Download Slides Only - Curriculum for the Hospitalized Aging Medical Patient

Mini CHAMP
Delirium in the Hospitalized Elder
Shellie Williams, M.D.
Assistant Professor of Medicine
Section of Geriatric Medicine
University of Chicago
Objectives:
• Increase recognition of delirium in hospitalized
elders.
• Identify a risk stratification for delirium in
hospitalized elder.
• Gain understanding of prevention for delirium.
• Enhance ability to evaluate patients for
delirium—assessment.
• Develop a strategy for treatment of delirium
from a non-pharmacologic and pharmacologic
focus.
Mrs. Fleming:
• 75yo female admitted from ER with
generalized weakness, UTI and pre-renal
azotemia.
• She is admitted to 5NE with IVF & cipro
• RN calls post-admit day#1: “She pulled
out her IV this morning and ordered me
out of her home. She is upsetting her
roommate and refused another IV. Shall I
initiate a sitter?”
Delirium: The Data
• Prevalence: 15-70%
• (20%) 12.5 million elderly admits
• Admission Onset: 20-33%
• Post surgical: 30-59%
Rockwood 1990; Francis 1992
Defining Delirium:
• Disturbance of consciousness and reduced
ability to focus, sustain or shift attention.
• Change in cognition (decline memory,
orientation, language, motor) not accounted for
by preexisting dementia.
• Disturbance that develops over short time and
fluctuates.
• Direct physiologic consequences of a specific
medical condition, substance intoxication,
withdrawal, or multiple causes.
Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition (DSM-IV)
Delirium: Pathophysiology
• Neurotransmitter Theory:
• Cholinergic deficits: benadryl, scopalmine
• Norephinephrine excess: antidepressants
• Dopamine excess: Parkinson meds
• Cytokines-IL1, IL2, TNF (Infection)
• Cerebral Hypoxia
• Stress related hormonal fluctuation
Why Focus on Delirium? Risk
• Increased LOS (2x)
• Increased Mortality (2-7x)
• 38% & 51% mortality 1yr/5yr post-hosp
• Increased ADL dependence (2x)
• Increased instituitionalization (2-3x)
Dolan J of Ger 2000;
Leslie Arch In Med 2005.
Why Focus on Delirium? Cost
Leslie, D.L. Arch In Med, 2008; 168: 27-32.
Why Focus on Delirium?: Cognition
• 60% persistent impairment from baseline
• 40% Progression dementia 1yr
• Premorbid Cognitive Impaired:
• 4% complete resolution prior d/c
• 20% complete resolution 3-6mo s/p d/c
Obstacles:
Under-recognition
• Poor recognition:
Nurse recognition <50%
Physician recognition 20%
Inouye 2001
Recognize Delirium Fluctuating Faces:
•
•
•
•
•
•
•
•
Hyperactive: 30%
Tremor
Agitation
Picking/Pacing
Vivid hallucinations
Irritability
Aggression
Hyperactive: 30%
• Hypoactive: 70%
• Sedate
• Psychomotor
retardation
• Poverty speech
• Diminished
awareness
Spiller, JA. Pall Med 2006; 20: 17-23.
Delirium Prevention:
Pre-hospital Risk
Inouye,SK. Arch Int Med; 1993, 119: 474-81.
Risk Stratification Based on
Pre-hospital risk:
Inouye,SK. Arch Int Med; 1993, 119: 474-81.
Risk Stratification: In-Hospital Risk
• Use of Physical Restraints (RR 4.4, CI 2.57.9)
• Malnutrition (RR 4.0, CI 2.2-7.4)
• >3 Medications added (RR 2.9, CI 1.2-4.7)
• Use of Bladder Cath (RR 2.4, CI 1.2-4.7)
• Any Iatrogenic Event (RR 1.9, CI 1.1-3.2)
Inouye, SK. JAMA. 1996; 275 (11): 852-7.
Risk Stratification:
Delirium at Discharge
Inouye, SK. Arch Intern Med 167 (13): 1406-12.
Prevention: Elder Life Program
• Elder Life Program
• Targeted protocols:
–
–
–
–
–
–
Cognitive impairment
Sleep deprivation
Immobility
Visual impairment
Hearing impairment
Dehydration
Inouye, SK. NEJM 1999; (340) 9: 669-675.
