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The Elderly Patient with Delirium Thomas Price, MD Emory University School of Medicine Division of Geriatric Medicine and Gerontology Overview Definition Presentation Pathophysiology Risk Factors Prevention Management Consequences What’s Going On? BT is an 85 year old man who has been admitted to the hospital for repair of a hip fracture he sustained while playing golf He has a history of hypertension and hypercholesterolemia, both of which are treated On review of systems, he admits to some “memory problems” and difficulty sleeping at night What’s Going On? The day after admission he undergoes total hip replacement Blood loss is estimated at 300cc Two units of blood transfused during the surgery Seems to recover well the next day after surgery, is talking with his family about “getting back on the course” What’s Going On? Four days post-op his wife voices concern that he is “not himself” He seems to ignore her at times during conversations and is not eating much She says he is often confused, saying that he asks her if she’s “taken the dog out” when they haven’t had a dog in years What’s Going On? That night he pulls his IV line out and is witnessed trying to remove his Foley catheter by the nurse Definition DSM-IV Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia. The disturbance develops over a short period of time and tends to fluctuate during the course of the day. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition. American Psychiatric Association, DSM-IV Definition Confusion Assessment Method (CAM) Inouye et al, 1990 56 subjects (65-96 yrs old), 26 with delirium and 30 without, measured with CAM Results • • • • 94-100% sensitive 90-95% specific PPV 91-94%, NPV 90-100% Interobserver reliability of CAM is high (=0.81-1.0) Inouye, SK et al. Annals of Internal Medicine 1990;113:941-948 Definition Confusion Assessment Method (CAM) All of: • Acute onset • Fluctuating course • Inattention And one of the following: • Disorganized thinking • Altered level of consciousness Inouye, SK et al. Annals of Internal Medicine 1990;113:941-948 Definition - ICU Patients Modified CAM - The CAM-ICU Ely et al. modified CAM • Visual recognition to test attention and short-term memory • Scale based on degree of consciousness • Head nodding and hand movements as responses • Sensitivity and specificity comparable to the basic CAM Ely EW et al. Crit Care Med 2001;29(7) Presentation Types of Delirium Hyperactive Delirium • Agitation, vigilance, hallucinations • Easiest to recognize (loud, disruptive patients) Hypoactive Delirium • Lethargy, reduced psychomotor functioning • More likely to go unrecognized (“good patients”) Mixed Delirium • Features of both hypo- and hyperactive delirium Normal Consciousness Delirium • Meet CAM criteria due to disorganized thinking Flacker, JM and Marcantonio ER Drugs & Aging 1998;13(2):119-30 Presentation Normal 13% Hypoactive 13% Mixed 57% Hyperactive 17% Original graphic by Thomas Price, adapted from data by Lipzin B, Levkoff SE (Br J Psychiatry 1992;161:843-5) Presentation So we can say that delirium… Is a common complication of illness in the elderly Is an acute change in mental status Always fluctuates Always features abnormal attention Is often a “missed diagnosis” Consequences Morbidity and mortality Francis and Kapoor, 1992 229 pts >70 years (223 survived hospitalization) followed up for 2 years • RR of Death 1.82 (1.04-3.19) • RR of Institutionalization 1.82 (1.31-2.53) • RR if pt with cancer 2.61 (1.32-5.18) • RR if pt with ADL dependence 2.00 (1.03-3.89) Francis J and Kapoor WN, JAGS 1992:40(6);601-606 Pathophysiology Cholinergic System Central cholinergic inhibition Elevated serum anticholinergic activity Endogenous anticholinergic substances • Dynorphin A • Myelin Basic Protein • Protamine Flacker, JM et al. Am Journal Geriatric Psych 1998;6(1):31-41 Flacker, JM and Lipsitz LA Journal of Gerontology 1999;54A(1):M12-16 and 54A(6):B239-246 Pathophysiology Cholinergic System