Download GNRS4Delirium - Geriatrics Care Online

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DELIRIUM
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OBJECTIVES
Know and understand:
• What is delirium?
• How to recognize and diagnose delirium
• The predisposing or precipitating risk factors
for delirium in elderly patients
• How to evaluate and treat elderly patients
with delirium
• Interventions to prevent delirium
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TO P I C S C O V E R E D
• Incidence and Prognosis
• Diagnosis and Spectrum
• Neuropathophysiology
• Risk Factors
• Special Populations: Surgery, Dementia
• Evaluation, Management, and Prevention
• Delirium Guidelines
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DELIRIUM IS ALSO KNOWN AS….
• Acute confusional state
• Acute mental status change
• Altered mental status
• Organic brain syndrome
• Reversible dementia
• Toxic or metabolic encephalopathy
INCIDENCE OF DELIRIUM AMONG
O L D E R PAT I E N T S I S H I G H
• 1/3 of inpatients aged 70+ on general
medical units, half of whom are
delirious on admission
• In ICU: more than 75%
• At end of life: up to 85%
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M O R B I D I T Y A S S O C I AT E D
WITH DELIRIUM
• Recent meta-analysis: 3000 pts followed for
almost 2 years showed increased risk:
2-fold for death
2.4-fold for institutionalization
12.5-fold for new dementia
• Persistence of delirium  poor long-term
outcomes
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RECOGNIZING DELIRIUM
Recognized by
doctors
Not recognized
Recognized
by nurses
Not recognized
• Physicians recognize and document only 20% of cases
• Nurses recognize and document <50% of cases
DIAGNOSING DELIRIUM
• DSM-5TM criteria precise but difficult to
apply
• Confusion Assessment Method (CAM)
 Clinically more useful
 >95% sensitivity and specificity
 Used 10 more frequently than DSM
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DSM-5 DIAGNOSTIC CRITERIA
• Disturbance in attention (reduced ability to focus
and sustain attention) or awareness (reduced
orientation to the environment)
• Change in cognition or a perceptual disturbance
not better accounted for by existing dementia
• Development over a short time (hours to days) and
fluctuation during the day
• Evidence from history, physical, or labs that the
disturbance is a direct physiologic consequence of
a medical condition or a drug
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CONFUSION ASSESSMENT METHOD
1. Acute change in mental status and fluctuating
course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
Requires features 1 and 2 and either 3 or 4
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CAM-ICU
• Version of CAM for non-verbal patients
• Uses same 4 features as CAM
 Attention: Vigilance A, Attention Screening
Exam
 Disorganized thinking: Yes/no questions
• Excellent in ICU/non-verbal patients
 Lower sensitivity in verbal patients
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THE SPECTRUM OF DELIRIUM
• Hyperactive or agitated delirium — 25% of
all cases
• Mixed
• Hypoactive delirium — 50% of all cases,
but less often recognized and appropriately
treated, and poorer prognosis
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N E U R O PAT H O P H Y S I O L O G Y ( 1 o f 2 )
Cholinergic deficiency
•
Delirium is caused by anticholinergic drug
overdose, reversed by physostigmine
•
Acetylcholine is an important
neurotransmitter for cognitive processes
•
Scales available to measure anticholinergic
burden of drug regimens
•
Cholinesterase inhibitors have not been
effective in preventing/treating delirium
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N E U R O PAT H O P H Y S I O L O G Y ( 2 o f 2 )
Inflammation
•
Especially important in postoperative, cancer, and
infected patients
•
↑ C-reactive protein, ↑ interleukin-1β, and ↑ TNF
•
Inflammation can break down blood-brain barrier,
allowing toxic medications and cytokines access to
CNS
•
Neuroinflammation may damage neurons, lead to
long-term cognitive effects
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R I S K FA C TO R M O D E L
• Delirium “caused” by “sum” of predisposing
and precipitating factors
• The greater the burden of predisposing factors,
the fewer precipitating factors required to
cause delirium
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P R E D I S P O S I N G FA C TO R S
• Advanced age
• Dementia
• Functional impairment in ADLs
• Medical comorbidity
• History of alcohol abuse
• Male sex (maybe)
• Sensory impairment ( vision,  hearing)
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DELIRIUM AND DEMENTIA
• Dementia: risk factor for delirium
• Delirium in a patient without dementia:
Associated with incident dementia
• Delirium in a patient with established dementia:
Associated with accelerated cognitive decline
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PRECIPITATING FACTORS
• Acute cardiac events
• Acute pulmonary
events
• Bed rest
• Drug withdrawal
(sedatives, alcohol)
• Fecal impaction
• Fluid or electrolyte
disturbances
• Indwelling devices
• Infections (esp.
