Leicester Geriatric Medicine

Delirium risk factor bingo: broken sleep, glasses in a drawer, new sedative, family sent home, no clock, 4 bed moves… Every square is modifiable. How many is your ward hitting today? #delirium

Mr G, 80, using a fentanyl patch for chronic back pain, developed a fever from a chest infection and, over the same day, became drowsy, pinpoint-pupilled and confused, with a slowing respiratory rate. The infection was real, but the delirium was opioid toxicity. Fever and warm skin had increased the absorption from his patch, and a dose that had been stable for months was suddenly delivering far more. The heat had turned a steady drug into an overdose. We removed the patch, but the point the team almost missed is that removal alone is not enough. The drug already absorbed sits in a depot under the skin and keeps releasing for many hours, so he needed close monitoring for a full day, with naloxone to hand and given in small titrated doses if his breathing worsened. Transdermal opioids deliver more when the patient is hot, whether from fever, a heatwave or a hot pack. In any febrile patient on a fentanyl patch who becomes drowsy and confused, think opioid toxicity, remove the patch, and keep watching well beyond it. #delirium

ℹ A family told me recently: "He was sharp as a tack on Monday. By Wednesday he didn't know my name." This is not dementia. Dementia does not appear in 48 hours. This speed of change in mental status is 𝐭𝐡𝐞 𝐬𝐢𝐠𝐧𝐚𝐭𝐮𝐫𝐞 𝐨𝐟 #𝐝𝐞𝐥𝐢𝐫𝐢𝐮𝐦: acute onset. Hours to days. I've seen delirium misdiagnosed as "progression of dementia" hundreds of times. The rationale is superficially reasonable - patient is old, patient has memory problems, therefore patient has dementia. This misdiagnosis is not the fault of staff - it emanates from a lack of attention to delirium in undergraduate and postgraduate training. But this common mix-up in clinical practise is serious and consequential. Dementia progresses over months and years. If the change happened this week, something else is happening NOW. Something medical. Something usually reversible. Every acute cognitive change in an older person deserves investigation. Infection. Medication change. Pain. Dehydration. Constipation. Hypoxia. Etc. ↳ 𝐖𝐡𝐞𝐧 𝐟𝐚𝐦𝐢𝐥𝐢𝐞𝐬 𝐭𝐞𝐥𝐥 𝐲𝐨𝐮 "𝐬𝐨𝐦𝐞𝐭𝐡𝐢𝐧𝐠'𝐬 𝐝𝐢𝐟𝐟𝐞𝐫𝐞𝐧𝐭," 𝐰𝐡𝐚𝐭 𝐢𝐬 𝐲𝐨𝐮𝐫 𝐧𝐞𝐱𝐭 𝐬𝐭𝐞𝐩?

#Delirium treatment is much more complex: treat the cause(s) - usually more than 1, optimise physiology (e.g. hydrate), detect & treat distress, prevent complications (e.g. falls, pressure sores, aspiration), communicate with family, rehabilitate, etc. #meded