Direct drug binding of receptors • Atropine, scopolamine Muscarinic binding of drug metabolites • Furosemide, cimetidine, digoxin Flacker, JM and Lipsitz LA Journal of Gerontology 1999;54A(6):B239-246 Pathophysiology Serotonin Affects cognition, mood and wakefulness Serotonin depletion • Phenyalanine tryptophan serotonin • Limited trials show branched-chain amino acid infusions reduce phenylalanine and increase cognition Can cause delirium in both over-stimulation and deficiency • SSRIs for delirium? Flacker, JM and Lipsitz LA Journal of Gerontology 1999;54A(6):B239-246 Pathophysiology Other biochemical suspects Dopamine (activation) GABA (increased activity) Glutamate (increased activity) Cortisol (excessive endogenous production) IL-1, IL-2, Prostaglandin D2 (increased in sepsis cascade) Flacker, JM and Lipsitz LA Journal of Gerontology 1999;54A(6):B239-246 Risk Factors Can be split into two categories Predisposing factors • “Pre-hospitalization” • Can alert the physician to risk but are often unmodifiable in the acute setting • Prevention can focus on these on a “chronic” timetable Precipitating factors • • • • “Post-hospitalization” Often iatrogenic Often modifiable Often preventable Predisposing Factors Past Medical History Falls Stroke Delirium Chronic Illness Cognitive disorders/dementia Poor vision or hearing Malnutrition Renal failure or chronic dehydration Predisposing Factors Psychosocial Age Male sex Alcoholism or other drug use Depression Functional impairment Prevention - The Short List At risk patients - key features Predisposing • • • • Visual impairment Illness severity Cognitive impairment BUN:Cr ratio >18 Precipitating • • • • • Malnutrition Use of physical restraints More than 3 medications added Use of a bladder catheter Iatrogenic (adverse) event Inouye SK and Charpentier PA JAMA 1996;275(11):852-7 Update on Our Patient In the morning, the attending is told the events of the previous day by his resident. “We had to restrain him and I gave him 2 mg Haldol to get him to stop yelling.” Medications are reviewed: Aspirin 325mg po daily Atenolol 25mg po daily Simvastatin 20mg po qHS Propoxyphene/APAP (Darvocet) 1 q4h prn pain Diphenhydramine 25mg po qHS prn sleep Update on Our Patient Physical Exam 130/62, HR 64, RR 16, SpO2 98% RA, T 95.4 F Patient is unrousable but responds to pain Lungs clear, heart regular, abdomen normal Surgical site intact, no inflammation/drainage Foley catheter in place Patient in wrist restraints, bruising along arms Heavily wrapped 20 ga. IV in left arm AC hooked to 75cc/hr NS Prevention Inpatient Consultation Inouye 1999 • 852 patients, 70 or older, admitted to general medicine unit at Yale New Haven Hospital (1995-98) • Intervention: Elder Life Program • Interdisciplinary team including geriatrician • Targeted six delirium risk factors Usual Care Intervention (HELP) Incidence of Delirium 15.0% 9.9% Delirium, Patient Days 161 105 (P=0.02) Delirium, Episodes 90 62 (P=0.03) Inouye SK et al. NEJM 1999;340(9):669-76 Data used with permission from the author. Prevention How did they do this? Cognitive Impairment • Orientation protocols • Therapeutic activities Sleep Deprivation • Nonpharmacologic sleep protocol • Sleep-enhancement protocol Immobility • Early mobilization protocol • Minimal use of tethers/restraints Inouye SK et al. NEJM 1999;340(9):669-76 Prevention How did they do this? Visual Impairment • Vision protocol Hearing Impairment • Hearing protocol Dehydration • Early recognition protocol • Encourage PO fluids Inouye SK et al. NEJM 1999;340(9):669-76 Prevention Inpatient Consultation Marcantonio and Flacker, 2001 • 125 patients > 65 years admitted for surgical repair of hip fracture • Consultation focused on 10 specific recommendations • Consultation reduced incidence of delirium during acute hospitalization after hip fracture Outcome With consult Usual care P-value Delirium incidence, cumulative 20 (32%) 32 (50%) 0.04 Severe delirium incidence 7 (12%) 18 (29%) 0.02 Marcantonio ER, Flacker JM, Wright RJ, Resnick