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Delirium in Older Adults Kathleen Pace Murphy, PhD, MS, GNP-BC Assistant Professor, UTHealth Division of Geriatric and Palliative Medicine Deputy Director, Consortium on Aging Kathleen Pace Murphy, PhD, MS, GNP-BC Assistant Professor, UTHealth Medical School Division of Geriatrics and Palliative Medicine Deputy Director, Consortium on Aging Neither I nor members of my immediate family have any financial relationship with commercial entities that may be relevant to this presentation. Delirium Incidence • 10-24 percent of the hospital patient population • Incidence increases with patient complexity • 60 percent occurs in older adult patients • 60-80 percent incidence in those admitted to a Medical ICU • 80-90 percent in older adults with terminal cancer. Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Critical Care Clinics. 2008;24:657-722/ Delirium or Acute Confusional State DEFINITION • Syndrome • Acute Brain Failure • Characterized by: – Acute – Disturbance in consciousness – Reduced ability to focus, sustain or shift attention – Occur over short period of time – Fluctuates over the course of a day Etiology • Potential causes of delirium include: o Inadequate pain control o Drug or toxin o Metabolic disorders o Neurovascular insult o Systemic organ failure o Complications from a systemic disease Figure out the trigger Drug use (hypnotics, anticholinergic) (30%) Electrolyte abnormalities (40%) Lack of drugs (withdrawal) Infection (40%) Reduced sensory input (24%) Intracranial problems (stroke) Urinary retention and fecal impaction Myocardial or metabolic problems (14- 26%) Often combination of several of the above. Francis J, Martin D, Kapoor W: A prospective study of delirium in hospitalized elderly. J Am Med Assoc. 263:1097-1101 1990 Delirium Increased mortality Poorer functional status Limited rehabilitation Increased hospital-acquired complications Prolonged hospital stay Increased risk of institutionalization Higher health care expenditures. Differential Diagnosis • Hypoactive Delirium • Hyperactive Delirium • Mixed Delirium (46%) • **The main feature differentiating delirium from depression from dementia: Acute – fluctuating nature of symptoms Delirium Differential Diagnosis Depression Delirium Dementia Onset Weeks to months Hours to days Months to years Mood Low Apathetic Fluctuates Fluctuates Course Chronic, Responds to treatment Acute, responds to treatment Chronic, with deterioration over time. Self-awareness Likely to be concerned about memory Maybe aware of changing cognition Hide or be unaware of memory ADLs May neglect basic self-care Intact or impaired Intact early, impaired as disease progresses IADLs Intact or impaired Intact or impaired Intact early, impaired before ADLs as disease progresses Sarutzki-Tucker & Ferry, 2014 Clinical Presentation • Clinical manifestations appear over a shorter period of time (few days) • Progressive decline in memory, awareness to surroundings or behavior • Fluctuate throughout the day • Inability to maintain normal sequential thought PATHOPHYSIOLOGY • Pathophysiology is unclear • Widespread derangement of cerebral metabolism or cerebral insufficiency that leads to decreased synthesis of cerebral neurotransmitters, especially acetylcholine. • Brain maladaptive reaction to acute stress (Ham et al, 2014) • The core group of clinical manifestations: – – – – Attention deficits Sleep-wake cycle disturbance Motor activity changes May present as psychosis, mood changes, fluctuating LOCs, disorientation, memory impairment, and disturbances in speech and language. MORTALITY • Delirium is a medical emergency • Persons who have delirium have a statistically significant higher risk of death compared to age cohorts who do not. Medication Hierarchy • Level 1 - Neuroleptic Level One - Neuroleptics • Level - – Analgesics; Sedatives-Hypnotics; Dopamine agonists Level 2 Two • LevelLevel 3 Three – Antihistamine; anti-inflammatory; anticholinergic; antidepressants; cardiac glycosides Level Four – H2 Antagonist, Dihydropyridine; Tricyclic antidepressants; anti-Parkinson; antimicrobials ANTICHOLINGERGIC MEDICATIONS Play a major role in delirium development