Download Dellirium or Dementia case accessory file

Spotlight Case
Delirium or Dementia?
Source and Credits
• This presentation is based on the May 2009
AHRQ WebM&M Spotlight Case
– See the full article at http://webmm.ahrq.gov
– CME credit is available
• Commentary by: James L. Rudolph, MD, SM
– Editor, AHRQ WebM&M: Robert Wachter, MD
– Spotlight Editor: Sumant Ranji, MD
– Managing Editor: Erin Hartman, MS
2
Objectives
•
•
•
•
3
At the conclusion of this educational activity,
participants should be able to:
State the key diagnostic differences between delirium
and dementia
Describe the Confusion Assessment Method for
workup of suspected delirium
Explain the risks associated with using physical
restraints in geriatric inpatients
Describe the initial workup of delirium in a
hospitalized patient
Case: Delirium or Dementia?
An 86-year-old woman, admitted with
complaints of shortness of breath and cough,
was found to have pneumonia. Her past
medical history included cataract surgery,
hypertension controlled with medications, and
type 2 diabetes controlled by diet. She was
ambulatory, lived alone, and at baseline
completed all activities of daily living
independently. According to her daughter, the
patient was never disoriented.
4
Case: Delirium or Dementia? (2)
At admission, the patient appeared mildly
dehydrated. Her oxygen saturation was 94%
on 2 liters oxygen by nasal cannula, and an
arterial blood gas showed a normal pCO2 of
40 mmHg. Her daughter requested to spend
the night at the bedside, but was told she
could not stay, per hospital policy.
5
Case: Delirium or Dementia? (3)
Overnight, nursing staff noted the patient to be
disoriented. She began pulling at her intravenous
lines and attempting to get out of bed. The
covering physician was called, and ordered that
the patient be placed in four-point restraints.
The next morning, the daughter returned to find
her mother in restraints, speaking incoherently
and severely short of breath. The daughter asked
the nurse what happened, and reiterated that her
mother had never been confused before.
6
Altered Mental Status
in Hospitalized Patients
• All patients should be screened for cognitive
impairment at admission in order to assess
for delirium and establish a baseline
• ~25% of general ward patients and ~80% of
intensive care unit patients experience
delirium during hospitalization
• Dementia cannot be diagnosed if delirium is
present
7
See Notes for references.
Delirium vs. Dementia
Clinical Feature
Delirium
Dementia
Onset
Sudden; may be worse at
night
Insidious, depends on cause
Progression
Abrupt
Slow but uneven
Sleep/wake cycle
Disturbed, frequently
reversed
May be preserved
Alertness
Fluctuates
Generally normal
Attention
Impaired, fluctuates
Generally normal
Generally impaired
Time orientation lost earlier
than person/place
Mild impairment until late
Orientation
8
Delirium Prediction Rule
Clinical Feature
Measurement
Points
Cognitive Impairment
MMSE < 24
1
Acute Illness
APACHE > 16
1
Visual Impairment
Corrected vision worse than
20/70
1
Dehydration
BUN: creatinine ratio > 18
1
The points are added. The incidence of delirium for 0 points is 3%-9%, 1-2 points is 16%-23%,
and for ≥3 points is 32%-83%. MMSE = Mini Mental State Examination; APACHE = Acute
physiology, age, and chronic health evaluation; BUN = blood urea nitrogen.
9
See Notes for reference.
Hospital Environment Predisposes To Delirium
• Many new faces: 10-20 staff
may see patient in one day,
leading to disorientation
• Decreased cognitive stimuli:
urinary catheters and
restraints confine patients to
bed, with attendant risks
• Loss of sleep due to noise or
intrusions
10
See Notes for references.
Psychomotor Variants of Delirium
• Hyperactive (25%)
– These patients are more likely to receive
chemical or physical restraints
• Hypoactive (50%)
– May be misdiagnosed as
depression or dementia
• Mixed (25%)
11
See Notes for reference.
Risks of Delirium in Hospitalized Patients
• Underlying cause of delirium may be missed
• Over-medication (especially in hyperactive
and mixed subtypes)
• Amplifies risks of hospitalization
– Deconditioning and malnutrition
– Aspiration pneumonia
– Nosocomial infection (especially due to urinary
catheters)
– Pressure ulcers
12
See Notes for reference.
Physical Restraints
• Risky for several reasons
– Independently associated with
development of delirium
– Reduce external stimuli  may
exacerbate delirium
– May exacerbate hyperactive behavior
13
See Notes for references.
Before Applying Restraints
• Consider:
–
–
–
–
–
What is intended effect of restraint?
Can intended effect be achieved by other means?
Is this the least invasive restraint?
Is using restraints in the patient’s best interest?
Are restraints being used for secondary benefits
(i.e., to limit calls or pages)?
– When will restraint be removed?
14
See Notes for references.
Case: Delirium or Dementia? (4)
The doctor was called and an arterial blood gas
was performed. The patient’s PaO2 was 91
mmHg, but the PaCo2 was 58 mmHg, a marked
increase since admission. Despite the patient’s
deteriorating clinical condition, the patient’s
worsening level of consciousness was attributed
to “senile dementia” and not impending
respiratory failure (as evidenced by the significant
carbon dioxide retention). No further action was
taken.
15
Case: Delirium or Dementia? (5)
Over the course of the day, the patient
developed worsening respiratory distress,
became comatose, and was transferred to
the intensive care unit. She subsequently
developed respiratory failure requiring
intubation and renal failure requiring dialysis.
Her condition did not significantly improve,
and she died 2 weeks later.
16
Confusion Assessment Method
Feature 1
Acute onset and
fluctuating course
Feature 2
Inattention
Feature 3
Disorganized thinking
Feature 4
Altered consciousness
• Diagnosis of delirium requires features 1 and 2, and either 3 or 4
17
See Notes for references.
Workup of Delirium
• History and physical examination
• Neurological examination
• Collateral information from family, nursing
• Review of medications
• Especially benzodiazepines, anticholinergics,
and antipsychotics
• Drugs that were recently stopped and may cause
withdrawal syndrome (opioids, antidepressants, alcohol)
• Basic laboratory tests for electrolytes, kidney
function, workup of suspected infection
Identify and treat underlying cause that precipitated delirium
18
The Role of Family Members at the Bedside
• Reorienting stimulus for patient
– 10-20 staff may see patient daily,
facilitating disorientation
• Source of cognitive stimulation
• Participate in care of patient to
the extent possible
19
See Notes for reference.
Take-Home Points
• Delirium, an acute change in cognition and attention,
is common, morbid, and costly
• In the inpatient setting, all new changes in mental
status should be assumed to be delirium until proven
otherwise
• The treatment of delirium is to identify and remedy
the underlying causes
• Elements of the hospital environment can contribute
to delirium and expose patients to safety risk
• Family members and caregivers are crucial to the
diagnosis and management of delirium; incorporating
them into the plan of care is strongly recommended
20