locally and nationally, on all the issues that affect you. Um, so just to speak a little bit around the coated you may have seen different BMA representatives on the news over last year, and we obviously voicing the issues surrounding the pandemic with particular focus on, of course, on the protection of healthcare workers, you can visit our website and we have got a dedicated part of the web site too coated. So if you want to see what we're doing to address or ongoing issues health care workers on a daily basis. Um, you can do so. We also have a 24 7 emergency helpline for advice on PP and others are coated concerns. So this is again it's free for for members and nonmembers. So if you have any concerns at all, anything ahead of vaccinations around vaccinations, pee pee, or just anything until you can get in touch with us. So going back to what we do more generally, um, we aren't indemnity company, so we sometimes get confused mg and MPs. Um, but we don't deal with patient complaints Were here solely to look after you. You're working conditions, so things like pay contracts, your wellbeing and also your professional development. So we understand sort of things that you might encounter, particularly when you become a junior or even or even now sort of ending med school so we can give you advice on the issues you might face. So this can be anything from from working hours to relationships with senior staff. So just keep us in mind, and we can take some pressure off you. If you're facing anything you feel you need support with, um, a big part of what we do is obviously supporting you with employment issues. So just ahead of starting F one, you may have heard of heard of our contract checking service, which can save you time and potentially quite a bit of money. Um, it's probably the key tool that you'll you'll use if you use B M. A service is this year. Um, so we'll check your contract in five working days compared to the national model that we negotiate. Um, and if there's any discrepancies, we can help get it sorted so they don't always mean to. But trust can sometimes slip in extra things. You're contract or or change wording, um, to mean sort of the opposite of what it should do. Um, so we just want to make sure your contract's correct and you're getting paid What, you what you should be. So it's quite staggering. But 2020% of the contracts we checked for F one last year were incorrect. So so that's as high as one in five. You, um, and it's it's just too high of a number, So if you guys will join and send your contract, then we can we can make sure that you're getting what you should be from the get go, preferably before you signed it as well. You can also check your roads compliant by using our road checker too, which is online, where you can just enter the details and the flag up if it's wrong or not. Um, as you guys are finding of students, um, you're actually eligible for the for the full BMJ to the proper doctor version of the BMJ. At the moment, it doesn't happen automatically. So if you want that if you want to deliver every every Friday, just get in touch with us and say I'm a final year and I want I want that version. Uh, alternatively, you can also opt out and be completely paperless and just have the the new version. Oh, as part of membership as well, you get access to our clinical non clinical learning tools. So you have full access access to BMJ Learning, which has over 1000 clinical non clinical models. There are courses and modules, uh, for example, vision as well, if you still need them and also looking ahead to complete your report failure when you begin your f one. It's all very interactive lots of audio and video module modules to to help you in more sort of stimulating environments. Um, and obviously it's kept very up to date with practice changing developments. And for each module, you can also print off a certificate. BMA Library has thousands of the books and journals, plus recent services, which you can access from anywhere. Library itself obviously close the moment due to coded, but like I said, you can. You can access all the books in the journals anywhere, Um, and we also have a series of webinars, which are free for members. And they're held like throughout the year and also available to view again on demand. If you think about your specialty options already, you can use our specialty exploratory, which helps you get a better picture of what suits you best. So that one's an online psychometric test, which takes about 20 minutes. Complete it last all sorts of work life balance questions. Then I'll give you a detailed report listing your top subspecialties, according to the answer is given. Um, it's very easy to use. Just just take boxes and then it covers all specialties and the reports of very far and give a big analysis of your answers. Um, if any time you feel you'd like to speak to someone about your your wellbeing, Um, even now when you become an f one, um, our services open 24 7 to all the students and doctors. Uh, and you have the choice. If you're speaking to give you a counselor or a peer support doctor, um, these services a completely confidential free of charge and open to everyone, regardless of whether you're in membership or not. So just to wrap up, I put some stuff in the, uh, in the chat some links. So if you're not currently remember, there's a bit of an offer because I've been invited along today. If you use the QR code on the screen or link on the screen, it's the same thing. You get a 10 lb And what about um so this works, uh, the first time joining. And also, if you're rejoining, uh, and obviously you're free to leave it As you wish. Membership finally, students is 3 lbs 66 months. So the 10 lb and a half patches like giving away three months free for Amazon. Um, and yeah, just one last chance to sign up to receive the digital support pack. But the link the link for that, as well is is in the is in the chat. So again, that's not signing up for membership. That is just to get some free stuff for us equivalent to depend on what not, um, that's it for me. Thanks for listening to me. And I'll let you start the session properly. Thank you so much, Dan. Perfect. So, um, what we're going to be talking about today is a delirium for F y. Once I'm a hash, I'm a medical registrar specializing endocrinology and diabetes. Um, I've also done a couple of teaching qualifications. Um, and that's me. Um, just to shout out to the MD you for also sponsoring this event. Um, so just remember that all all F ones do need