Delirium in the Elderly

Dr.leila kashani 92/3/23 نارهت یکشزپ مولع هاگشناد یکشزپناور رایتسد هبزور ناتسرامیب

D EFINITION     Acute and clinically significant deficit in cognition , attention or memory Impaired or altered perception , illusion Disturbances of circadian rhythms Acute change in mental status with a fluctuating course   Altered level of consciousness Behavioral disturbances

K EY        F EATURES Acute onset Inattention Disorganized thinking Altered level of consciousness Cognitive abnormalities (disorientation, language difficulties, impairment in memory/learning) Perceptual disturbances (illusions, delusions, hallucinations) Emotional disturbances (anxiety, fear, irritability, anger, depression, euphoria)

O THER NAMES  Acute confusional state      Encephalitis - encephalopathy Acute brain failure Toxic metabolic state CNS toxicity Sun downing   Organic brain syndrome Cerebral insufficiency

I NCIDENCE HIGH A MONG E LDERLY P ATIENTS IS  1/3 of patients presenting to ER   1/3 of inpatients aged 70+ on general med units Incidence ranges 5.1% to 52.2% after noncardiac surgery   Highest rates after hip fracture ( 50 % ) and aortic surgeries In ICU : 70 -87 %

D ELIRIUM : I NCREASED R ISK OF …  Functional decline   New nursing home placement Persistent cognitive decline:  18-22% of hospitalized elders with complete resolution 6-12 months after discharge

H OW TO D ISTINGUISH D ELIRIUM FROM D EMENTIA  Features seen in both:   Disorientation Memory impairment     Paranoia Hallucinations Emotional lability Sleep-wake cycle reversal  Key features of delirium:   Acute onset Impaired attention  Altered level of consciousness

P RODROME 

Patients may describe and/or manifest

:   Decreased concentration Irritability, restlessness, anxiety, depression    Hypersensitivity to light and sound Perceptual disturbances Sleep disturbance - daytime somnolence and nocturnal agitation

Delirium may be the only manifestation of life-threatening illness in the elderly patient

D ELIRIUM : PSYCHOMOTOR S UBTYPES Hyperactive (most recognized) ↑ psychomotor activity (agitation, mood labiality, refusal to cooperate, disruptive behaviors, combativeness) Hypoactive (under recognized) ↓ psychomotor activity (sluggish, lethargic, withdrawn, apathy) Mixed (highest risk for morbidity/mortality) Fluctuating course

A M ODEL OF D ELIRIUM A multifactorial syndrome that arises from an interrelationship between: 

Predisposing factors

vulnerability  a patient’s underlying  AND

Precipitating factors

 noxious insults

P REDISPOSING F ACTORS I .

E . BASELINE UNDERLYING VULNERABILITY  Baseline cognitive impairment  25-31% of delirious patients have underlying dementia  Medical comorbidities:       Any medical illness Infections Toxins, including drugs Substance withdrawal Organ failure: heart, liver, kidney, etc.

Metabolic     Primary brain disorders Visual impairment Hearing impairment Functional impairment     Depression Advanced age History of ETOH abuse Male gender

P RECIPITATING I .

E . NOXIOUS INSULTS F ACTORS   Medications

Bedrest

   

Indwelling bladder catheters Physical restraints

Iatrogenic events

Uncontrolled pain

 Fluid/electrolyte abnormalities  Infections     Medical illnesses

Urinary retention and fecal impaction

ETOH/drug withdrawal Environmental influences

S OME DRUG CLASSES THAT ARE ASSOCIATED WITH DELIRIUM  Medications with

psychoactive effects

:   3.9-fold increased risk 2 or more meds: 4.5-fold  

Sedative-hypnotics

: 3.0 to 11.7-fold

Narcotics

: 2.5 to 2.7-fold  

Anticholinergic drugs

: 4.5 to 11.7-fold Risk of delirium increases as number of meds prescribed rises

P REVENTION =G OOD E LDERLY P ATIENT H OSPITAL C ARE FOR THE RISK FACTOR Cognitive impairment Sleep deprivation INTERVENTION Orientation protocol, cognitively stimulating activities 3x/day Nonpharmacologic protocol, noise reduction, schedule adjustments Immobility Visual impairment Hearing impairment Dehydration Ambulation or active ROM exercises; minimize equipment Glasses or magnifying lens, adaptive equipment Portable amplifying devices, earwax disimpaction Early recognition and volume repletion

