(hyperactive) delirium while on call
as a junior
Out of hours, you're most likely to be called for hyperactive delirium, but your workup remains the same.
My finals notes: https://smolmedic.github.io/#Delirium
establish the baseline
- How do you know they're confused? Has anyone taken a collateral?
- “patient is a poor historian” just means you don't have enough sources of information
- Sources of information: NOK, carers (care agencies, sheltered accommodation managers), care home staff, previous therapists docs
- document who gave you the collateral
approaching the patient
- usual physical examination and secondary survey – looking for any source of infection, signs that they injured themselves as a result
- mental state examination (https://smolmedic.github.io/#Mental%20state)
- can they tell you about any delusions or hallucinations? voices/noises/telling them to do things? seeing people/things/animals? are these frightening? these can contextualise behaviour, help you reassure the patient and risk assessment
- the last one can help you step into their world for a bit
bedside investigations: aim to rule out reversible causes
- think U PINCH ME
- retention – bladder scan
- hydration/nutrition – fluid status, bloods
- metabolic – bloods, blood sugars
- environment – environmental stimuli can sometimes be a focus for a delusion/hallucination (i.e. misinterpreting stimuli) – hearing aids in, glasses on!
bedside paperwork: working with nursing staff
- bowel chart – they must poo. nuff said. “type 7”/watery stool may be overflow
- food chart – if not eating, look in mouth (easily missed) – mouth care? thrush? cognition = needs prompting to finish food?
- behaviour chart – full of incredibly useful information. are they sleeping at night? consultants might like sedatives, but as a junior, making sure they have adequate pain relief can be an easy win
suggestions for management
- family visits can help re-orient/reassure esp with paranoid ideation
- 1:1 may be needed if very very hyperactive
- MHLT can help +/– old age psychiatrists to help with antipsychotic dosing, weaning of psychotropics, follow up/discharge planning e.g. for dementia unit
- Meds a geriatrician might use (from local experience): risperidone/olanzapine esp with violent behaviour, quetiapine with PD patients (less anti dopaminergic effect I believe), sedatives to even out sleep pattern