some form of indemnity as well. Um, as you using the BMA for that support, and they will offer you some free gifts if you sign up with them. We placed a link again to sign up on the chat. So talking about the Lyrica things, I'm going to go through our an introduction of what delirium is different types, how to assess delirious, what the investigation is involved and then the management, and I'll go through each of these sections. So the first question the first thing to consider is. Why is it important? Well, it's important because it's very common as a as an F one on the ward, Whether you're on medicine or surgery. Unless you're in pediatrics, you're going to see lots of delirium. It affects about 20 to 30% of patients in the medical wards and up to 10 to 15% of patients after they've had surgery. Um, particularly old early cohort, and it's frequently associated with life threatening pathologies, and it can be very difficult to assess these patients. The reasons are are they're confused. They can be quite aggressive, and for those reasons, it can be very difficult to examine. These patients will be able to take a history from them, so you might be on court, and this is very commonly that you might receive, Um, so you're bleeding from Sarah, who's a nurse who's a nurse on a corn world, and she tells you this that Mr Andrews is on the ward, and he's presented confused following the fall. His past medical history includes diabetes, high potential dementia, and he's confused. And so you're asked to go attend to him and see if you can provide some help because they're very worried about whether the fact that he's confused might suggest that he is unwell. You're given some observations. His heart rate is 115. His respiratory rate is 20 so he's tachycardic with a borderline normal, normal higher respiratory rate. His BP is 102 over 75 so that's mildly low, and his temperature is is borderline raised at 37.9, that's that's normal. You have a look at him. Look at his investigations from the computer and you find that he's come in. And when he had his admission blood, his inflammatory markers were raised. The mild AKI and the and the C G, which showed a Sinus tachycardia. Well, here are the types of delivery, so different types of delirium include hyperactivity, little hyperactive and the mixed type hyperactive. It tends to be quite obvious patients agitated, psychotic, aggressive. They're often trying to punch or push or kick. They're trying to get out of the bed, and this poses quite a significant risk of the patient. So what they can do is they can fall out of bed and injure themselves. But also they can impact the safety of staff and other patients. Hyperactive delirium is often missed. This is the less lethargic, inattentive patient, the sleeping patient. They're often deemed the good patient because they're not really asking for anything much. They're not really demanding much from the nursing staff for the medical stuff, but that's actually because they're delirious and have no idea what's going on. And that's really something to watch out for. So it's really important that when you do assess the patient on the ward round or assess an elderly patient, you ask them what's happening. Do you know where you are? Do you know who you are? And then finally, there's a mixed type where they can fluctuate between the two. What are the risk factors for delirium? Well, the biggest risk factor is age, and having previous cognitive issues, such as previous delirium dementia co morbidities, are also quite significant risk factor for developing delirious so alcoholism, which can quite significant impact your your brain underlying chronic pain or serious underlying health issues affecting your lungs, your heart, your liver, Um, and then the last thing is frailty. So anything which from frequent falls to being able to function as a normal person can. So needing support with your activities of daily living, including shopping, dressing, washing and feeding, and then finally being elderly. So these are the people that you really need to watch helpful. And make sure you ask, Do you know what's happening? Do you know who you are? The cause of delirium. A lot of people use this acronym, Um, and so what you'll find is when you do meet these patients, when when you bleed about them, you can use this acronym, jotting it down in the notes to see to show showcase that you've considered all the different things that might be causing their delirium. So pain that's uncontrolled and underlying infection. Not having nutrition. So not having eaten or drunk any fluid's being constipated. So it's really important to check the bowel John hydration. Do they have an A k I. Are they tachycardic? Do they have features suggest they're dehydrated medications, particularly things that are sedating and environment. If it's particularly dark, they don't have the hearing aids. They can't see. They don't know what time is. All of those things can make somebody very disoriented and therefore confused. Another acronym that's often used is delirium. So this stands for drugs, dehydration, detox. Uh, so detox mean alcohol, detox or alcohol withdrawal? Electrolytes. So sodium and calcium very much cause confusion. Environment we talked about before. Lack of sleep because of things being very loud. Bell bells, alarm bells and things like that can keep the patient up, not let them sleep. Um, infection, but also infarction, myocardial infarction, renal failure. Um, developing a k I fecal impaction, also known as constipation. A urinary tract infection is something to be aware of, but it's often the thing that everyone immediately assumes is the cause of the DeLaria. So this is usually overcalled rather under called in In this this patient cohort and the metabolic, um so hypoglycemia, abnormal thyroid function and malignancy. So bearing on all of these, these in mind it will tell you roughly what kind of investigations are going to send off. So your assessment. So you're gonna try and take as much of a history of examination as you can in that history. What you're going to do is you're going to see does this. Is the patient experiencing any pain? Do they have any focal symptoms, such as shortness of breath or cough or abdominal pain? Um, but often you can't really get much in the way of history. You also examine examine them, doing a general review of all kind of systems. So are they tachycardic? Are they well, perfused? Do they have any abdominal pain? Do they have any crackles on their lungs? It's really