NM JAGS 2001;49(5):516-522 Data used with permission from the author. Prevention How did they do this? Geriatric consultation focused to make recommendations on 10 specific areas Adequate CNS oxygen delivery Fluid/electrolyte balance Treatment of severe pain Elimination of unnecessary medications Regulation of bowel/bladder function Adequate nutritional intake Early mobilization and rehabilitation Prevention, early detection, and treatment of major postoperative complications Appropriate environmental stimuli Treatment of agitated delirium Marcantonio ER, Flacker JM, Wright RJ, Resnick NM JAGS 2001;49(5):516-522 Prevention Potentially inappropriate medications included: Sedatives (sleeping meds, benzos) Antihistamines (diphenhydramine) Neuroleptics (phenytoin, phenobarb) Antiarrhythmics (digoxin) Narcotics (meperidine, propoxyphene) Tricyclic antidepressants Anticholinergics (atropine, scopolamine) Prevention Nursing Programs Milisen and Foreman, 2001 • Small study; 120 pts (mean age 80) admitted for hip fracture • Intervention included cognitive screen, pain protocol, and staff education • Results: • No significant effect on delirium incidence • Reduced duration of delirium (1 v. 4 days, P=0.03) • Reduced severity of delirium (P=0.015, scored by CAM) Milisen et al. JAGS 2001;49(5):523-32 Management History and physical exam Last bowel movement Pulse Ox Blood glucose Post-void residual Lab workup LP not suggested as routine workup CT or not CT? Management Delirium is almost always multifactorial in origin Work up should approach several possible diagnoses at a time Correcting a single derangement will rarely resolve the delirium Correct Underlying Pathology Iatrogenic Causes Environmental • Tethers • Lighting • Noises • Lack of reorientation • Sensory impairment Correct Underlying Pathology Iatrogenic Causes Medications Untreated (or under-treated) pain Constipation/impaction Urinary retention Nutrition (modify diet if needed) Correct Underlying Pathology Infections Urinary tract infections Respiratory tract infections Cardiopulmonary events Acute coronary event Congestive failure Reduced output (atrial fibrillation, SVT) Hypoxia (PE, CHF, pneumonia) Correct Underlying Pathology Metabolic Abnormalities Dehydration • Hypernatremia, ARF Hypo/hyperkalemia Anemia Pharmacologic Management Antipsychotic agents are preferred over benzodiazepines Haloperidol • 0.25-0.5 mg IV or IM, q1-2 hrs prn • Long-term use is associated with EPS/dyskinesia Risperidone • 0.25 - 0.5 mg PO or oral dissolvable, q8-12 hrs prn Olanzapine • 2.5 - 5 mg IM q1h prn, 2.5 - 5 mg PO QD Quetiapine • 12.5 - 25 mg PO q8-12 hrs prn, 12.5 - 25 mg PO BID Ziprasidone • 10 - 20 mg PO/IM q12 hrs prn Pharmacologic Management It takes smaller doses of sedatives to “knock” an elderly patient out Notify family of the need for use Use of antipsychotics in long term care facilities carry additional complications Update on Our Patient Diphenhydramine-induced urinary retention diagnosed and treated - foley removed Urinary tract infection diagnosed and treated Propoxyphene replaced with hydrocodone/APAP IVF stopped and IV removed Update on Our Patient Patient woke up the next day In three days was cooperating with inpatient PT again Some residual confusion handled well with redirection and reinforcement Successfully transferred to subacute rehab facility 9 days post-op with improved cognitive function Caveats Delirium can persist from days to months after treatment of the underlying cause but is often reversible Discharge destination may need to be reconsidered upon diagnosis of delirium Dementia and delirium often co-exist Many patients experience some degree of permanent cognitive function loss after a delirium episode Take Home Points The cause of delirium is multi-factorial Delirium may be preventable or its severity lessened by targeted interventions Treatments for delirium are interdisciplinary and involve multiple approaches Psychotropic drug therapy (at appropriate dosage) is a last resort The End