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IT'S NOT THE YEARS IN YOUR LIFE THAT COUNT. IT'S THE
LIFE IN YOUR YEARS.” ABRAHAM LINCOLN
DELIRIUM
(and DEPRESSION)
Dr E Holbeach
Geriatrician
DELIRIUM- Outline
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What is it
Why do we care
Why does it happen
What can we do
CASE STUDY
• Evening shift
• Page- please review Mrs M bed 5B UnA. Very
agitated. Need diazepam please.
Delirium definition
• Transient mental disorder
• Impaired concentration, cognition and
altered conscious state
• Fluctuating course
• Acute onset; Lasting days –weeks – months
Criteria for delirium, according to the (DSM IV)
– fluctuations of the conscious state – fluctuating wakefulness, nocturnal disturbance,
poor attention, disorientation
– perceptual disturbance – usually visual hallucinations, other hallucinations also
common including auditory hallucinations and tactile hallucinations,
misinterpretations
– thinking disturbance – often persecutory delusions
– Onset over short time frame
– Evidence that it is secondary to medical condition/ drugs/ substance intoxication
Clinical variants
– Hyperactive 15-47%
• Hyper-reactive,
• autonomic arousal
• Wandering, hallucinations, aggression, agitation.
– Hypoactive 19-71%
• Lethargic, drowsy
• Apathetic, depressed
• Quiet, confused
– Mixed 43-56%
Delirium- IMPORTANCE
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Common problem
Often unrecognized
Serious complications
$$$
Often preventable (40-50% cases)
And importantly…
• INTERNS ARE FREQUENTLY ASKED TO
MANAGE THE BEHAVIOURAL PROBLEMS!!!
Epidemiology
Delirium Rates
Hospital:
-Prevalence (on admission)
-Incidence (in hospital)
-Post hip fracture
Postoperative:
Intensive care unit:
Nursing home/post-acute care:
Hospital mortality:
One-year mortality:
10-40%
15-60%
40-55%
15-53%
70-87%
20-60%
Mortality
22-76%
35-40%
Delirium - importance
• Increases risk of poor outcomes:
– Increased risk of death
– Increased risk of morbidity
• ↑ 2-3 times hospital acquired complication
• Eg- falls, pressure areas, pneumonia
– Increased risk of functional decline
• higher risk of discharge to residential care: x 3-7
– Increased length of stay: x 2.2; ≈ 5day
• Cost to the healthcare system
– Hospital costs
– Post hospital costs
DIAGNOSIS
• FREQUENTLY MISSED!!
• Previous studies: 32-66% cases unrecognized
by physicians
• Yale-New Haven Hospital study (1988-1989):
– 65% (15/23) unrecognized by physicians
– 43% (10/23) unrecognized by nurses
CAM- Confusion Assessment Method
Uses 4 criteria assessed by CAM:
(1) acute onset and fluctuating course
(2) inattention
difficulty focusing, distractiblity, trouble following conversation
(3) disorganized thinking
incoherent, rambling, irrelevant conversation, illogical flow, unpredictable switching between topic
(4) altered level of consciousness
lethargy, stupor, hypervigilant/ hyperalert
Delirium= the presence of criteria: (1), (2) and (3) or (4)
Pathophysiology
- Not really understood… but:
- Functional rather than structural lesion
- Characteristic EEG findings (generalized
slowing)
- Final common pathway of many
pathogenic mechanisms—resulting in a
failure of cholinergic transmission
- Other neurotransmitters also invovled:
dopaminergic excess, NA, 5HT3, GABA,
cytokines etc etc etc
Aetiology
• Almost always multifactorial
• Predisposing factors (vulnerable patients)
• Precipitating factors ( noxious stimuli)
• Similar to concept of seizures and seizure
threshold – with enough noxious stimuli
delirium can occur in “normal” brain or
alternatively with minimal noxious stimuli in
a “vulnerable” brain
AETIOLOGYmultifactorial model
Predisposing factors in hospital
patients (high level of evidence)
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Age > 70 years ( increases with ↑ age)
Blind -sensory impairment – particularly visual
Cognitive impairment – dementia
Co existing illness - severity, co morbidity
Drugs– on more than three medications
Depression
Electrolyte imbalance – abnormal Na
Exposure to procedures – particularly IDC,
physical restraints, multiple procedures
So- elderly, frail, cognitively impaired, sensory
deprived with multiple medical conditions on
multiple drugs….
Delirium - Management
Identify precipitating factors
– reverse these where possible
Manage the symptoms
-provide supportive care environment
Prevent complications
-pressure sores, falls (risk reduction measures)
Educate patient carers and families
-can be very scary for the patient and their family
Case Study
• Mrs M is a 78 year old female from home alone. Day one of
admission to hospital with urinary incontinence, raised
inflammatory markers, likely infective exacc COPD. Started
on Ceftriaxone, Azithromycin, bronchodilators,
prednisolone. Also started on Gliclazide for DM and
oxycontin for back pain.
• Comorbidities- T2DM, COPD, Microcytic anaemia, GORD,
osteoarthritis with chronic back pain.
• On review- Restless. Pulling at bed clothes, trying to get out
of bed. Distracted. Starts screaming and scratching when
you try to examine….
Step 1- identify precipitants
• Review History
• Collaborative history
– Incl baseline functional status, baseline cognition
– Incl ETOH/ drug history (NEVER ASSUME)
• Examination/ Observation
• Review Medication Chart
– Then review it again
• Investigations
Examination
NEVER EVER WRITE “UNABLE TO EXAMINE DUE TO AGITATION”you can ALWAYS observe something that is helpful in the
assessment.
