Therapeutic Handbook - GGC Prescribing

Management of Acutely Disturbed Patients,including DeliriumThis guideline outlines the management of acutely disturbed patients and includes brief guidance ondelirium and highlights the special considerations in elderly patients. More detailed information on thediagnosis, prevention and treatment of delirium can be found on StaffNet.This guideline does not cover the management of acutely disturbed young people or adolescents.Instead contact your local adolescent psychiatry liaison for young people or adolescents for advice.IntroductionMost violent, aggressive or bizarre patients in general hospital wards or A&E departments are notmentally ill. Many have delirium caused by an acute physical illness and may be seriously unwell. Avery small number have nothing wrong with them and should, once serious illness is excluded, bemanaged according to local policy for Management of Violence and Aggression.• Causes of confusion or coma may include:T ........Trauma, temperatureI .........InfectionP ........PsychiatricS ........Space occupying lesion, subarachnoid haemorrhage, shockA ........Alcohol and other drugsE ........Endocrine, exocrine, electrolytesI .........Insulin (diabetes)O ........Oxygen (lack of), opiatesU ........Uraemia• Head injury Refer to senior staff immediately and see head injury guideline page 186.• If acute alcohol withdrawal suspected see alcohol withdrawal guideline, page 173, but excludeother serious problems first!Signs and symptoms of delirium:• Recent change (hours / days) in cognition, behaviour or other mental function.• History of change from relatives / GP letter / ward staff.• May be withdrawn ('hypoactive delirium') / unresponsive / drowsy.• May be agitated, uncooperative, suspicious ('hyperactive delirium').• Common if age > 65 years and acute illness / surgery / change in drugs / pre-existing cognitiveimpairment or dementia.Further information on preventing and diagnosing delirium on StaffNet.Assessment / monitoring• Consider delirium – see above• Basic observation: RR, oxygen saturation (SpO 2), BP, temperature, blood sugar, GCS• Check nursing notes, medical notes and observation sheets for possible causes of acuteconfusional states e.g. documented vital signs preceding abnormal behavior.• Review recent drug initiation or withdrawals as cause of confusion.• Have you excluded Hypoglycaemia, Hypoxia, Shock and Sepsis?Central Nervous SystemPage 167