M ANAGING

A PPROACH

C ONFUSED

S TRATEGIES

B EHAVIORS : Introduce yourself at each encounter Use touch as appropriate Start with the “ Soft Approach ” Smile Warm demeanor Pleasant voice tones Go slow Talk in short, simple sentences Avoid correcting/confrontation Appeal to the emotion and let the patient know you will keep him/her safe Be flexible in getting tasks accomplished

K EYS TO E FFECTIVE M ANAGEMENT 

Find and treat the underlying disease(s) and contributing factors

    Comprehensive history and physical Including neurological and mental status exams Choose lab tests and imaging studies based on the above

Review medication list (

Psychotropics, narcotics, anticholinergics ,Digoxin, prednisone, furosemide, cimetidine have anticholinergic properties.)

         CBC, electrolytes, BUN, Cr, glucose, LFTs, albumin O2 Saturation Urinalysis TSH, B12 ? Toxin screen CXR CNS imaging remains debatable. LP in febrile patient with meningeal signs Cause not identified in 15 to 25%

D IAGNOSIS    History from family and/or caregivers Bedside observations DSM-IV diagnostic criteria  Diagnostic errors are common in :   Hypoactive form The setting of rapid fluctuations of cognition.

D IFFERENTIAL D IAGNOSIS 

Dementia

 Alzheimer dementia  Functional psychiatric disorders – delusional psychosis or depressive states   Misdiagnosed as depression in as many as 40% of cases Schizophrenia has a more chronic hx with highly systematized delusions.

T REATMENT OF  D ELIRIUM Treatment of underlying disorder will usually resolve in rapid improvement of delirium  The diagnosis of delirium may serve as a marker for future cognitive and functional decline

A LWAYS T RY M EASURES F N ONPHARMACOLOGIC IRST       Presence of family members Interpersonal contact and reorientation (Provide clocks, calendars ) and environmental support Provide visual and hearing aids Remove indwelling devices: i.e. Foley catheters Mobilize patient A quiet environment with low-level lighting  Uninterrupted sleep   Reduce noise levels.

Minimize room changes in the hospital

M ANAGEMENT : H YPERACTIVE , A GITATED D ELIRIUM   Use drugs only if absolutely necessary: harm, interruption of medical care First line agent: haloperidol (IV, IM, or PO)    For mild delirium:   Oral dose: 0.25-0.5 mg IV/IM dose: 0.125-0.25 mg For severe delirium: 0.5-1 mg IV/IM repeated q30 min until calm  Patient will likely need 2-5 mg total as a loading dose Maintenance dose :loading dose divided BID  May use quetiapine and risperidone ,…

W HAT ABOUT LORAZEPAM ?



Second line agent



Reserve for

:   Sedative and ETOH withdrawal Neuroleptic Malignant Syndrome

 S UMMARY OF K EY P OINTS Evaluation should focus on ruling out infection, medication toxicity, neurological events, metabolic abnormalities, and new cardiorespiratory problems.

 Prevention is the best therapy and environmental support.

– focus on interpersonal  antipsychotics and benzodiazepines symptom control.

are useful in

T AKE H OME E LDERLY P OINTS : D ELIRIUM IN THE      A multifactorial syndrome: predisposing vulnerability and precipitating insults Prevention should be our goal If delirium occurs, treat the underlying causes Always try nonpharmacologic approaches Use low dose antipsychotics in severe cases

 thanks and any Questions?