respiratory,
urinary)
• Medications
• Restraints
• Severe anemia
• Uncontrolled pain
• Urinary retention
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POSTOPERATIVE DELIRIUM
INCIDENCE
50%
50%
Cardiac surgery
Hip fracture repair
15%
Noncardiac surgery
AAA repair surgery
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INCIDENCE & RISKS FOR
POSTOPERATIVE DELIRIUM
Increased risk with preoperative
risk factors:
• Age over 70
• Cognitive impairment
• Physical functional
impairment
• History of alcohol abuse
• Abnormal serum
chemistries
• Intrathoracic and aortic
aneurysm surgery
50%
10%
1 or 2 risk factors
3+ risk factors
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K E Y S TO P R E V E N T I N G
P O S TO P E R AT I V E D E L I R I U M
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• Peak onset: 1st postoperative day
• Peak prevalence: 2nd postoperative day
• Associated with postoperative pain, anemia, use
of sedatives and opioids
• Recent randomized trial used bispectral monitor
to titrate intraoperative sedation (propofol):
 Delirium rate: light sedation―19%, usual care―40%
D E L I R I U M A N D P O S TO P E R T I V E
COGNITIVE DECLINE
2012 study in cardiac surgical patients: delirium
and postoperative cognitive decline are related
• Patients with delirium experienced a sudden
decline in cognitive function after surgery
• Differences in cognitive trajectory persisted over
1 year of follow-up
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E VA L U AT I O N :
H I S TO RY & P H Y S I C A L
History
• Focus on time course of cognitive changes, esp.
their association with other symptoms or events
• Medication review, including OTC drugs, alcohol
Physical examination
•
•
•
•
Vital signs
Oxygen saturation
General medical evaluation
Neurologic and mental status examination
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E VA L U AT I O N :
L A B O R ATO RY T E S T I N G
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• Base on history and physical
• Include CBC, electrolytes, renal function tests
• Also helpful: UA, LFTs, serum drug levels, arterial blood
gases, chest x-ray, ECG, cultures
• Cerebral imaging rarely helpful, except with head trauma
or new focal neurologic findings
• EEG and CSF rarely helpful, except with associated
seizure activity or signs of meningitis
M A N A G E M E N T:
GENERAL PRINCIPLES
• Requires interdisciplinary effort by MDs, nurses,
family, others
• Multifactorial approach is most successful
because multiple factors contribute to delirium
• Failure to diagnose and manage delirium 
costly, life-threatening complications; loss of
function
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K E Y S TO E F F E C T I V E M A N A G E M E N T
• Identify and treat reversible contributors
 Optimize medications (see next slide)
 Treat infections, pain, fluid balance disorders, sensory
deprivation
• Maintain behavioral control
 Behavioral and pharmacologic interventions
• Anticipate and prevent complications
 Urinary incontinence, immobility, falls, pressure ulcers, sleep
disturbance, feeding disorders
• Restore function
 Hospital environment, cognitive reconditioning, ADL status,
family education, discharge planning
MANAGEMENT:
DRUGS TO REDUCE OR ELIMINATE
Almost any medication if time course is appropriate
• Alcohol
• Barbiturates
• Anticholinergics
• Benzodiazepines
• Anticonvulsants
• Chloral hydrate
• Antidepressants
(anticholinergic only)
• H2-blocking agents
• Antihistamines
(anticholinergic only)
• Antiparkinsonian agents
• Antipsychotics
• Non-benzodiazepine
sedatives
• Opioid analgesics (esp.
meperidine)
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M A N A G E M E N T:
NONPHARMACOLOGIC
• Use orienting stimuli (clocks, calendar, radio)
• Provide adequate socialization
• Use eyeglasses and hearing aids appropriately
• Mobilize patient as soon as possible
• Ensure adequate intake of nutrition and fluids, by hand
feeding if necessary
• Educate and support the patient and family
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M A N A G E M E N T:
B E H AV I O R A L S Y M P TO M S ( 1 o f 2 )
• Provide “social” restraints: consider a sitter or
allow family to stay in room
• Avoid physical or pharmacologic restraints
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M A N A G E M E N T:
B E H AV I O R A L S Y M P TO M S ( 2 o f 2 )
Medications may be initiated for behavioral symptoms not
otherwise managed. More about managing delirium with
medications:
• Assess for akathisia and extrapyramidal (EPS) effects
• Avoid in older people with parkinsonism
• In Parkinson disease or Lewy body dementia, a secondgeneration antipsychotic with fewer EPS effects can be
substituted (quetiapine)
• Monitor for QT interval prolongation, torsade de pointes,
neuroleptic malignant syndrome, withdrawal dyskinesias
• Use benzodiazepines for sedative and alcohol withdrawal and
history of neuroleptic malignant syndrome
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THE BEST MANAGEMENT
IS PREVENTION
• HELP Interventions: cognitive impairment, sleep
deprivation, immobility, sensory impairment,
dehydration
• Focus on nonpharmacologic approaches (eg,
sleep protocol involving warm milk, back rubs,
soothing music)
• Limit or avoid psychoactive and other high-risk
medications
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DELIRIUM GUIDELINES
National Institute for Health and Clinical Excellence
(NICE) Guidelines 2010
• Assess risk factors on admission
• Implement preventive interventions
• Screen for incident delirium
• To manage delirium, treat underlying causes,
provide a suitable environment, manage distress
with behavioral methods, use antipsychotics only
if needed
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S U M M A RY ( 1 o f 2 )
• Delirium is common and associated with
substantial morbidity for older people
• Delirium can be diagnosed with high sensitivity
and specificity using the CAM
• A thorough history, physical, and focused labs
will identify the underlying cause(s) of delirium
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S U M M A RY ( 2 o f 2 )
• A careful medication review is mandatory;
discontinue any agent likely to contribute to
delirium, if possible
• Managing delirium involves treating the
primary disease, avoiding complications,
managing behavioral problems, providing
rehabilitation
• The best treatment for delirium is prevention
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CASE 1 (1 of 4)
• A 76-year-old woman is admitted to the hospital for
elective right hip replacement.
