Transcript here - Boston University Medical Campus

Delirium in the
Older Adult
Matt Russell,MD, MSc
Assistant Professor of Medicine
Boston University School of Medicine
Slide show courtesy of Drs. Lisa Caruso
and Serena Chao
Objectives
 To
elicit key features of and define
delirium
 To review epidemiology, risk factors, and
precipitants of delirium
 To discuss management strategies around
delirium.
Case: 2pm Admission

Agnes D: 88 year old female ALF resident with
history of Dementia( MMSE 21/30), HTN, CAD,
hearing loss, history of GI bleed (diverticulosis),
hyperlipidemia, and COPD presents with a 3 day
history of progressive dyspnea, purulent sputum,
and wheezing. Per nursing home flow sheet,
oxygen saturation was in the low 80s% on room
air. She is admitted with COPD exacerbation. At
baseline, she is AAOx2. She is minimal assist
with some ADLs (dressing and toileting) and
ambulates independently.
What is your first
thought?
What could possibly go
wrong?
A case for contingency planning…
Case continued

Agnes is admitted to the inpatient medical
service. She is placed on 2 liters NC. Her other
admission medications are as follows:
•
•
•
•
•
•
•
•
ciprofloxacin,
Solumedrol IV,
Donepezil
Famotidine for GI prophylaxis
Advair 500/50
Spiriva
zolpidem prn
D5 ½ NS at 75 cc/hour
Case cont’d
 Because
of history of GI bleed, the team
puts her on venodyne boots for DVT
prophylaxis.
 She is placed on telemetry and continuous
oxygen saturation monitoring
 The patient is settled in and the medical
team goes home
Beep Beep!
Dear Dr.Nightfloat….
“Hi, are you covering for
Agnes D?....”
Delirium: She is OFF THE WALL!!
Delirium
Definition?
Delirium =
Syndrome
Definition: An acute disorder of
attention and cognition; acute
confusional state
“Delta MS” or “Mental Status Changes”
are vague, inappropriate terms and should
not be used—CALL IT WHAT IT IS!
Your next step is….
MEDICAL EMERGENCY!
Next steps
 Go
to bedside and see patient
 Approach in comforting fashion-NOT
GUNS A BLAZIN’!!
 Obtain history of baseline mental status
from all available sources
 Perform bedside testing for delirium
screening
Recognition
 Delirium
is unrecognized by physicians in
32-67% of cases in hospitalized patients
 Reasons for this include



lack of awareness of syndrome as important
cognitive assessment not done
misdiagnosed or not detected
Inouye SK. The dilemma of delirium: Clinical and research controversies regarding
diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;
97:278-88.
Diagnosis: Confusion
Assessment Method
(CAM)
1. Acute change in
mental status with a
fluctuating course
2. Inattention
AND
3. Disorganized
thinking
OR
4. Altered level of
consciousness
Sensitivity > 94%; specificity > 90% ; gold standard
used was ratings of psychiatrists
Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion. The Confusion
Assessment Method: A new method for detection of delirium. Ann Intern Med 1990;
Assume it is delirium until
proven otherwise:
Delirium may be the only
manifestation of a lifethreatening illness in the
elderly patient.
Please complete Agnes’
Delirium Map
Agnes’ Delirium Map
 Risks:
 Precipitants:
 Your
interventions:
Epidemiology





Complicates hospital stays for more than 2.3
million persons 65 years of age and older per
year
Prevalence on admission to the hospital is 1424%
Incidence of new cases arising during
hospitalization is 6-56%
Independent predictor of mortality up to 1
year after occurrence; mortality in patients
who develop delirium in the hospital is 2533%
$$$
Etiology
 Biology
is poorly understood
 “The development of delirium involves
the interrelationship between a
vulnerable patient and noxious insults.”1
1 Inouye SK. Delirium in older persons. NEJM 2006;354:1157-65.
Approaches to Clinical Problem
Solving
“simpler explanations are, other
things being equal, generally better
than more complex ones"
Agnes’
Delirium Map

Risks:





Precipitants:




Age
Dementia
Medical illnesses
Hearing impairment- no hearing aids!!
Change in setting
Hidden restraints (IV tubing, venodynes, oxygen)
Medications (solumedrol, cipro, ambien,famotidine)
Interventions:








Treat underlying process
Eliminate restraints
Maximize sensory input (hearing aids)
Eliminate unnecessary and/or harmful meds:
d/c famotidine and use PPI
d/c ambien
Additional Non-pharm: family presence, orient, remove overt and hidden restraints, soothing
tones, reassurance
Pharm: haldol if necessary. Start low
Agnes’ case continued
 Agnes’
daughter comes in to help settle
her mother down. She asks to speak to
the doctor…..
What the hell are you
people doing to my
mother??!!!
A brief skills practice….
Management and
Treatment

Treat medical illness, as possible
 Always try non-pharmacologic treatment
first





don’t change room if possible
encourage family visits….EDUCATE FAMILY
MEMBERS!!
quiet room with low level lighting
make sure patients have their glasses and hearing
aides
limit IV’s, catheters, other restraints
Management and
Treatment
 Pharmacologic




management
indicated if the patient is endangering him- or
herself or others
AVOID BENZODIAZEPINES except for
alcohol withdrawal (delirium tremens)
mainstay is the antipsychotic, haloperidol
(Haldol); start with 0.5-1 mg, check vitals in
20 min, repeat dose as needed
olanzapine (Zyprexa) may be a useful
alternative
How to distinguish Delirium from
Dementia

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
Slide courtesy of Serena Chao, MD
Management and
Treatment




Haldol: advantages Haldol: disadvantages
 extrapyramidal SE
readily available
 contraindicated in
PO, IM, IV
quick onset of action pts with Parkinson’s
disease
or
high therapeutic
parkinsonism
index
 neuroleptic
malignant syndrome
Conclusions
Identify risk factors
Implement prevention strategies
Recognize syndrome when occurs
Determine etiology and treat if possible
When in acute fevers, pneumonia,
phrenitis, or headache, the hands are
waved before the face, hunting through
empty space, as if gathering bits of
straw, picking the nap from the coverlet,
or tearing chaff from the wall--all such
symptoms are bad and deadly.
Hippocrates, [460-375 BC]
Acknowledgements
 Dr.
Lisa Caruso
 Dr. Serena Chao
Thank You
Some 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
 antihistamines (Benadryl, Atarax)
 antispasmodics (Lomotil)
 tricyclic antidepressants
 antiparkinsonian agents (Cogentin, Artane)
 antiarrhythmics (Quinidine, Norpace)
Etiology: Medications

Cardiac (digoxin, lidocaine)
 Antihypertensives (beta-blockers, Aldomet)
 Miscellaneous
 H2-blockers
 steroids
 metoclopramide
 lithium
 anticonvulsants
 NSAIDS
Evaluation

Recognize syndrome
 History
 establish patient’s cognitive and functional
baseline
 thorough medication review: drug toxicity may
account for up to 30% of all cases of delirium
Evaluation
 Physical





Exam
vital signs including O2 saturation
search for signs of infection
neurological exam
include cognitive evaluation (ex. MMSE)
other tests for attention
• forward digit span (able to repeat 5 digits forward)
• months of the year or days of week backwards
Evaluation

Individualized work-up
 Metabolic: CBC, electrolytes, BUN/Cr, glucose,
Ca2+, phosphate, LFT’s, magnesium. Consider
also TSH, drug levels, tox screen, ammonia.
 Infection: urine cx, CXR, blood cultures, consider
LP
 If no obvious cause, ABG, ECG, brain imaging,
EEG
Prevention: It can be
done!