important to try and get them to move all of their four limbs, or at least passively move them to ensure that they you are missing, that they've had a fall and they've injured themselves. And it's the same reason really important to have a look at their head and have a look and see if they've got any bruising or any injuries around the face or the back of the head. In your assessment, you should also do an A M T s or abbreviated mental test score. I'll go into the components of that in a second, and if you've got time, particularly if you're on the warfarin, it's or your parking a patient. It's really important to take a collateral. That's where you speak to the family to work out what is normal for this patient. I mean, normally this confused or is this different? Because delirium is acute confusion, and it might be that actually, they're not delirious. They are just chronically confused and always in the state that you're seeing in front of you except the A. M. T s or abbreviated mental test score. Has these components age, time of day, name of hospital. You have to provide them an address. Um, and often the one that's given is 42 West Street. And then ask a couple of more questions and then recall the address at the end that you can see they need to recognize to people, for example, what you do for work and what one of your colleagues doesn't work as well. The current year, the name of the Queen, their data there, date of World War two or something else, which is culturally appropriate, and then count back from 20 and and then finally recall the address. It's very difficult to remember these off the top of your head. So what we often do is go. We use applications like MG Coke, where you can simply just go on their website or download their app, and you can then just just score on there. So it's much of an easier, easier way than remembering all of the questions. So what the A. M. T s does is it measures cognition Generally, what it can do really well is differentiate between delirium and dementia or some sort of cognitive impairment. So that's important to recognize that what you're looking for is you're looking for an acute confusion. So the M T s is a lot worse than you would expect it normally to be, then that can suggest that patients delirium. But the other thing that we can use is the 4 80 which is a specific delirium assessment tool, and this looks at it's very quick within two minutes. But it's this is whether you think the patients got delirium, whether there might be something else going on, and so that looks like they're alertness, asks part of the A m T s e n t four and then also checks for attention. Um, so in this case, it uses the months backwards, and it asks the question, Is this an acute or fluctuating course? So you can have a chat with the nursing staff or or collateral from the nursing home, the GP or family? Tha work out whether this is something that's a cute or something. That's something that's been quite chronic for many months. The next thing you want to do is you want to send off some investigations. So apart from the observations, you also want to make sure you check the glucose because that's a very easy, quick thing to identify and fix. You don't want to send off some routine bloods, and you want to make sure that human dynamics have also been sent off. So hematinic, meaning B 12 folate and iron studies. TFT Um, so I have a normal thyroid function, particularly hypothyroidism and abnormal electrolytes. Specifically, sodium and calcium can often contribute to diarrhea. It's important to send off a urine urinary um, CNS, and so, if you need it I/O specimen I you put a catheter in patient and then take it out immediately after to get that clean sample, then you should do so. A urine dip in is not usually reliable, because often the patients with delirium are above the age of 65 and above the age of 65. It's quite common for these patients have asymptomatic bacteria bacteria in the urine all the time, and therefore they're nitrite positive on a urine dip that actually don't have an infection. You can't rely on a positive urine dip. What you need to do is either rely on symptoms or treat them empirically whilst waiting for the urine. CNS to Come back You must have a chest X ray on all of these patients. Every patient pretty much admitted under the medical take should have a chest X ray. And then, if you still can't find out, you still can't find a cause of delirium and none of these. None of these seem to apply. Then you want to have a look and see whether whether a CT head is appropriate and I would have a low threshold for considering a CT head in these patients. What you're specifically looking for are any strokes or injuries bleeding? Intercranial hemorrhage is, uh, malignancy. There's lots of things that you might pick up. So you should have a very low threshold if you can identify raised inflammatory markers. Uh, the patient is constipated. All the bloods are absolutely normal. I very much would advice, um, a CT head to be considered. And so that's the treatment algorithm. You want to identify the underlying course you want to support and orientate the patient, and you want to consider medication if necessary, and then explain. Uh, stool is so in terms of the underlying course. That's exactly what what we've discussed already. So it's by sending off all of those by doing a history examination, sending off all of this investigation. You will hopefully find one of those pinch me or delirium causes of why this is occurring. And if it's drugs, you elect to stop or reduce, particularly sedating drugs. So opiates are a frequent thing that will cause both constipation, um, and also cause cause delirium in itself. Electrolytes, sodium and calcium, as I mentioned, are the common electrolytes. And so if you find abnormalities of these, you should escalate this to your shh or registrar to discuss how best to manage this constipation and often in elderly patients. Things like more vehicle or docusate are very helpful. So my vehicle you can give one or two sachets or docusate. You can give one or 200 mg, and these patients can can benefit from these because they tend to be still softener's or osmotic laxatives. Because often with these elderly patients who haven't been mobilizing so much, that still gets very hard. And by giving them a softening or or osmotic laxative, you can loosen things up and help them past. Or, if you find the inflammatory markers are raised or they've got temperature, you should look for an infection