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Assessing the Geriatric Psychiatric Patient in the Subacute Setting: Approach to Delirium Assessment Stephen M. Scheinthal, DO, FACN Associate Professor, Psychiatry University of Medicine and Dentistry of New Jersey School of Osteopathic Medicine (UMDNJ-SOM) Image created by the University of Medicine & Dentistry of New Jersey School of Osteopathic Medicine Assessing the Geriatric Psychiatric Patient in the Subacute Setting: Approach to Delirium Assessment This geriatric psychiatry presentation for general psychiatry residents is offered by the New Jersey Institute for Successful Aging. This lecture series is supported by an educational grant from the Donald W. Reynolds Foundation Aging and Quality of Life program. Learning Objectives • To describe the risk factors for acute confusion in older patients • To distinguish between appropriate and inappropriate use of psychoactive medications in a patient with acute confusion • To utilize effective management strategies in the treatment of hypoactive delirium • To recognize the value of the interdisciplinary team in caring for patients in the subacute setting Approach to the Geriatric Consult in the Subacute Setting History Medication Review Psychiatric Evaluation Diagnosis and Plan Follow Up History Components Chart Review Current status Hospital course Collateral Information Nursing Social Work Physical Therapy Family Medication Review Case of Mrs. M. Image © Yuri_arcurs | Dreamstime.com (http://www.dreamstime.com/senior-female-patient-in-hospital-image11308837#) Consults Case of Mrs. M Consult Request Dr. Smith, Geriatric Psychiatry Reason for Consult Patient depressed and tearful Please evaluate and treat History Patient Mrs. M is a 78 year old female Case of Mrs. M Past Medical History Stroke Hypertension Hospital Course Diabetes mellitus Admitted to subacute facility 2 Coronary artery days ago from local hospital for disease rehabilitation following right hip Degenerative joint fracture disease Patient fell at home Osteoporosis Hospital stay of 5 days Urinary tract infection Patient became very confused and agitated on Hospital Day 3 Case of Mrs. M Interdisciplinary Notes Nursing Patient has been very lethargic since admission. She is not participating in therapy. Sleeps most of the day. Only eats 50% of her meals. Social Work Patient was widowed and living alone. Two children live out of the area and not very involved in care. She was independent up until fall. No prior psychiatric history. She is a college graduate and a former teacher. Family Concerned that patient is over medicated. She was never like this before. Family reported patient on no psychiatric medications prior to hospitalization. PT Notes Case of Mrs. M Physical Therapy Prior function: Family reported patient was living independently. Fully functional, no deficits noted. Current function: Not ambulating, non weight bearing, not participating in therapy, tearful, but does not admit to any pain. Medication Review Components Current and previous medications Conduct medication reconciliation Review medications started in hospital and reasons they were started High risk medications Potential for adverse events Drug-drug interactions Risk versus benefit Medications Case of Mrs. M Current Medications New Medications Ambien 10mg QHS Seroquel 50mg TID Glucophage 500mg QD Ativan 0.5mg BID Metoprolol 50mg BID Plavix 75mg QD Reglan 10mg QD No OTC Things to Think About Why is patient on Seroquel? Patient was restless and agitated on Hospital Day 3 Stat Psychiatry Consult for agitation ordered Psychiatry Consult reflects delirium, but no etiology identified Hospital records show Seroquel was started for delirium Records show medication was effective in reducing agitation Things to Think About If acute behavior has resolved, why was the medication continued? Psychiatrist did not return to see patient before discharge Medication was just transposed to transfer form and continued at subacute unit Things to Think About What are the risks of continuing this medication? Sedation/Falls/Dizziness/Orthostatic Hypotension QT Prolongation Diabetes Mellitus/Weight Gain Hyperlipidemia Extrapyramidal Symptoms (EPS)/Tardive Dyskinesia (TD) Constipation/Abdominal Pain/Upset Stomach Abnormal Liver Function Tests Neuroleptic Malignant Syndrome (NMS) Antipsychotic Use in Delirium Antipsychotics are the drug of choice in delirium Referred to as the major tranquilizers Used to address the severe behaviors while the underlying medical cause is treated Practice guideline for the treatment of patients with delirium. Am J Psych 156(5 Suppl):1-20, 1999. Antipsychotic Use in Delirium Recommended Haldol dosing in Delirium 0.5-1mg po Q1 hour until desired effect is reached Avoid IV Haldol due to risk of Torsade des pointes unless the patient is on a cardiac monitor Antipsychotics should be tapered and discontinued over 2-3 days after symptoms resolved. Risks Falls, orthostatic hypotension, sedation Neuroleptic Malignant Syndrome (NMS) Extra Pyramidal Symptoms (EPS)/ Tardive Dyskinesia (TD) Increased risk of cerebral adverse events Markowitz JD, Narasimhan M. Delirium and antipsychotics: