Download Delirious … you or the patient?

Delirious … You or the Patient?
Questions to ponder…
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What risk factors are associated with delirium?
What tools are available to assess delirium?
What is the importance of diagnosing delirium?
What is the appropriate workup?
What medications are associated with confusion in the
hospitalized older patient?
Can delirium be prevented?
Is delirium a marker for bad outcomes?
Once delirium occurs, can multitargeted strategies change the
outcome?
Are medications useful for the management of patients with
hyperactive or agitated delirium?
Is preventing delirium cost effective?
Overview
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Background and definition
Risk factors
Screening tools
Workup
Preventing delirium
Delirium as a marker of bad things to come
Treating delirium
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Multitargeted strategies
Medications
Definition and Background
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DSM IV: reversible state of confusion with reduced
level of consciousness manifest as inability to focus,
sustain or shift attention
Acute confusional state
Acute onset, fluctuating course
Attention impairment
Up to 60% hospitalized elders
Often iatrogenic, often misdiagnosed
Risk Factors
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Advanced age
Underlying dementia/cognitive impairment
Acute medical illness
Alcohol abuse
Male gender
Depression
Malnutrition
Terminal illness
ICU stay (up to 80%)
Iatrogenic Risk Factors
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The things we do…
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Physical restraints
Polypharmacy
Malnutrition
Other restraints…
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Foley catheters
IV lines
Telemetry boxes
Oxygen tubing
Screening or Assessment Tools
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DSM IV definition
Serial MMSE
Confusion Assessment Method (CAM)
CAM-ICU
DSM –IV Definition
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Acute confusional state associated with:
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Disturbance of consciousness with reduced ability
to focus, sustain, or shift attention
Change in cognition (memory impairment,
disorientation, language deficits) or development
of perceptual disturbance that is not due to
underlying/established dementia
Development during hours/days with fluctuating
course
MMSE
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Pro: familiarity
Con: not specific (deficits may be due to
underlying dementia, limitations due to low
literacy level)
How to use: serial MMSE during hospital
course; change in performance suggests
delirium
Confusion Assessment Method
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Quick and easy
Sensitivity 94–100%, specificity 90–95%
CAM
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Acute onset and fluctuating course (history can be
obtained from family/friends or staff)
Inattention (did the patient have difficulty keeping
track of conversation?)
Disorganized thinking (was conversation rambling or
incoherent, unclear, illogical or unpredictable?)
Altered level of consciousness (vigilant, lethargic,
stupor, coma; anything other than “alert”)
Disorganized Thinking
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Set A
1. Will a stone float on
water?
2. Are there fish in the sea?
3. Does 1 lb weigh more
than 2 lbs?
4. Can you use a hammer to
pound a nail?
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Set B
1. Will a leaf float on water?
2. Are there elephants in the
sea?
3. Do 2 lbs weigh more than
1 lb?
4. Can you use a hammer
to cut wood?
Workup: Delirium is a Marker!
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Medication review
Labs: Na, glucose, ca, creat/BUN
Infection (UTI, pneumonia)
Hypoxemia
Neuroimaging for subdural
EEG
Sleep apnea
Pain (skin, urinary retention)
Myocardial ischemia
Alcohol or benzo withdrawal
Consider LP (arboviral infections/encephalitis in elderly!)
Review for underlying dementia
Medications Associated with Delirium:
First Think Drugs!
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General: anticholinergics and benzodiazepines!
Opioids (especially meperidine)
Tricyclic antidepressants
Antihistamines (DO NOT USE BENADRYL FOR SLEEP!!!!)
Anti-Parkinsonian meds: levodopa/carbidopa, amantadine,
bromocriptine)
H2 receptor blockers
Antibiotics (ciprofloxacin)
Anticonvulsants
Prednisone
Clonidine
Perioperative Delirium
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Orthopedic and vascular surgeries: 40–50%
incidence
Vascular surgeries: associated with
underlying hyperlipidemia, amputation, age
over 65, depression
Cardiac Surgery and Delirium
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Associated with delirium and persistent memory
impairment
Microembolism, hypoperfusion, inflammatory
responses
Highest risk: history of cerebrovascular disease,
PVD, diabetes, cardiomyopathy, urgent operation,
long surgery time, high transfusion requirement
CABG with “beating heart/off pump” technique
associated with less delirium
Preventing Delirium, Can It Be Done?