and try and treat it. UTI We talked about how it's offered, not a UTI, and you cannot rely on a positive urine dip. You really do need to send the urine MCPs for your more than 65 an age of more than 65 and then nutrition and environment. So thinking about do they have access to food to water to help as well. So any aides that they might have, such as glasses or hearing aids. It's really helpful to orientate these patients, telling them this is where you are. This is why you're in hospital that you're in hospital and this is what we're doing because by frequently orientated these patients, you can make it a lot easier for them to be. They can feel a lot more comfortable about what's happening. One of things that you should try and avoid doing is medication so often. What will happen is your called by the nursing team, uh, your bleeped, because Mr Andrews is very aggressive, Uh, and he's very difficult to manage. He's asking lots of questions. He's constantly calling the nurses, and for that reason they asked whether he could be offered some sedation just to keep keep him more calm. But it's important to recognize that this might actually not be the most beneficial thing. It can make things worse because it can take a patient from being semi orientated to completely confused about what what's occurring in the situation. The times that medication are more helpful or when the patient is more kind of aggressive, so either at risk to themselves or others or two staff, because at that point, avoiding the medication is likely to cause a lot more harm than giving the medication. And if you do, you should aim for low and small doses, and you can always titrate them up. So we often use haloperidol in most trusts. But you can have a look at your own trust policy. And so a small dose, like 0.5 mg orally or I am, uh, so I am meaning intramuscularly, um, haloperidol. You need to be aware that it can prolong the QT, or it can worsen symptoms of Parkinson's disease or Lewy body dementia. So in these patients, you shouldn't give haloperidol, and instead you should use the lorazepam again. 0.5 mg, which you can give I am, or really, And the idea of this is to essentially keep him sedated enough that they are no longer at risk to others or to themselves. So with all of that in mind, let's say I'm the F one who's been called to see Mr Andrews. I just reviewed him, and I'm now going to document to say that I've reviewed him and all of the things that I've done. So what this does is it summarizes all of all of what we just discussed. This is how how one documents, because this was a question that was often asked on when you guys were registering for the Webinar. So I'll begin with my name. F Y. One. What my title is so would cover. So what My role is at that time and the date and the time. Oh, right, that I want to see this patient. So ask to see patient a TSP for confusion by nursing stuff. This is 86 year old male who's come in with a presenting complaint of a fall with a background of type two diabetes, hypertension, dementia with three times, uh, per day package of care. You can also do P. O C. T s. The history that you've managed to get, which is that this patient is aggressive. He's shouting. He's threatening the staff with fists. You're unable to engage in any conversation. There's a M. T s zero out of 10. Then onto examination. It's important to say from from a medical legal perspective, what you were, what were you weren't able to do so that if you didn't miss anything, you can say why you missed it. So in this case, he was pushing my hands away when I attempted examination. But I was sitting comfortably in his chair. So what I did was I assessed as much as I could, which is that I saw him, uh, moving all of the four, all of his four limbs, and seem mobilizing without discomfort. He had bruising over his right lower lips. Uh, right, lower ribs, Probably from his fault. His abdomen was soft and nontender. I was unable to perform a chest examination to assess for any cardiovascular respiratory pathology, but I noted that he didn't have any respiratory distress. His capillary refill time was less than two seconds. And in terms of his observations, when I assessed him, his heart rate was 104. His SATs were 94%. His respirations slightly elevated. 21. His temperature was 37.9. Um, I also obtained the blood sugar, which was 6.4. Reviewing his investigations. His inflammatory markers were raised. And as we noted, uh, when we reviewed the system for his blood test and his creatinine was raised above baseline, demonstrating that he had an a k i. He's already had hematinic and liver function tests as part of his routine bloods. Um, he's already had a CT head as part of his delirium swing. And that's negative. His EKG shows the Sinus tachycardia and, uh, an important thing I could've mentioned here. Or there are no ischemic features because it can be very easy to miss a myocardial infarction when your patient isn't complaining of chest pain or isn't able to complain of it because they're confused and the chest X ray is a poor film. But there's features suggest that there's left basal consolidation. So with all of my assessment, everything taken taken into consideration. My impression is this patient has hyperactive delivery secondary to a community, acquired pneumonia and also has acute kidney injury suggested by his creatinine being off his baseline of 64. And he's had a forward rib bruising with no other injury. And that's really important. I have not noted that he's had any other injuries, such that I'm missing a hip fracture or I'm missing any other fractures anywhere else, which, which are important to pick up an address. So my Plan IV Cokes, the club and fluids, which may be your trust policy for a community acquired pneumonia. I attempted verbal de escalation to the chair successfully and So what I mean by that is that I spoke to him and I, uh, while he was being aggressive and trying to perhaps, let's say, leave, leave the area. And I said, Uh, Mr Andrews, you're in hospital. You're here because you've got a chest infection and we're trying to help you get better and you've been a little confused. It's a Wednesday. The date is the seventh of April. It's 8 30 PM um, and then basically, just keep repeating that until he understands what's happening. Or at least that's soothing and calming voice. And if that doesn't work, then what I will often do is say Okay, What we're going to do is we're gonna get you to sit down in a chair. I'm going to give you some food, something