A systematic review of epidemiology and somatic treatment options. Psychiatry 5(10):29-36, 2008. Practice guideline for the treatment of patients with delirium. Am J Psych 156(5 Suppl):1-20, 1999. Antipsychotic Use in Delirium Atypical Antipsychotics have also been shown to be effective May have lower incidence of anticholinergic side effects Recommended dosing of Risperdal in Delirium Dosing 0.25-0.5mg po or dissolvable tab Q 8-12 hours Do not exceed 2mg in 24 hours Practice guideline for the treatment of patients with delirium. Am J Psych 156(5 Suppl):1-20, 1999. Things to Think About Why is the patient on Ativan? Chart reflects Ativan 0.5mg Q 8 hours is for crying Hospital notes reflect patient was crying Ativan was started on Hospital Day 2 for crying Follow up notes reflect patient much calmer, no crying Ativan is a renally cleared benzodiazepine Patient may have been calmer due to tranquilizing effect Ativan is not a treatment for depression Benzodiazepines Minor tranquilizer Indicated for anxiety, muscle relaxants, status epilepticus, nausea/vomiting, preoperative sedation Contributes to an increase risk of: Falls Confusion Depression/Suicidal ideation Delirium Very habit forming Indications for Medication Use for Acute Confusion Psychotropic medications reserved for patients in distress due to severe agitation or psychotic symptoms Avoid psychotropic medications for the specific purpose of controlling wandering Aim for monotherapy, lowest effective dose, and tapering as soon as possible Antipsychotics are the treatment of choice Use of Benzodiazepines should be avoided Reserved for delirium caused by withdrawal from alcohol/sedative hypnotics Recupero PR, Rainey SE. Managing risk when considering the use of atypical antipsychotics for elderly patients with dementia-related psychosis. Journal of Psychiatric Practice 13(3):143-152, 2007. Case of Mrs. M Exam Mental Status Exam Appearance 78 yo female who appears much older than stated age. Fair dress and grooming. Patient is in bed, min-cooperative, poor eye contact. Speech Speech sparse, underproductive, no pressure. Affect/Mood Mood “horrible” with a sad/tearful affect. Thoughts No suicidal or homicidal ideation, no auditory or visual hallucinations, no looseness of associations, no flight of ideas, no ideas of reference, no paranoia. Sensorium/ Cognition AAOX 2 (self and place, not date). Memory: short term memorylimited, long term memory-good, insight and judgment-fair. Things to Think About What is happening with the patient? Dementia Delirium Depression Assessment Case of Mrs. M Does the patient have depression? Tearful Not eating Says she is depressed Not participating in therapy No prior history of depression DSM-IV-TR Diagnostic Criteria for Depression A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. 1) 2) 3) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. DSM-IV-TR Diagnostic Criteria for Depression A. Cont’d 4) 5) 6) 7) 8) 9) insomnia or hypersomnia nearly every day. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). fatigue or loss of energy nearly every day. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. DSM-IV-TR Diagnostic Criteria for Depression B. C. The symptoms do not meet criteria for a Mixed Episode. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000. Assessment Case of Mrs. M Does the patient have dementia? Decline in function Short term memory limited Long term memory good DSM-IV TR Criteria for Dementia of the Alzheimer’s Type A. The development of multiple cognitive deficit manifested by both: 1) Memory impairment (impaired ability to learn new information or to recall previously learned information). 2) One (or more) of the following cognitive disturbances: (a) (b) (c) (d) B. aphasia (language disturbance) apraxia (impaired ability to carry out motor activities despite intact motor function) agnosia (failure to recognize or identify objects despite intact sensory function) disturbance in executive function (i.e. planning, organizing, sequencing, abstracting) The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. DSM-IV TR Criteria for Dementia of the Alzheimer’s Type C. The course is characterized by gradual onset and continuing cognitive decline. D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following: 1) 2) 3) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g. cerebrovascular disease, Parkinson’s disease, Huntington’s disease, subdural hematoma, normal-pressure, hydrocephalus, brain tumor) systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection) substance-induced condition DSM-IV TR Criteria for Dementia of the Alzheimer’s Type E. F. The deficits do not occur exclusively during the course of delirium. The disturbance is not better accounted for by another Axis I disorder (e.g., Major Depressive Disorder, Schizophrenia) DSM-IV TR Criteria for Dementia of the Alzheimer’s Type References 1. Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can Fam Physician 47(1):101-107, 2001. 2. Practice guideline for the treatment of patients with delirium. Am J Psych 156(5 Suppl):1-20, 1999. 