Cumulative anticholinergic burden **ACA= anticholinergic activity Score 3- High ACA Score 2 – Moderate ACA Score 1 – Mild ACA Amitriptyline Amantadine Alprazolam Atropine Belladonna Atenolol Clozapine Carbamazepine Bupropion Darifenacin Cyclobenzaprine Captopril Desipramine Cyproheptadine Chlorthalidone Diphenhydramine Loxapine Cimetidine Doxepin Meperidine Clorazepte Hydroxyzine Methotrimeprazine Codeine Imipramine Molindone Colchicine Nortriptyline Oxcarbazepine Diazepam Olanzapine Pimozide Digoxin Oxybutynin Fentanyl Paroxetine Furosemide Quetiapine Haloperidol Tolterodine Metoprolol Imipramine Prednisone Screening Tools • Richmond Agitation Sedation Scale (RASS) • Confusion Assessment Method (CAM) • Confusion Assessment Method for ICU (CAMICU) • Neelon and Champagne Confusion Scale (NEECHAM) E. Wesley Ely, MD MPH and Vanderbilt University, 2002. Confusional Assessment Method (CAM) Delirium if you have 1 + 2 +[either 3 or 4]. Diagnostic Features Definitions and Characteristics 1. Acute Onset Fluctuating Course • Is there evidence of an acute change in mental status from baseline? • Did the abnormal behavior fluctuate during the day, does it come and go, or increase and decrease in severity? 2. Inattention • Did the patient have difficulty focusing attention (easily distracted) or have difficulty keeping track or what was being said? 3. Disorganized Thinking • Was the patient’s thinking disorganized or incoherent, e.g. rambling, irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. Altered LOC • LOC – alert (normal), vigilant (hyper alert), lethargic (drowsy but easily arousable), stupor (difficulty to arouse) or coma (unarousable) Inouye SK, vanDyck CH, Alessi CA, et al. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med 1990:113:941-8. Delirium Management Listical • Knowledge and addressing the underlying cause • Be mindful of the environment • Do not over stimulate • Good patient care • Medications (hopefully last resort) Assessment Vital Signs: BP, P, HR, T, Pulse Ox, Pain Physical Examination Urinalysis Cr, Na, K, Ca, Glucose CBC with differential Review old and new anticholinergic medications Review old and new sedating medications Review the need for Foley catheters, IV lines, and other tethers Apply glasses, insert hearing aides Intervention Step 1 • Identify and Treat reversible contributors – Medications – Infection – Fluid balance disorders – Impaired CNS oxygenation – Severe pain – Sensory deprivation – Elimination Problems Intervention Step 2 • Maintain behavioral control – Behavioral interventions – Pharmacologic Interventions • Necessary for behavior that is dangerous to patient or others and does not respond to other management strategies Intervention 3 • Anticipate and prevent or manage complications – Urinary incontinence – Immobility and falls – Pressure ulcers – Sleep disturbance – Feeding disorders Intervention 4 • Restore function in delirious patients – Hospital environment – Cognitive reconditioning – Ability to perform ADL – Family education/support/ participation – Discharge Prevention • Limit use of medications known to cause delirium • Ensure good nutrition and hydration • Correct sensory deprivation • Encourage normal sleep patterns • Promote cognitive stimulation Prognosis • Delirium is usually reversible. • Take several weeks for mental function to return to normal levels • The longer the delirium goes untreated – there is worsening global cognition and executive function worsening. • Pathophysiological evidence – inflammation – neuronal apoptosis – brain atrophy References • Catic AG. Identification and management of in-hospital drug-induced delirium in older patients. Drugs Aging. 2011:28(9):737-748. • Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review. Age and Ageing. 2011. 40:23-29. • Gatewood M. Managing delirium among elderly patients in the ED. Physician’s Weekly, 2013. • Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Critical Care Clinics. 2008;24:657-722. • Reade MC, Finfer S. Sedation and delirium in the intensive care unit. New England Journal of Medicine 2014;370(5):444-454. • Sarutzki-Tucker A, Ferry R. Beware of delirium. The Journal for Nurse Practitioners 2014:10(8); 575-581.