Download Geriatric psychiatry: Acute Management of Agitation and Delirium

Delirium
M. Asif Khan, MD
Assistant Professor, Baylor College of Medicine
Staff Psychiatrist General Mental Health Clinic (GMHC)
Michael E. DeBakey VA Medical Center
Objectives
• Overview of Delirium: Understand the pathology of
delirium and how to diagnose and identify delirium
in a clinical setting.
• Managing Agitation in Delirium: Pharmacological and
non pharmacological management of delirium
• Caveats of Medication Management:
Delirium
• Very Common reason for Consultation Liaison
Psychiatry Consult in the hospital setting and very
often misdiagnosed as depression, anxiety and
advancing dementia.
• Major cause of prolonged hospital stay.
• Preventable in many cases
• 11% mortality rate
Delirium occurs in:
• 10-15 % of all hospitalized adults
• 30-50% of all geriatric admissions
• 80% of ICU patients has some form of Delirium.
Delirium
• Delirium is often described as:
1. An acute confused state
2. Septic Encephalopathy
3. Acute Brain Failure
4. ICU Psychosis
Delirium Defined
• Delirium is a disturbance of consciousness
characterized by acute onset and fluctuating
course of inattention accompanied by either a
change in cognition or a perceptual
disturbance, so that a patient’s ability to
receive, process, store, and recall information
is impaired.
DSM 5 Criteria for Delirium
• A. Disturbance in attention (i.e., reduced
ability to direct, focus, sustain, and shift
attention) and awareness (reduced orientation
to the environment).
• Patient will be able to see and acknowledge
you however they will not be able to sustain
the attention
DSM 5
• B. The disturbance develops over a short period
of time (usually hours to a few days), represents
an acute change from baseline attention and
awareness, and tends to fluctuate in severity
during the course of a day.
• Patient will have an abrupt change in cognition
from baseline and symptoms will be fluctuating.
Patient will go in and out of a state of confusion.
Sundowning.
DSM 5
• C. An additional disturbance in cognition (e.g.
memory deficit, disorientation, language,
visuospatial ability, or perception).
• Patient has difficulty with attention and is
accompanied by an additional disturbance in
cognition.
• Very Low Mini Mental Score
DSM 5
• D. The disturbances in Criteria A and C are not
better explained by a pre-existing, established
or evolving neurocognitive disorder and do
not occur in the context of a severely reduced
level of arousal such as coma.
• Not a progression of a pre-existing dementia
(dementia predisposes) , remember acute.
• Patient has to be able to respond to verbal
stimulation.
DSM 5
• E. There is evidence from the history, physical
examination or laboratory findings that the
disturbance is a direct physiological consequence
of another medical condition, substance
intoxication or withdrawal (i.e. due to a drug of
abuse or to a medication), or exposure to a toxin,
or is due to multiple etiologies.
• There is always a medical reason for delirium,
trick is to find it.
DSM 5 Specifiers
(1)substance intoxication delirium
(2)substance withdrawal delirium
(3)medication-induced delirium
(4)delirium due to another medical condition
(5)delirium due to multiple etiologies
(6)acute
(7)persistent
(8) Hyperactive: Agitation
(9) Hypoactive: quiet, compliant or depressed
(10) mixed level of activity
Predisposing Factors
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Older age
Cognitive Deficits
Sensory: Hearing, Vision, Dentures
Medical Comorbidities
Polypharmacy
Anticholinergic Meds
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1.
2.
3.
4.
ANTIHISTAMINES
(H-1 BLOCKERS)
chlorpheniramine
cyproheptadine
diphenhydramine
hydroxyzine
• CARDIOVASCULAR
1. furosemide
2. digoxin
3. nifedipine
4. disopyramide
• PSYCHIATRIC
1. quetiapine
2. paroxetine
• GASTROINTESTINAL
1. cimetidine
2. ranitidine
3. chlordiazepoxide
4. dicyclomine
• URINARY INCONTINENCE
1. oxybutynin
2. probantheline
3. solifenacin
4. trospium
Pathophysiology
Pathogenesis of Delirium is not fully understood,
most likely due to the accumulation of several
factors. The straw that broke the camel’s back?
• Neurotransmitter: Increase in Dopamine and
decrease in Acetylcholine
• Encephalopathy and Inflammation : Increase in
cytokines IL-8, TNF, Cortisol
• Disturbance in the sleep wake cycle: GABA
• Decrease in oxygenation to the brain
Pathophysiology
Precipitating Factors and Iatrogenic
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D:
E:
L:
I:
R:
I:
U:
M:
S:
Drugs and Dementia
Eyes, Ears and other sensory deficits
Low O2 states
Infection
Retention (Bowel and Bladder)
Ictal state
Under Hydration and Nutrition
Metabolic Causes
Sleep and Subdural
Preventing Delirium
Diagnosis
• Delirium is a Clinical Diagnosis
• Difficult to obtain from EEG or Imaging.
