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‫• בן ‪ 83‬בדיור מוגן‪ .‬אלמן ואשתו נפטרה לפני חצי שנה‬
‫• ברקע‪ :‬יתר ל‪.‬ד‪ ,.‬סוכרת עם סיבוכים‪ ,‬תעוקת לב‬
‫• שבועיים ירד בתפקוד‪ .‬לא הגיע למועדון‪.‬‬
‫• יום לפני העברה למיון ישן מול הטלוויזיה‪ .‬היה קושי בדיבור‪ ,‬אי‬
‫שליטה בשתן‬
‫• אין מחלת נפש ברקע‬
‫• היה שקט ושיתף פעולה‬
‫• נתרן נמוך ונמצא שיש לו ‪UTI‬‬
‫• פסיכאטר הגיע להעריך מצבו לדיכאון‬
‫• לוקח‪Insulin, normiten, Vasodip, Aspirin :‬‬
‫• במבחן ‪ MMSE‬צבר ‪ .9/30‬לא מסתקל אליך‬
He is presenting as a classic example of
hypoactive delirium however:
• Urinary incontinence with altered mental status
should prompt concerns about normal pressure
hydrocephalus
• He could have had a stroke or fall given his diabetes,
hypertension and peripheral neuropathy- he needs a
head CT
• The UTI and hyponatremia could cause delirium and
even with appropriate treatment mental status may
take weeks and even months in the elderly- some
may never return to baseline
Other possible contributing factors:
• Meds such as benzodiazapines
• Glycemic abnormalities- how are his blood sugars?
• Would need to rule out alcohol withdrawal or
overdose-always do a urine tox screen
• Is he depressed?
• Is he demented?
• The low MMSE reveals severe impairment which is
common in delirium. His poor effort could signal
inattention or depression.
Confusion
Dr Gary Sinoff
Department of Gerontology
University of Haifa
Outline of Lecture
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Definition of Delirium
Pathophysiology
Epidemiology
Clinical Presentation
Causes
Diagnosing
Treatment
Prognosis
Confusion
Confusion: a loss of one's capacity to think clearly
and coherently, and it is a non-specific symptom of
many different mental disorders or organic pathology.
Both delirium and dementia are characterized by a
global impairment in cognitive functioning.
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Why is Delirium Important?
Common,
Morbidity/Mortality,
& Costly!
1. Definition
Characteristics of Delirium
• Disturbance of consciousness
• Abnormal cognition
• Acute in onset and fluctuating in course
• Precipitated by a cause
• Misdiagnosis is frequent
Definition
DSM –IV TR (APA, 2000)
1. Disturbance of consciousness : reduced ability to focus,
sustain, or shift attention, easily distracted.
2.
Disturbance in memory: disorientation to time and place,
disturbed recall.
3.
Disturbance in language: dysarthria, dysgraphia, incoherent
speech, switching of topics.
4.
Over a short period of time: usually hours to days,
fluctuating during the course of the day
5.
Evidence that it is caused by a medical condition, substance
intoxication, or medication side effect.
2. Pathophysiology
Many hypotheses exist including:
• Neurotransmitter abnormalities
• Inflammatory response with increased cytokines
• Changes in the blood-brain barrier permeability
• Widespread reduction of cerebral oxidative metabolism
• Increased activity of the hypothalamic-pituitary adrenal
axis
Neurotransmitters and Cytokines
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↓ Acetylcholine
↑ Dopamine
↑ Noradrenaline
↑ Serotonin
↓ Histamine
GABA
Cytokines : IL-1, IL-2,
IL-6, TNF; IF
3. EPIDEMIOLOGY
Prevalence Rates
Common in hospitalized older adults:
Approximately 40% of hospitalized elderly >65
• Emergency Department 10%
• Post-hip fracture
35 - 65%
• Surgical Wards
15 - 30%
• General Medicine
11 - 26%
• Known dementia
30 - 90%
Residential care
9% -16%
Community dwelling elderly?
Expect higher rates with an ageing population
and a shift away from hospital-based care.
EPIDEMIOLOGY
• Delirium is OFTEN UNRECOGNIZED!!
• Many cases undiagnosed
– ~40% of elderly with delirium sent home from ED
in one study
• Misdiagnosed as depression
– ~40% of cases in one study
Cole MG. Am J Geriatr Psychiatry. 2004;12(1):7-21
Epidemiology of delirium
Delirious patients experience greater morbidity:
• Prolonged hospitalizations
• More hospital-acquired complications
• Greater cognitive decline
• Functional decline
• High risk for institutionalization.