to drink, and often that's enough to basically calm somebody down and get them to sit in their chair and stop being so aggressive because for these patients were confused out of their own environment, it can be so, so scary to not know what's going on. And often that's what's needed rather than medication. But if needed, what you could do is you can say look, if this doesn't work, particularly because he's being aggressive and threatening with his fists, I will need to consider medication. I'll give him regular paracetamol. Um, so one grand Q. D s. Uh, the reason being is that he's got this fall with the bruising, and so it might all be delirium secretary to pain. And I will complete the rest of the delirium screen, which include all those investigations that I discussed before. So thyroid function, test and bone profile to measure that calcium is what's missed. And then finally, I'll send a urine, um, CNS, just in case this isn't a chest infection that's caused these raised inflammatory markers. And perhaps I'm missing a urinary tract infection. And either circumstance, though I'd be cold box. The cloud will cover both, so I'm happy that this management plan will cover all situations. The other thing that is important to do is explain to the family what delirium is because you can often get a lot of complaints, particularly as an F one, so complaints as an F one, the most common reason that you will ever receive a complaint from family or patients is lack of communication, so if you put communication is important, Um, if you if you try and aim to communicate well, then you're very much unlikely to get complaints. So some of the things that I often use are explaining to two relatives that elderly people can get a bit muddled when their brain is under some stress, and lots of things can cause them to have to get stressed. Um, if you get dehydrated, they get constipated. They develop an infection where, as some of us, if we were under stress from all of these things, we would feel a bit unwell. We feel dehydrated. We might feel a bit dizzy. Elderly people. What tends to happen is their brain tends to get stressed, so they get confused. Even after we treat the underlying trigger, It can sometimes take a few days or a few weeks to get better. It tends to be more prolonged when they're not in their own environment, because they're not used to all of where everything is, and it doesn't feel quite familiar, so they don't feel comfortable and therefore they can. Therefore, being in hospital can make things worse, and so it does tend to get better at home. And so even if they do remain confused, it's often better to to get them home if we can't find any underlying causes or we've treated the underlying cause, whereas where it will recover, but it will take time. But it will be quicker than them staying in hospital. And then the final thing to stress is that it can reoccur because it suggests that the patient has a frail brain, which means that anytime another stress or affects that patient, they may get delirium again. And it's important to recognize that so relatives don't get scared or worried the next time it happens, because this can be very, very frightening for relatives. Two and often they will say, Oh, no. Does that mean that he's going to be like this the rest of his life? Well, no, it's the chances are he will recover, Um, pretty well, for the most part, yes, there's a chance that he might not be 100% for a few weeks, but they do. These patients do tend to recover and get that get quite close to the normal state. So just to summarize all the things that we've talked about today we talked about the different types of delirium. So hyperactive delirium where the patient is lethargic, drowsy, uh, not really communicating, not really knowing what's going on. And sometimes this can be really easily missed and hyperactive delirium, which tends to be the one that hits you in your face because the patient is quite aggressive moving around, potentially punching. And so these are the ones you often called about. Whichever the case, the way to approach it is to consider all the different causes, and an acronym like Pinch Me is really helpful for them. What you'll do is you'll do a history examination investigations. So history. Looking through all the symptoms that the patient may complain of, you may not get much information on examination to go through their chest, their abdomen and whether they're moving their limbs. It's also important to do an A M. T s so you can assess how confused they are with you. So the next person who sees them knows whether they're more or less confused bloods, including a full blood cow. You're using these CRP LFTs, bone profile, thyroid function, hematinic all of these standard things to have a look and see what might be. The underlying course. Imaging would include a chest X ray. And if there is any concern that the patients have had a fall, may have injured the head or you're unsure what the cause of their delirium is. All of these investigations come back negative, then have a low threshold for considering a CT head. Be your best off in the in your first couple of weeks discussing this with your Shor registrar. And then, finally, the important thing is to find the cause and treat it, because that's what's going to help. Medication will only be a temporary fixing measure, and it may actually make the patients worse. They're trying to avoid these medications unless it's absolutely necessary because the patient themselves are at risk or other staff members are at risk or there is a risk of harm harm to anyone else. And so that concludes. All of the things that I want to talk about today, and so what's important is that I answer all your questions, so please send in lots of questions, and it's also important that you fill in your feedback. And so we're doing these free webinars to try and help you guys, because I appreciate that a lot of you guys haven't had the same chemical exposure do too coated. And so we're running these webinars, um, to try and help you with that. That's what we're trying to do is tailor it to what? What you want. So please make sure when you fill out the feedback that you give us lots of information and what you find useful, what you would like to improve because we will listen. I will personally be going through all of that feedback over the next day or two, such that we change whatever is necessary for our next session. But also, we need that feedback for our own portfolios because we need to