Objective: To evaluate the effectiveness of a
multicomponent strategy for the prevention of delirium
Design: Controlled clinical trial. Randomization not
possible but pts meeting criteria admitted to intervention
unit were prospectively matched by age, sex and baseline risk of delirium (meaning for number of risk factors).
Subjects: 852 patients >70 yrs old admitted to general
medicine service at a teaching hospital
426 usual care, 426 intervention
Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to
prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.
Prevention: Modify Risk
Factors




Intervention was standardized protocols to manage
six risk factors for delirium
Risk factors targeted were: cognitive impairment,
sleep deprivation, immobility, vision impairment,
hearing impairment, dehydration
Intervention unit staffed by a trained team (geriatric
nurse specialist, two specially trained Elder Life
specialists, a certified therapeutic-recreation
specialist, a physical therapy consultant, a
geriatrician and trained volunteers.)
Outcomes: Delirium by Confusion Assessment
Method, severity, recurrence
Prevention: Modify Risk
Factors
OUTCOME
INTERVENTION
(Experimental
Event Rate)
USUAL
CARE
(Control
Event Rate)
MATCHED
Number
Needed to
Treat (NNT)
(unmatched)
1ST episode of
delirium (number
of pts)
42 (9.9%)
64 (15%)
OR,
0.60 (95%
CI 0.390.92);
P=0.02
19.4
(10.4-134.2)
Total days of
delirium
105 days
161 days
P=0.02
Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to
prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.
Prevention: Modify Risk
Factors

Intervention did not change the severity of the delirium
episode.
 Rates of recurrence of delirium did not differ in the two
groups.
 Adherence rates high; lowest in non-pharm sleep
protocol at 71%.
 Cost of intervention per case of delirium prevented
was $6,341.
Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to
prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.
Risk Factors
Risk Factor
Studies/Pts in
analysis (n/n)
Combined
Odds Ratio
(95%
Confidence
Interval)
P Value: Test of
Homogeneity
Dementia
12/289
5.2
(4.2, 6.3)
.01
Medical illness
4/3
3.8
(2.2, 6.6)
.47
Medications
(narcotics)
2/128
1.5
(0.9, 2.3)
.096
Male gender
6/103
1.9
(1.4, 2.6)
.32
Depression
5/78
1.9
(1.3, 2.6)
.01
Alcohol
3/27
3.3
(1.9, 5.5)
.90
Abnormal
sodium
2/23
2.2
(1.3, 4.0)
.03
Hearing
impairment
3/122
1.9
(1.4, 2.6)
.17
Visual
impairment
3/112
1.7
(1.2, 2.3)
.05
Diminished ADL
2/33
2.5
(1.4, 4.2)
.60
Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly
Hospitalized Patients. J Gen Intern Med. 1998;13:204-12.
Risk Factors
Risk Factor
Studies/Pts in
analysis (n/n)
Combined
Odds Ratio
(95%
Confidence
Interval)
P Value: Test of
Homogeneity
Dementia
12/289
5.2
(4.2, 6.3)
.01
Medical illness
4/3
3.8
(2.2, 6.6)
.47
Medications
(narcotics)
2/128
1.5
(0.9, 2.3)
.096
Male gender
6/103
1.9
(1.4, 2.6)
.32
Depression
5/78
1.9
(1.3, 2.6)
.01
Alcohol
3/27
3.3
(1.9, 5.5)
.90
Abnormal
sodium
2/23
2.2
(1.3, 4.0)
.03
Hearing
impairment
3/122
1.9
(1.4, 2.6)
.17
Visual
impairment
3/112
1.7
(1.2, 2.3)
.05
Diminished ADL
2/33
2.5
(1.4, 4.2)
.60
Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly
Hospitalized Patients. J Gen Intern Med. 1998;13:204-12.
Etiology
1940’s: Cortical function on EEG
characterized by abnormal slow-wave
activity.
 Exception: alcohol and sedative withdrawal
showing predominately low-voltage, fastwave activity
 Subcortical structures important, also.
 Patients with subcortical strokes and basal
ganglia abnormalities are more susceptible to
delirium.

Etiology
Role of Acetylcholine (Ach)





Neurotransmitter involved in multiple aspects of
cognitive functioning including memory
Anticholinergic medications are frequent causes of
delirium
Patients with Alzheimer’s disease are particularly
susceptible
Serum anticholinergic activity (SACA) is increased in
older pts with delirium and in postoperative delirium
Some evidence that certain patients with delirium
improve with administration of acetylcholinesterase
inhibitors, such as physostigmine and donepezil