• Collateral information from patients family,
nursing home, nursing staff about acute change
in mental status from baseline.
• Many tools and rating scales to chose from
CAM-ICU: Confusion Assessment Method for the
ICU. Very high sensitivity and specificity.
Richmond Agitation-Sedation Scale
CAM-ICU
CAM-ICU
• If CAM-ICU is positive and delirium established then
look at RASS again.
• Hyperactive Delirium: RASS +1 to +4
• Hypoactive Delirium: RASS -1 to -3, useful to
distinguish from depression.
• Delirium can start as hypoactive and progress to
hyperactive, be mixed type, and can vacillate between
hypo and hyper active form.
Treating Delirium Looking for Change
Question
• Which of the following psychotropic
medication(s) has the following Black Box
warning?
“Not approved for dementia-related
psychosis; increase mortality risk in elderly
dementia patients…most deaths due to
cardiovascular or infectious events.”
Question
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A) Risperidone
B) Clozapine
C) Olanzapine
D) Haloperidol
E) All of the above
F) None of the Above
G) B and C
Answer
• E) All of the above
• All antipsychotic medications have the Black
Box warning of increased death when used in
elderly patients with psychosis. This includes
first, second, and third generation
medications.
Treating Delirium
• Antipsychotic medications are the mainstays
of treating Delirium
• Very important to document that the benefit
of the treatment outweighs the risk of nontreatment.
• Start low and titrate up as needed.
Treating Delirium
1. Start low dose antipsychotic medication and
titrate up as needed.
• Haloperidol is the most commonly used
medication to treat delirium and is considered
the gold standard.
• Second generation antipsychotic medications
such as risperidone, olanzapine, quetiapine can
also be used, considered second line agents.
• Always try to use oral medications before going
to IM and IV dosing.
Treating Delirium
• Hypoactive Delirium: RASS -1 to -3
• Patient with hypoactive delirium present with
sedation and appear lethargic. They respond
questions slowly and have decrease
spontaneous movement, very often confused
with depression.
1. Treating and reversing underlying cause
2. Haloperidol 5mg PO or 0.5-1mg IM or IV BID
3. Risperidone 1mg PO or 0.5- 1mg IM or IV BID
Treating Delirium
• Hyperactive Delirium: RASS +2 to +4
• Patient with hyperactive delirium present with
agitation, restlessness, combative and often
exhibit psychotic symptoms of hallucinations
and delusions. Patients are often a danger to
self and others.
Treating Delirium
1. Initial Haloperidol dose; 10mg PO or 5mg IM or IV and
reassess in 45-60 minutes. If the patient continues to be
agitated the next dose should be 10mg PO or double the
IM/IV the dose 10mg and reassess in 45-60min. If the
patient continues to be agitated then continue giving the
dose of 10mg either PO, IM/IV every hour until the
agitation is controlled.
2. When the agitation is controlled add up the total doses of
haloperidol given. Take that number and divide by two,
that amount is the standing dose of haloperidol given BID.
3. Continue to use the standing dose until the delirium clears
up and the patient is back to baseline.
Caveats of using Medication
• Haloperidol has the risk of increasing the QTc
interval on an EKG, IV >>IM>>PO, QTc should be
under 500 to be safe.
• Prolonged QTc interval increases the chance of
developing Torsade de Pointes which is a fatal
arrhythmia.
Torsade de Pointes
• DOCUMENT that the benefit of the treatment outweighs the risk of
non-treatment, that all other non restrictive and non evasive
options were exhausted.
• 1:1 Monitoring
• Continuous EKG monitoring especially in ICU setting
• Electrolytes: Keep Magnesium and Potassium at upper levels of
normal to protect against Torsade de Pointes from forming.
• Torsade de Pointes is very rare, however it is fatal if untreated and
requires cardioversion
Dystonia
• Dystonia: involuntary movement disorder in
which a person's muscles contract
uncontrollably in a twisting manner.
Haloperidol usually affects the neck muscles.
Dystonia
• Patients with high muscle mass and low body
fat are more prone to develop dystonia with
haloperidol. Mesomorph > Ectomorph >
Endomorph.
Dystonia
• Dystonia is not an allergy to a medication, it is an
idiopathic response.
• Treatment of Dystonia is with anticholinergic
medications such as benztropine. Despite being
an anticholinergic medication is indicated when a
patient has dystonia or is high risk for developing
dystonia.
• Benztropine dose for dystonia is 1-2mg PO or IM
BID. Patients with Mesomorphic body type
should be given benztropine along with
haloperidol.
Benzodiazepines
• Benzodiazepines are not recommended for
the treatment of agitation or delirium in
elderly patients.
• Benzodiazepines have the potential to cause
more agitation due to dis-inhibitory effects of
the medication.
The End