evidence and you'll get the same thing when you're F ones. You'll also need evidence that you have given teaching and you've got four more feedback in the same way that you'll need it. We also need it, so we'll be really grateful if you can fill in feedback. Great, thank you very much. And I think that was a really, really good presentation. Certainly answered all of my questions about delirium. We have a couple which have come in via the chat if you're ready to take them now. Yeah, course. Guys as a cash said, keep them coming. Um, and we'll get to all of you eventually. So, um, first question was, are we requesting an e c g when we review this patient. So I think this was talking about the the simulated patient you had earlier, given the fact that he was tachycardic and you couldn't carry out a cardiovascular exam. And I'm guessing that yes, you would try to do an EKG if he was cooperative. Um, I 100% agree. So if if the patient is part of your basic assessment that every single patient is admitted under the medical take should have an EKG. And if you're concerned in any way, um particularly there tachycardia, you should definitely get in the CD. So if a patient is on, um, well, you should request the CGM. What you can do is when you are on the phone to the nursing staff, asking for the observations. And you know the fact that tachycardic at that moment, you can say, Look, I really appreciate the c. G. I will come as soon as I can because I'm dealing with X y Z task. And so it would be helpful to read that ACG when when I'm there. Yes, there will be times when you can't get an EKG and you can write that down so you can say, Look, I've requested an EKG. I was not able to get a good quality trace because the patient was uncooperative or confused. Thanks very much. And it's just on the on the last point that you said about sort of documenting that you tried and you referred to this earlier about kind of the medical legal protection of having to say that you've tried to do things when you, you know when you're physically couldn't, um I was wondering if you could talk a bit about kind of, um, this might be a bit UK specific, but the dolls. So the deprivation of liberty safeguards if you do have to give somebody sort of medication to calm them down, etcetera. Is that something you can do as an F one? When would you want to get your kind of seniors involved? And when would you consider doing the dolls? Yeah. Um, let's answer those in turn. So if a patient lax capacity, um so essentially, to assess somebody's capacity is those four pills that you've gone through on the S J. T. And gone through lots of many talks. So where they understand the information that you presented to them way that information when they retain that information, whether they can communicate that information back to you. So, for example, if Mr Andrews, you could ask him Do you know why you're here? Do you know what's happening? Um, and he'll say he may say, No, I don't know. I just want to leave the hospital and then you explain, Know you're here because you've developed a chest infection. Uh, I'm the doctor treating you were trying to get you better. And that's why you can't leave because it's quite dangerous. If you leave and we don't treat your infection. Uh, and if he doesn't show any signs of understanding or retaining that, then you can say that he doesn't have capacity to make a decision about whether it's safe for him to leave. It's likely that he probably won't have the capacity to make a decision about other things, too. So that's why we need to think about what we're going to do. It may be in their best interest to sedate them, and at that point, the first important thing is you. Do you? Do you do the right thing for the patient, And so if sedating, they're giving them an IM injection and you need to do all of that, go ahead and do that. Yeah, I would definitely ask for one of your seniors to be there just because you need more hands. If you've got a patient who's aggressive like that, it's very, very difficult for you to do it on your own. And so if you've got a patient who's actively trying to leave and you don't think they've got capacity, uh, or even if you do think they've got capacity, it's important to have another person there. So you can co document saying that this is what we both have agreed on for your safety, particularly first few weeks. You may need to call security, um, and so the nursing team will help you with that, and they're very, very good at helping restrain the patient, safely harming them, and so often, if one's feel really reluctant to call them. But it's important that you do. Call them your estate Joe's or your registrars can help you make an assessment of what restraint is, what restraint you should and shouldn't use, and how to make sure that you maintain the safety of that patient. And then, finally, your last question was on. When to use the dolls so does is very UK specific. It's a deprivation of liberty. Safeguard, um, and what your what that basically says is documentation to say this patient does not have capacity. And therefore what I'm doing is I'm depriving their liberty in some way, for example, stopping them from leaving hospital and putting on mittens or something to stop them pulling their cannula out. And this is necessary because they lack capacity and it's in their best interest. And what that people it does is it goes to various departments to ensure that what you're doing is lawful and appropriate. And so that is definitely some sort of paperwork that does need to be done, and the nursing team will guide you through the hospital specific paperwork and how the dolls process works for your hospital. That's usually done in hours. And that's usually done by the team that no, no, the patient, because they would want to discuss that with the relatives. Um, and the final thing to bear in mind is that does is likely in the next year or two going to be changed to perhaps a new system because it's it's quite an old system, and so they are planning on updating it, although to be fair, they have been planning on updating it for a number of years, so I can't tell exactly when they will get updated. Does that answer all those questions? I think that does, and it's really useful to go through the practicalities. That's kind of what you would do on the job. I think that's something you know, a lot of our struggle with. Another thing I wanted to ask you about this this is from me. Um, we talked about kind of UTI s. And when you know when you