Delirium Is Deadly !!!
Mortality rates:
10% - 65%
BUT
With appropriate management, may be reversible
in up to 50%.
Recognizing Delirium
Recognized by
doctors
Not recognized
Recognized
by nurses
Not recognized
– Nurses recognize and document <50% of cases
– Physicians recognize and document only 20%
4. Clinical Presentation
Prodrome Stage
• Patients may describe and/or manifest:
– Decreased concentration
– Irritability, restlessness, anxiety, depression
– Hypersensitivity to light and sound
– Perceptual disturbances
– Sleep disturbance
Precipitating factors
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Polypharmacy
Infections
Dehydration
Immobility including restraint use
Malnutrition
The use of bladder catheters
Sensory Deprivation
Change of room
High noise level
Male gender
Dementia
Identified risk factors for prevention
Cognitive impairment
RR 3.6
Abnormal BP
RR 2.3
CHF
RR 2.9
< 10 mg morphine/day
RR 5.4
“Severe pain”
RR 9.0
Clinical characteristics
• Develops acutely (hours to days)
• Characterized by fluctuating level of
consciousness.
• Reduced ability to maintain attention
• Agitation or hypersomnolence
• Extreme emotional lability
• Cognitive deficits occur
• Disturbed concentration
Types of delirium
• Hyperactive or hyperalert
• Hypoactive or hypoalert
• Mixed
Hyperactive or hyperalert
– Patient is hyperactive, combative and
uncooperative.
– May appear to be responding to internal stimuli
– Frequently these patients come to our attention
because they are difficult to care for.
Hypoactive or hypoalert
– Patient appears to be sleeping on and off
throughout the day
– Unable to sustain attention when awakened,
quickly falls back to sleep
– Misses meals, medications, appointments
– Does not ask for care or attention
– This type is easy to miss because caring for these
patients is not problematic to staff
Mixed
– a combination of both types just described
– The most common types are hypoactive and
mixed accounting for approximately 80% of
delirium cases
5. Causes
Causes
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D
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L
I
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U
M
S
Causes
• Drugs - particularly narcotics and
anticholinergics, withdrawal of
alcohol and benzodiazepines
• Endocrine - hypo /hyperglycemia,
hypercalcemia,
hypo /hyperthyroidism
• Low oxygen – hypoxia
• Infections - particularly UTI and pneumonia
Causes
• Retention- urinary
• Inflammatory arthritis - gout, meningitis
Intoxication
• Underperfused – CHF, CVA, Acute MI
• Metabolic – sodium, potasium, liver failure
• Stool – fecal impaction
Drugs commonly causing delirium:
• Analgesics
NSAIDs, opioids
• Antibiotics
Acyclovir, cephalosporins,
penicillin, quinolones,
sulfonamides, tobramycin
• Anticholinergics
• Anticonvulsants
Carbamazepine, phenytoin,
valproate
• Antidepressants
TCAs, SSRIs
• Cardiovascular
Amiodarone, B blockers,
digoxin, diuretics
• Corticosteroids
• Dopamine agonists
• H2 antagonists
Cimetidine, famotidine,
ranitidine
• Sedative/Hypnotics
• Miscellaneous
Baclofen, donepezil, interferons,
oral hypoglycemics
6. Diagnosis
Diagnosis
• History from family and/or caregivers
• Bedside observations
• DSM-IV diagnostic criteria
• Reliable diagnostic instruments:
– Confusion Assessment Method
– The Delirium Rating Scale- Revised-98
– Delirium Symptom Review
• Diagnostic errors are common in:
– Hypoactive form
– The setting of rapid fluctuations of cognition.
Confusion Assessment Method (CAM)
1. History of acute onset of change in patient’s normal
mental status & fluctuating course
AND
2. Lack of attention
AND EITHER
3. Disorganized thinking
4. Altered Level of Consciousness
Sensitivity: 94-100%
Specificity: 90-95%
Kappa: 0.81
Inouye SK: Ann Intern Med 1990;113(12):941-8
Recognizing Delirium
Lewis et al. Unrecognized delirium in ED geriatric patients.
Am J Emerg Med 1995; 13(2): 142-5.