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Inouye NEJM 1999
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Randomized trial of 852 patients
Multicomponent intervention plan
Delirium developed in 9.9% intervention group vs
15% usual care group
Total number days with delirium: 62 intervention
group, 90 in control group
NO DIFFERENCE in severity or recurrence of
delirium once it developed: KEY IS PREVENTION
Preventing Delirium
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Recognizing patients at risk (screening high risk patient)
Avoiding risky medications
Close observation for infection
Family/friend involvement
Decrease isolation: hearing aids, glasses
Decrease sleep disturbances
Environmental cues (opening blinds…)
Avoiding restraints
Avoiding “restraints” (foley catheters, oxygen, IV fluids,
telemetry boxes) that are not needed
Vigilance for withdrawal syndromes (benzo, ETOH, SSRI)
Delirium, Bad Things to Come?
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Observational data suggests that delirium
associated with adverse outcomes including
loss of independence, need for placement,
cognitive decline, increased mortality
Problem: confounding… (those at highest
risk for delirium are also the oldest and the
sickest)
Prognostic Significance of Delirium…
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Prospective studies do demonstrate delirium
and dementia being associated with decline
in cognitive and functional status, even up to
12 months after hospital stay
Highest decline in patients with both
dementia and delirium
Can Multi-targeted Strategies Change
Outcomes of Patients with Delirium?
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Lack of data
Several studies have failed to demonstrate a
difference in patients with delirium treated
with various strategies compared to “usual
care”
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Problem: “Hawthorne Effect”
Studies randomized, but “usual care” group likely
benefited from presence of study itself
Antipsychotic Use
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Commonly used… maybe too commonly
Care to ensure not missing underlying pain, urinary
retention, psychiatric disorder, withdrawal syndrome,
infection!
If used, use atypicals in very, very low dose!
Remember, no great data to support this use… so
use care
Avoid benzodiazepine use (unless for withdrawal)
Typical Antipychotics
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Haloperidol
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Try to avoid
High risk of tardive diskinesia and EPS with long
term use (over 50% in elderly)
If used, use low dose (0.5 mg), and limit to 1–3
days
Newer routes of atypical agents (IV, sublingual,
IM) should make use of haloperidol in this setting
obsolete
General Risks of Antipyschotics…
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Much less risk of EPS and TD with atypicals
Orthostasis
Sedation
Cardiovascular effects (QT prolongation)
Weight gain
Edema
Risperidone (Risperdal)
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Begin 0.25 mg – 0.5 mg, 1–2 times/day
Effectiveness at low doses in elderly (max 1–
3 mg/day)
Olanzepine (zyprexa)
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2.5– 5 mg
Sedation (usually started at night) with more
anticholinergic side effects
Routes: PO or rapidly dissolving tablet
(Zydis)
Link with weight gain and diabetes
Quetiapine (seroquel)
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Start at 25 mg
Can rapidly increase up
Sedating, use at night
More commonly used longer term for
behavior problems with dementia (limited
EPS and TD effects)
Ziprasidone (Geodon)
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Restricted use at UNC
IV form
20–80 mg
Contraindicated with acute CV disease
(nondose dependent QT prolongation)
Clozapine
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Great with underlying Parkinsonian
symptoms due to little risk of increasing
tremor
Significant rate of agranulocytosis
Restricted use
Antipsychotic Use
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FDA Black Box warning
Increased association with stroke and sudden death
Do not improve delirium; may increase LOS; likely
just makes your delirious patient a more sedated
delirious patient
May benefit a subset of patients with psychotic
symptoms or aggressive behavior patterns
Chemical restraints
Anticholinesterase Inhibitors??
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Agents such as donepezil being studied
Observational data suggest benefit with
behavioral disturbances with dementia
Is Preventing Delirium Cost Effective?
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Probably cost neutral…
Take Home Points
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Delirium is very common and often missed in
hospitalized older patients (15% on a general
medical unit, up to 50% undergoing
surgeries)
Think drugs, lines, sleep deprivation, pain,
infection
Think prevention!
Take Home Points:
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Avoid drugs such as benadryl for sleep!
Avoid benzodiazepines!
When using narcotics, stay with one narcotic
and try to avoid agents such as darvocet
Prevent
Treat WITHOUT ADDING MORE DRUGS
Avoid antipsychotics!