hear an elderly person has delirium for some reason, everybody's mind just jump straight to oh, do they have a UTI? And, uh, you talked about the sort of the unreliable nature of urine dipsticks because of the bacteria that elderly people generally have. Um, would you say that? Actually, it's more reliable to sort of just rely on the clinical signs that things like super pubic tenderness, you know, strange smelling urine, etcetera, rather than sending an m. C n s. Because that can also come back with a false positive. Yeah, So it's the reason to send the M C and S is because we know that there are particular species that are likely to be more pathological, and there are particular species that are likely to be less pathological. And so the reason that is helpful is if it does, if it does come back positive, they will characterize what species they are and what what exactly what bacteria in it is and how likely that is to be contributing to your urine tract infection. Or they will also say whether there are mixed flora means lots of different bacteria, suggesting that not one of the that this isn't a urinary tract infection is simply contamination, which is causing the nitrites to be positive. And that's the utility in, uh, in getting an M. C. And s allows you to understand whether it's one colony or mixed colony is because the patients elderly and therefore always has bacteria, which which is contributing to all of this. But it is important to treat them empirically and use those signs. So if they do have super pubic tenderness, um, or they are passing urine more frequently, or it does look like it's hurting them when they are passing urine. All of those are great signs to suggest that the urinary tract infection is likely underlying diagnosis, diagnosis, and you should treat for that. But that doesn't mean it's the only diagnosis, and you should always be on the safe side. I assume it's multifactorial. What isn't helpful just to bear in mind is I can smell the urine. It smells strongly. That is not a good discriminator, for if the patient does have a urinary tract infection. Sure, thanks very much for that. Another thing. So we talked a lot about the treatment. Well, not really the treatment of delirium, but kind of how to how to reorient eight people and make sure that they're you know, they're okay in hospital, etcetera. Would you say that those same techniques that kind of useful also in preventing the development of delirium. So when you do Clark in a patient, would you say that it would be useful to kind of make sure that people are in patients in regular contact with their family? Where possible, kind of holding medications that could, if they're not needed, could have a sedative effect, etcetera? I think 100% important. So if you look at how geriatricians treat treat their patients, one of the things that they do absolutely massively, massively well is that they stop medications that are likely to be causing more harm than good. Um, so your statins, which might be reducing your muscle mass, your PPI s, which might be causing hyponatremia. And there's lots of medications that that they do tend to stop. Um, they do ensure that the patient has all of the hearing aids, their visual aids etcetera, because arguably, if you don't give them all of those things, they might not hear or see the right things to prevent a fall. You're having your walking stick to make sure that you are safe when you're mobilizing. All of these things are quite key. Is there a randomized control study saying, If you orientated person they're less likely to get hospital induced delirium. I don't know of one. There might be, um, but is it important to keep your patients up to date with what's happening with them? 100%? Um, I often advised particular elderly patients who are at risk of delirium or the relatives to give a couple of pictures or give a try and call regularly just because it does. Anecdotally, it does. Patients do seem to do a lot better. Uh, when? When those things are done? Yeah, And I guess it's been even more even more difficult with covert and everything now with, you know, people not being able to to see their relatives and doctors being in masks, etcetera, healthcare staff, kind of having their face is obscured. So, uh, no, thank you. And we have another question that's just come in and keep keep them coming. Guys, we still got a couple of minutes. So if the patient isn't improving without medication but they're not a risk to themselves or others, would you still prescribe medication? So I presume this is medication to sedate them. Yeah, I presume. I presume that's the case as well. Um, so I wouldn't give you. I wouldn't give any medication in that instance, because that actually may prolong the delirium. So sedating medications like lorazepam and haloperidol may may have literally the exact opposite of the effect that you want. They are. They are. They don't fix or cure delirium. They're simply symptomatic kind of measures to prevent a flare being dangerous, if that makes sense, you the real thing that's gonna cure or treat their delirium is finding the underlying cause and treating them and doing that whole multifactorial approach and making sure you look at every single one of those calls and address every single one of those courses, Right? I think you answered that question perfectly. So you're saying that that, like you said, the medications have a paradigm, etcetera. They don't necessarily treat the delirium. They're only kind of helping you in making sure that the person isn't harming themselves or other people. Exactly. That kind of if they're delirious. Sure, that's all the questions that we've got so far. Perfect. If anyone has got any questions on anything outside of delirium or generally about F one, given we've got another 10 minutes, you are welcome to ask otherwise, this is a great opportunity for you to fill in your feedback. So we've got another one. Another one. Just come in. Uh, so let me just read it before reading it out. Okay? So if you've given a patient a sedative, would you ask the nurse to start a behavioral chart to ensure that the drug is having an impact on the patient? So would you kind of start sort of behavioral obs after giving them after giving a sedative medication? That is a very interesting question. Um, I would probably do it even before you give the medication. If you've got a person who is delirious and having displaying abnormal behaviors in any way, I would automatically put them on a behavior chart. The reason