• History includes hypertension and type 2 diabetes
mellitus. Medications are enalapril and metformin.
• She complains of mild forgetfulness, often misplacing
her keys or where she left the mail, but otherwise has
been healthy.
• Until 3 months ago, she was swimming 3 miles a
week. Since then, her activities have been limited by
right hip pain.
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CASE 1 (2 of 4)
• On physical examination, vital signs are stable. BMI
is 22 kg/m2. There is decreased range of motion of
the right hip and pain.
• The patient’s score on the Mini–Mental State
Examination is 28 of 30, with 1 point lost on serial 7s
and 1 point lost on recall of 3 words at 5 minutes.
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CASE 1 (3 of 4)
Based on current guidelines, which of the following is
appropriate for preventing delirium in this patient?
A. Delay ambulation by ≥1 additional days after surgery to
encourage early healing.
B. Prescribe a rapid-onset benzodiazepine to promote
sleep hygiene.
C. Avoid multiple moves between rooms during the
postoperative period.
D. Start a low-dose cholinesterase inhibitor.
E. Avoid rigorous hydration during the perioperative period
to prevent pulmonary edema.
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CASE 1 (4 of 4)
Based on current guidelines, which of the following is
appropriate for preventing delirium in this patient?
A. Delay ambulation by ≥1 additional days after surgery to
encourage early healing.
B. Prescribe a rapid-onset benzodiazepine to promote
sleep hygiene.
C. Avoid multiple moves between rooms during the
postoperative period.
D. Start a low-dose cholinesterase inhibitor.
E. Avoid rigorous hydration during the perioperative period
to prevent pulmonary edema.
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CASE 2 (1 of 4)
• An 89-year-old woman is admitted to the hospital with
a urinary tract infection and change in mental status.
• History includes type 2 diabetes mellitus, depression,
and anxiety.
• She moved in with her daughter 8 months ago
because of worsening confusion. Her family notes
that her short-term memory is impaired and that she
has vivid visual hallucinations of children in the
house. They are unaware of any specific diagnosis
regarding her cognition.
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CASE 2 (2 of 4)
• On examination, temperature is 38°C (100.5°F), BP
is 132/78 mmHg, heart rate is 86 beats per minute,
and oxygen saturation is 96% on room air.
• Examination is unremarkable except that the patient
is unable to recite the months of the year or days of
the week forward.
• Although nonpharmacologic treatment is initiated for
delirium, the patient becomes severely agitated
overnight.
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CASE 2 (3 of 4)
Which of the following is the most appropriate
treatment for this patient’s agitation?
A.
B.
C.
D.
E.
Haloperidol
Rivastigmine
Quetiapine
Trazodone
Physical restraints
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CASE 2 (4 of 4)
Which of the following is the most appropriate
treatment for this patient’s agitation?
A.
B.
C.
D.
E.
Haloperidol
Rivastigmine
Quetiapine
Trazodone
Physical restraints
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CASE 3 (1 of 3)
• A 78-year-old man is admitted to the hospital for elective
left total-knee arthroplasty. History includes
hypercholesterolemia, obesity, and osteoarthritis.
• He tolerates the surgery without difficulty, but 3 days later
he appears somnolent. He falls asleep during breakfast
and, even though the nurse converses with him, dozes
off during his dressing change. When he is awake, he
stares out his window.
• Vital signs and laboratory findings are stable. Neurologic
examination is otherwise normal. His surgical wound
shows no evidence of infection.
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CASE 3 (2 of 3)
Which of the following is most likely to help establish the
diagnosis?
A. Orientation to person, place, and time
B. Orientation to person, place, and time and ability to
draw a clock
C. Ability to recite the months of the year or days of the
week forward
D. Score on Geriatric Depression Scale
E. Score on visual analogue pain scale
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CASE 3 (3 of 3)
Which of the following is most likely to help establish the
diagnosis?
A. Orientation to person, place, and time
B. Orientation to person, place, and time and ability to
draw a clock
C. Ability to recite the months of the year or days of the
week forward
D. Score on Geriatric Depression Scale
E. Score on visual analogue pain scale
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GNRS4 Teaching Slides Editor:
Barbara Resnick, PhD, CRNP, FAAN, FAANP, AGSF
GNRS4 Teaching Slides modified from GRS8 Teaching Slides
based on chapter by Edward R. Marcantonio, MD, SM
and questions by Angela Botts, MD
Managing Editor:
Andrea N. Sherman, MS
Copyright © 2014 American Geriatrics Society