3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000. Assessment Case of Mrs. M Does the patient have ongoing delirium? Lethargic Fluctuating mental status Acute onset Disorientation Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can Fam Physician 47(1):101-107, 2001. DSM-IV-TR Diagnostic Criteria for Delirium A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. B. A change in cognition (e.g., memory deficit, disorientation, language disturbance). C. Development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. D. Disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000. Psychomotor Variants of Delirium • Hyperactive (30%) Agitation, combativeness, restlessness, hallucinations Easiest to recognize (loud, disruptive patients) • Hypoactive (24%) Lethargy, reduced psychomotor functioning More likely to go unrecognized (“good patients”) • Mixed (46%) Features of both hypo and hyperactive delirium Agitated and combative with alternating episodes of somnolence and hypoactivity Meagher DG, O’Hanlon D, O’Mahony E, et al. Relationship between symptoms and motoric subtype of delirium. J Neuropsychiatry Clin Neurosci 12(1):51-56, 2000. Delirium versus Dementia Symptom Delirium Dementia Onset Acute Insidious Duration Days to weeks Months to years Course Fluctuating Slowly progressive Attention Poor Usually unaffected Consciousness Impaired Clear until late in course of illness Confusion Assessment Method (CAM) Criteria 1. History of acute onset of change in patient’s normal mental status & fluctuating course AND 2. Lack of attention Sensitivity: 94-100% Specificity: 90-95% AND EITHER 3. Disorganized thinking 4. Altered level of consciousness 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;113(12):941–948. Pompei P, Foreman M, Cassel CK, et al. Detecting delirium among hospitalized older patients. Arch Intern Med 1995;155(3):301-307. Acute Onset and Fluctuating Course Usually obtained from family member or somebody who spends a lot of time with the patient “Is there evidence of acute change in mental status from the patient’s baseline?” “Did the behavior fluctuate during the day; that is, did it tend to come and go or increase/decrease in severity during the day?” Inattention “Did the patient have difficulty in focusing attention?” “Was the patient easily distractible?” “Is the patient having difficulty in keeping track of what was being said?” Serial 7s or spell the word “world” backwards Disorganized Thinking “Was the patient’s thinking disorganized or incoherent?” “Rambling or irrelevant conversations?” “Unclear or illogical flow of ideas?” “Unpredictable switching from subject to subject?” Assessment Axis I Axis II Axis III Axis IV Axis V Case of Mrs. M Delirium, to consider Dementia NOS, to consider Depression NOS, to consider Adjustment Disorder with Depressed Mood Defer S/P Fx hip, HTN, DM, CAD, DJD, Osteoporosis, UTI Social, financial, chronic medical illness 50 Search for Underlying Cause D Drugs E Electrolytes L Lack of drugs (poor pain control, sedative or alcohol withdrawal) I Infection Reduced sensory input (restraints, visual or hearing R impairment) I Intracranial (seizure, subdural hematoma, stroke) U Urinary retention/fecal impaction M Myocardial (congestive heart failure, MI) Who is at risk for developing delirium? Pre-existing cognitive disorder Depression Visual impairment Age greater than 70 Environmental change Alcohol history Psychoactive medication history Surgical procedure Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can Fam Physician 47(1):101-107, 2001. How do you manage delirium? Establish underlying causes & treat D/C or drugs Fluids, lytes, nutrition, O2 Supportive care + reorientation Minimize environmental isolation Glasses/hearing aids Attention to patient concerns & fears Remove immobilizing lines and devices Avoid restraints Adequately assess and treat pain Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can Fam Physician 47(1):101-107, 2001. Plan Case of Mrs. M 1. D/C Seroquel. Patient does not have any signs or symptoms of agitation or psychosis. Can be increasing sedation, can exacerbate Diabetes. Can cause QTC prolongation. 2. D/C Ativan. Benzodiazepines do not treat depression (tearfulness). Benzodiazepines can increase confusion, lethargy, falls, cause agitation and may increase depression. Prognosis and Follow Up It will take 7 to 14 days to allow the medication to wash out. Patient did not have prior psychiatric history This is a good prognostic indicator Greater likelihood that patient will return to baseline Avoid temptation to treat side effects with more medication, this is called the prescribing cascade. Cannot determine if patient had dementia or depression until delirium has resolved. Pearls Multiple sources of information are key to adequate assessment. Do not exclude the roles of nursing, social work, physical therapists. Don’t assume because a patient is on a medication that it should be continued. Antipsychotics are the drug of choice for delirium but can be safely removed once the acute episode has ended. Pearls Medications are frequently prescribed for reasons that they are not indicated. Dementia is the major risk factor for Delirium. Dementia and Depression commonly co-exist and it can be difficult to distinguish between the two.