for that is a behavior chart really helpful for, uh, the day staff to know what's happening with their patients so they can impose any safeguards to prevent things from escalating during the night discharge planning. So ensuring you know what kind of behavior is your patients are having such that when you discharge them to a home or to their own, to their own home or two residential home to a nursing home. The wherever they're going is set up in a way which can cope with those behaviors in case they're likely to persist in terms of asking. Answering that question specifically, you are really looking for a response to your treatment per se, as in you yourself aren't likely to stay there to look for a response to your treatment while you're looking to see. Uh, all I would tend to do is ask the nursing staff, Um, give this medication. I'll be there whilst you're giving this medication and I will stay for a few minutes afterwards just to make sure that the patient and tolerates that okay or in case things further escalate. And once, Once the patient's been given the medication and it's been a few minutes, then I tend to say, Look, if there's any further issues, just give me another call. But I think the important thing is that we continue using these verbal de escalation strategies, talking to the patient, reassuring them, telling them what's happening where they are and trying to get them to sit down or sit in their bed and keep trying those treatment strategies. And if they don't work. Please give me another call More than happy to come to give you another hand. And if you do get called again, um, and you're asked to see the same situation for anything Anything you ever do in medicine. If you called for a second time, you should definitely ask for a senior just to give you a hand to make sure that there's anything else you could do that that is done. We always prefer to come to situations early and fix them before they get worse. The last thing I want to do is get to a delirious patient after they've been confused, agitated, moving around, walking around, they've fallen. They've been injured themselves. They've now got intercranial hemorrhage. And then I called rather be called much, much, much earlier. So please escalate as soon as you think that you're like I'm not exactly sure. Or this situation is not exactly something that I'm familiar with. Just escalate immediately. Thanks dot And I think, yeah, as you say, that's really important. Just getting help as early as possible, making sure that your seniors are aware of what's happening. Um, so anyone who's still watching keeping questions coming um, cash is happening to answer anything, um, within reason about medicine f one applications, et cetera. And also, if you want to leave any feedback about webinar or suggested topics and the comments, um, that would be great. Okay, so we've got a non delirium related question. That's fine. Um, so, first of all, a cash really enjoy the teaching session. That's always good news. Um, so this question isn't related to delirium. Um, the person who has posted it has recently found themselves working as a GPS T in E. D. They want to ask how much of a mental health history is warranted in E. D. In the e. D. Setting while seeing patients that come in with mental health causes such as the paracetamol overdose. So sort of, if you, if somebody presents to e. D with with a manifestation of the psychiatric condition, like having overdosed etcetera. How much of a mental health history? I guess the question is asking is down to you in e. D to take and how much of your colleagues in psychiatry. So I think what we need to understand is that all of these patients will be seen by the psychiatric services as soon as it's possible to see them. So if it's a parasite from overdose, they should be well, they should be alert. They should be awake and be able to answer all those questions. But if they are drowsy or they've taken something which has made them quite confused, agitated, it can be really difficult to get their history. I think the important thing to identify at that moment in time is, um, is there anything major that's gonna, uh, affect how you treat the patient? And then also, what's the risk to the patient? So the important thing is to ask our any previous overdoses, Uh, what their intent was with the overdose, where they aiming to kill themselves? Or do they think that the overdose would kill themselves? Did they use any measures to try and avoid detection? Did they plan this, or was this a spur of the moment activity? And then, finally, in the past psychiatric history, uh, what what psychiatric diagnoses do they do? Do they have, uh, how does it impact them? Have they had any treatment for that? I think these are all key questions that are going to affect how you that patient there at that moment? Um, and it was also important that you pass on all of that information because patients may only be happy to talk to the first doctor that they meet. Then after that, when they, when they kind of reflect back on the situation, feel really upset or angry or annoyed, they may shut down. So the more information you can get, the better for the patient. But I also appreciate that e d setting you may need to move on to the next patient to ensure that they get safe and effective and quick treatment. So it's a balance which which you can only get ready with practice. I hope that answers your question. All right. Thanks very much. Are there any more questions to it's not at the moment. No. Perfect. So, um, what we'll do is we'll close the session right there. Um, so thank you so much everyone for attending this talk and delirium, you can still continue asking lots of questions. And the best way to do that is by leaving the comment on the article on the mindedly page on delirium. But also, you can email them, email them throughout. Mind the beef at gmail dot com. I'm more than happy to answer as many more questions you've got. We'll have another seminar. I will have another webinar next week. If you haven't registered for Webinars again, check out the mind's blank page. There is a link to register, um, and like the page so that you get these notifications, but they run every week from 8 to 9 PM We've got plenty of talks lined up. So do you. Make sure you register to make sure that you get into notifications and make sure you attend, but yeah, once again, thank you. So so much for attending today's talk. And I hope you have a lovely evening. Thanks. A cash. That was great. Thank you.