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Go to our site at: www.onthewards.org A series of podcasts offering advice to hospital based doctors in the earliest stage of their careers when they first work on the wards. Now celebrating our 100th podcast!
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Summary: Jeff Duncan
Editor: Eve McClure
James speaks with Dr Scott Murray, Geriatric Physician, about an issue that concerns all of us working late at night or in the early mornings on the wards.
Scott Murray is a Director of Prevocational Education and Training and a Senior Staff Specialist in Geriatric Medicine at Royal Prince Alfred and Balmain Hospitals, Sydney. Scott commenced Advanced Training at RPA and Concord Hospitals before completing his FRACP at University College London and St. Pancras Hospitals in London. His special interests include acute care for older patients, continence and JMO education.
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With Dr Scott Murray, Geriatrician, Royal Prince Alfred Hospital, Sydney, Australia
Delirium, sometimes called “acute confusional state”, is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course. It usually develops over 1-2 days (1). It is a common clinical problem and a challenge for junior doctors afterhours. It is under-recognised with rates of approximately 20-30% in general medical wards, 50% on geriatric wards and in orthopaedic patients, can approach 85%. Hyperactive delirium manifesting as agitation, confusion and restlessness is often easy to recognise, whilst hypoactive delirium, manifesting as sedation, quietness and psychomotor retardation, is very easy to miss (2). Early intervention in hospitalised patients reduces the risk of delirium, the severity and the duration of symptoms. With inattention and fluctuation signify the hallmarks of delirium, the CAM score is a rapid assessment tool for nursing and medical staff and may help distinguish delirium from other conditions such as depression, dementia and acute psychosis (1).
Case – You are a junior doctor working afterhours covering the acute medical ward. You are called to see Joan, a 78 year old female who was admitted three days prior with community-acquired pneumonia and has been worrying the nurses this evening. She is crying out, moaning and, whilst attempting to get out bed, had a fall. The nurses are requesting an assessment and the prescription of a tranquiliser to limit future activities.
1. Initial Assessment
How sick is the patient?
Observations including blood sugar
To yourself, staff and the patient
2. Outline your assessment by the bedside
The patient with a calm manner
In a non-threatening way
Ask simple questions
Has there been any previous cognitive impairment?
Severity of the admission illness?
Brief cognitive assessment – orientation, attention, simple questions
Assess hydration status – examine for hypotension, low urine output
Generalised cardio-respiratory examination – examine for hypercapnia, hypoxia, respiratory rate etc.
Gastrointestinal system examination
Neurological assessment where possible – although this is admittedly very difficult and it may be sufficient to focus on tone, power and brief sensory testing
An assessment of urinary retention
Important to assess the blood sugar level by the bedside
3. Investigations for delirium – both acutely at time of review and the following day
Full Blood Count, Biochemistry, Electrolytes/Urea/Creatinine
Specifically hyponatraemia, renal failure, hypercalcaemia, abnormal liver function (encephalopathy)
A positive U/A in a confused patient with fever may warrant antibiotics
A negative U/A can be VERY helpful in ruling out urinary tract infection
Look for pulmonary oedema or infection
Look for confusion secondary to underlying myocardial infarction