• Conscious State/ Behaviour
• Observations, including BSL, bowel chart review
• FULL examination
– Chest/ Abdo/ Skin/ Peripheries
– Fluid status
– Neuro- abbreviated examination
• Limb movement/ pupils/ facial asymmetry/ cogwheel
– IDC/ IVC/ telemetry leads
– shackles
• ANY ACUTE ILLNESS!
• Don’t forget constipation, urinary retention- bladder US if unsure
Medication Chart
• Almost all drugs may contribute
• Increased number of drugs ↑ risk
• Particular medications significantly increase
risk
• Any psychoactive medication or medication
with significant psychoactive side effects (
i.e. anticholinergic, opiates)
Think Medications
• Which ones?!
– Sedatives
– Opiates, narcotics
– Anticholinergics
– Steroids
– Centrally acting drugs
– Multiple medications- think drug-drug interactions
– Diuretics –watch for hyponatraemia, dehydration,
ARF
Investigations
• Bloods:
FBE, UEC, LFT, CRP, Ca++
– Make sure B12, Fol, Vit D, TSH checked in last 3m
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MSU
CXR
B cultures
Others as per clinical picture
– ABG- check for hypercapnoea, hypoxia
– CTB if focal neuro, hx of head trauma or delirium not
resolving
– Ammonia if history of CLD
– Consider LP, EEG, CK, trop
STEP 2- MANAGEME THE SYMPTOMS
SUPPORTIVE CARE ENVIRONMENT
• Environment
– lighting, quiet, orientation cues
• clock, familiar objects
– Maintain sleep-wake cycle
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Avoid room changes, regular carers, staff
Provide access to hearing aids, glasses
Maintain oral intake, maintain hydration
Maintain regular bowel function
Maintain independence with ADL’s – mobility
Avoid IDC, physical restraints
Good communication – i.e. interpreters
Use 1:1 care and family to sit with patient
Escalating behaviours…
• Agitation, aggression to the point that patient
or others at risk
• May need to use pharmacotherapy
– Start low, go slow!
Antipsychotic management
• Haloperidol only agent in RCT, less data on atypicals
• Low doses initially –
– Haloperidol
0.25 mg – 0.5mg (po/ IM)
– Risperidone 0. 25 – 0.5mg
(po, quicklet)
– Olanzapine
2.5mg - 5mg
(po/ wafer/ IM)
– Quetiapine
12.5 – 25mg
(po)
• Avoid benzodiazepines if possible as can worsen
delirium unless EToH withdrawal
– If you need to use (eg- parkinsons/ DLB patients, not
responding to above):
• Oxazepam 7.5- 15mg (po) intermediate acting benzodiazepine
Antipsychotic risks
• All antipsychotics cause sedation and
drowsiness – which can perpetuate delirium
• All can cause extra pyramidal side effects
(greater with haloperidol)
• All can increase QT (avoid if QTc >500)
• Olanzapine/ Risperidone – increased risk
stroke in elderly pts with dementia
• Make a plan to wean these medications !
– IF DISCHARGED ON THESE MEDICATIONS
PLEASE WRITE ON DISCHARGE SUMMARY FOR
GP TO REVIEW AND REDUCE DOSAGE!!
Step 3: Prevent complications
• Reduce risk of falls
– Hi-lo bed
– 1:1 nursing
– Close to nurse station
– Avoid use of physical restraints !
• Reduce risk of pressure areas
– Air mattress, elevate heels, reposition
• reduce risk of other injury
– Remove all unnecessary catheters lines
etc
Step 4: Education to Family
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Educate family as to what delirium is
Educate family as to how they can help
Educate family as to what to expect
Educate patient as they are improving!!
Delirium outcomes
– only 4% completely resolved at
discharge
– 18% completely resolved at 6 months
– 31% improved but relapsed post
discharge
– 31% still met DSM criteria at 6 months
– Ensure discharge plan takes into
consideration decreased cognition and
ensure follow up is arranged
DEPRESSION
DEPRESSION
• Common!
• Often under-diagnosed and undertreated
• In hospital, THINK about depression for patients
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Loss of appetite, persistent nausea
Non specific symptoms
Not making gains/ not participating in Physio
Psychomotor agitation/ retardation
• Do a suicide assessment:
– Thoughts versus specific plan
Antidepressants
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Not every depressed patient needs antidepressants!
KNOW YOUR DRUGS, know that they are also used to treat other conditions (pain)
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SSRI
– Eg- citalopram, escitalopram, fluoxetine,
– SE: GI, Insomnia, Sedation, Sexual dysfunction, Hyponatraemia
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SNRI
– Eg- venlafaxine, Duloxetine
– SE: GI, headache, sweating, agitation, dizzyness, sexual dysfunction, hyponatraemia
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Others:
– Mirtazepine; SE: sedation, increased apetite, weight gain
– TCA (amitriptyline, dothiepin, doxepin: main use now is in neuropathic pain due to high SE
profile
– MAO A inhibitors
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Drug interaction: AVOID TRAMADOL!!– Risk serotonin syndrome:
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neuromuscular excitation: hyperreflexia, clonus, myoclonus, tremor, rigidity
Autonomic effects: hyperthermia, sweating, tachycardia, mydriasis
CNS effects: agitation, anxiety, confusion
“Knowing is not enough;
we must apply.
Willing is not enough;
we must do.”
Goethe