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Compared the ED physician’s conventional assessment to
the CAM
385 Patients over age 64
CAM: 38 of 385 (10% prevalence)
Physician: 34 of above 38 charts completed
21 of 34 (62%) admitted
Only 6 of 34 (17%) identified with delirium
13 of 34 (38%) discharged
6 of 13 (46%) discharged as “status post fall”
Differentiation Between Delirium
and Dementia
Clinical feature
Delirium
Dementia
Nature of onset
Abrupt onset
Gradual, ill-defined onset
Rapidity of progression
Rapid - hours
Slow - months
Duration of condition
Temporary - days
Long lasting - years
Variability of symptoms
Fluctuating from hour-tohour
Lucid intervals common
Stable from day-to-day
No lucid intervals
Attention span
Very short, variable from
moment-to-moment
Unaffected in early
disease, stable in chronic
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disease
7. Treatment
Treatment
• Based mainly on observational data
• Reduce or discontinue psychotropic,
anticholinergic, narcotic medications.
• Careful focus on intake, nutrition, physical
therapy/mobility, aspiration risk.
NON-PHARMACOLOGICAL MANAGEMENT
Assess safety
– Prevent harm to self or others
– Try to avoid physical restraints
Establish physiological stability
– Adequate oxygenation
– Restore electrolyte balance
– Restore hydration
Address modifiable risk factors
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Correct sensory deficits
Manage pain
Support normal sleep pattern
Minimize room changes
Delirium Reduction
• You can get improvement of delirium with
such simple measures as:
–
–
–
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Glasses
Using hearing aids
Fluids/nutrition
Reducing noise
Early mobility
Familiar faces
Soft lighting
Inouye S. N Engl J Med. 1999;340(9):669-76.
Treatment
• Morphine for pain control
• SSRIs for suspected depression/anxiety
• Benzodiazepines for anxiety
• Neuroleptics for agitation
8. Prognosis
Prognosis
• Delirium is independently associated with:
– Increased functional disability
– Increased LOS
– Admission to long-term care
• Increased hospital mortality of 2 to 20 fold
• May persist for months or indefinitely Delirium
becomes chronic in substantial numbers of
patients
• Two factors related to better outcomes:
– Admission from home
– Better premorbid functioning
Prognosis
CMAJ 1993; 149 (1):41-6. Prognosis of delirium in
elderly hospital patients. Cole MG; Primeau FJ
• Medline, 1980-1992. Meta-analysis of 8 studies
• N = 563
• LOS 21 days*
1 month
6 months
Cognitively
improved
Institutionalized
Died
55%
47%*
14%*
43%*
* p < 0.05
Prognosis
J Gen intern Med 1998; 13(4):234-42. Does delirium contribute
to poor hospital outcomes? A three-site epidemiololgic
study. Inouye et al
•
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N = 727
New nursing home placement: OR 3.0 at d/c and at 3 months
Death or new nursing home placement: OR 2.1 (2.6 at 3 mo)
Functional decline: OR 3.0 (2.7 at 3 months)
Institutionalized
Institutionalized or died
discharge
9%
14%
3 months
13%
25%
Prognosis
J Gen Intern Med 2003; 18(9):696-704. The
course of delirium in older medical
inpatients: a prospective study. McCusker
et al.
• N = 193
Discharge
12 months
# delirium Sx
(cog intact)
3.4
2.2
# delirium Sx
(dementia)
4.5
3.5
Prognosis
JAGS 2003; 51(7): 1002-6. Dementia after delirium
in patients with femoral neck fractures.
Lundstrom et al
• 5 year prospective follow-up study
• N = 78
Dementia Died
No delirium
20%
35%
Delirious
69%
72%
Total group
38.5%
Acute Confusional State
Pearls
•
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Often not recognized
Common among hospitalized patients
Is frequently preventable
Accounts for significant morbidity and
mortality
• Impaired attention is the hallmark
53
Acute Confusional State
Pearls
• In elderly think meds/polypharmacy first
• Consider underlying dementia in elderly who
develop ACS
• Known dementia patients may develop ACS due
to a treatable cause – it is not always
deterioration due to dementia!
• Common irritants such as constipation or urinary
retention may cause ACS in the elderly
54
Acute Confusional State
Pearls
• Consider capacity, competency, and
surrogate issues in informed consent of ACS
patients – write it in the record!
• There is often a time lag of days to weeks
between effective Rx and clinical response
(most significant lag in the elderly)
55
Next Week ?????
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