Away from the track; Physio & Delirium Management

Patient in her 90's, post- hemi arthroplasty for #NOF.

• Day one: "I think you're the devil. I don't believe you. You're not to touch me. I'm not getting up.... The water tastes off, I think it has been poisoned. You're one of them, they're watching me from next door - I can hear them".  - patient mobilised out to chair, tolerated sitting for 15minutes and returned to bed.
• Day four: "oh you're the Phil I keep hearing about.... I'm a practical lady, of course I can get myself up [out of bed]" - patient mobilised with standing hoist, then with zimmer frame ~5m to commode.

Patient in her late 80's, post- proximal femoral nail antirotation (PNFA) for #NOF.

• Day one to five: laughing histically at anything and everything, pleasantly confused and cooperative. Seemingly happy to walk with the  healthcare staff and a walking frame. "I'm a bit sore you know, it's not usually like this... the colour scheme here is really nice... I always have lunch in the dining room - shall we go there now?". - patient mobilising varying distances up to 20m with nursing staff

Patient in his 70's,  post- open reduction, internal fixation (ORIF) for tibial plateau #.

• Day one: patient aggressive toward staff and fighting to get himself out of bed. "Fuck off, go away, leave me now, I'm leaving, you cannot hold me here, there is nothing wrong with me.... " - no attempt to mobilise with physio as patient unable to cooperate with instructions and aggression was inappropriate.

Patient in her 70's, post- revision of her total hip joint replacement (THJR) following dislocation.

• Day one: "Yes I know what you're here to do, right lets go [get up out of bed]. I need go to the toilet, so lets hurry"  - patient mobilised up with steady-eddie to commode and taken to toilet.
• Day two: "I feel like I'm on another plain. I saw bars up there earlier [pointing to the ventilation on the ceiling] and thought I was in jail. I feed drowsy and not sure that I should trust you" Patient mobilised with walking frame ~1.5m to chair.
• Day three: "What's the point, I can't get out of my house, nor afford a taxi, I have no family or friends, my sisters have died and it's just me.... ". - Patient declined to mobilise with physio.
• Day four: "I'm feeling much better today, my bowels are slowly moving - I'm currently on a bed pan and it's uncomfortable on my hip, but I need it, it comes in bursts and squirts". - Later in the day,  the patient mobilised ~15m using frame with the physio.

Background

Delirium is a transient state of acute confusion, often contributing to a patient's prolonged stay in hospital. It is a serious condition that has a rapid onset, fluctuates over the day and is associated with altered consciousness and disordered cognition, inattention, poor recall of events, impaired judgement and hallucinations. Patients experiencing delirium can be irritable and/or anxious.

Delirium clinically diagnosed and classified into three sub-types, hyperactive, hypoactive and mixed. Clinicians use the 4AT screening tool (see below).

Predisposing risk factors include: pre-existing cognitive impairment, dehydration/malnutrition, multiple comorbidities, visual/hearing impairment, physical frailty, history of previous delirium.

Precipitating risk factors include: catheterisation, consitpation, medications, environmental/physical restraint, sleep deprivation, hypoxia, surgery, drug withdrawl, neurological events.

Delirium has a high previlence in hospital, especially affecting ICU, neurological (e.g. stroke), general medicine and surgical/orthopaedic patients.

So what can physiotherapist's do about it?

Identify delirium early.
Physiotherapists usually have early patient contact, usually for early mobilisation if they're new to the ward. Nurses and family present are also instrumental in identifying abnormalities suggestive of delirium. The screening of delirium should be routinely applied to anyone with risk factors. The physiotherapist is able to assist in the management directly and indirectly...


Strategies to prevent and manage delirium.

• Orientate the patient to the ward and what the usual processes are on the ward, as well as day/time using a clock or allowing natural light into the bedspace.
• Encourage a small number of familiar faces to be bedside during the day. Call upon hospital volunteers as required.
• Early mobilisation, and mobilisation throughout the day. Promoting sitting out of bed, in a chair, for meals and establish expectations for a daily routine similar to the patient's usual routine if able. Avoid pyjama paralysis if able. Set-up participation activities, the ward may have an activities trolley.
• Minimise use of restraint (physical/environmental), including that of placing walking aids away from the patient. Provide appropriate equipment if necessary and ensure nursing staff know how to safely mobilise the patient.Use a patient 'watch' (staff member) that engages proactively rather than sitting back and watching.
• Coordinate with nursing and occupational staff about use of sensory aids such as magnifying glasses and provide handouts suitable for the patient.
• Educate the patient and family about delirium, and ask that they inform staff if they experience signs/symptoms.
• Ensure effective pain management, including educating the patient about seeking patient medication
• Document delirium symptoms, AT4 screening tool score, and inform the multidiciplinary team.

Implementing the above will help to get your patients back on track.