Delirium Prevention
• Decreased incidence of delirium
(9.9% vs 15.0%) p=0.02
• Decreased days of delirium
(105d vs 161d)
p=0.02
• No statistically significant change in
severity or recurrence of delirium
Inouye, SK. NEJM 1999; (340) 9: 669-675.
Evaluation of Delirium
• MULTIFACTORIAL is the rule of thumb
(2.8/pt)
• Focused, patient-centered investigation
• History guides diagnostics
• Examination guides diagnostics
Evaluation: Algorithm to Recall
Delirium
Evaluation
Management
History
(h/o dementia?)
Physical exam ("head to toe")
Treat Findings
(Reassure,
d/c restraints)
focal exam
non-focal
Do appropriate next step
(eg, fever-->cx;
neuro abnl-->head CT)
Review meds
Order addn'l tests
Treat Findings
Treat Findings
non-agitated
Non Pharmacologic
agitated
Non Pharmacologic
& Pharmacolgic
DOCUMENT DELIRIUM!
Confusion Assessment Method:
CAM
Evaluation: CAM
Confusion Assessment Method
Acute Onset &
Fluctuating Course
AND
Inattention
plus
either
Disorganized
Thinking
Altered LOC
DELIRIUM
Inouye SK et al. Ann Intern Med 1990;113:941-948.
Evaluation: R/o Dementia
• Hx of dementia?
• Need hx of sundowning to dx it!
• Agitated dementia = delirium
• Understand delirium-dementia
relationship
DEMENTIA
DELIRIUM
Distinguishing the 3 Ds:
ONSET
ATTN/LOC
COURSE
DELIRIUM
DEMENTIA
DEPRESSIO
N
Sudden
Insidious
Insidious
(days)
(yrs)
(wks)
Persistent
Abnormal
Fluctuates
Normal
Normal
HALLUCINS Us. Visual
INVOL
MVMNTS
Tremors,
picking,
asterixis
Stable, slow Slow
decline
Absent
Us. Absent
until late
Absent
Absent
until late
Evaluation: Physical Exam
• “Head to toe”
–
–
–
–
–
–
–
–
Vitals
CNS
Pulm
CVS
GI
GU
Extrem
Skin
(temp, HR, RR, BP, pulse ox)
(CVA, bleed, meningitis, sz, blind, deaf)
(pneumonia, PE, CHF)
(ischemia, CHF, arrhythmia)
(ischemia, impaction, bleed)
(UTI, retention)
(pain, volume status, CVA)
(pressure ulcer, volume status)
Evaluation:
Most common causes of delirium
1. Medications 30%
2. Infections 40%
3. Fluid/Electrolyte imbalance 40%
Evaluation: Medications (30%)
• Too little (alcohol or other drug withdrawal)
6%
• Too much
narcotics
neuroleptics
anti-cholinergics
anti-emetics
• >3 new medications introduced
Francis 1990, Schor 1999, Lawlor 2002
Evaluation: Medications
•
•
•
•
•
•
•
•
•
•
•
•
•
Antibiotics (aminogly, PCN, ceph, sulfa)
Benadryl
Benzodiazepines (triazolam, alprazolam, diazepam)
Digoxin
GI (Reglan, Bentyl)
Lithium
Narcotics
Neuroleptics
Steroids
NSAIDs (Indocin)
H2 Blockers (Cimetidine,…)
Parkinsons drugs (Levodopa, Benztropine, Amantadine)
Tricyclics
Evaluation: Anti-cholinergic Medications
Fecal/urine impacted, confused, flushed, dry, low
bp
Elavil (amitriptyline)
Flexeril (cyclobenzaprine)
Cogentin (benztropine)
Atarax/Vistaril(hydroxyzine)
Bentyl (dicyclomine)
Welbutrin/Zyban (bupropion)
Ditropan (oxybutynin)
Antivert (meclizine)
Detrol (tolterodine)
Ipratropium (atrovent)
Benadryl (diphenhydramine)
Phenergan (promethazine)
Zyprexa (olanzapine)
Atropine
Levsin (hyoscyamine)
Belladonna Alkoloids
Evaluation: Brain CT?
• Controversy on routine ordering
• Low yield if lack focal neuro findings
• Documented head trauma with new neuro
findings or high risk bleed
Francis, J. Clin Res 1991 (abstract); 39: 103.
Evaluation: Additional tests
• Labs
– CBC, lytes, liver, renal
– Consider TSH, B12
• Drug levels (digoxin, valproic, phenytoin)
• Urine tox, UA/culture
• CXR
• EKG
• EEG**
Management: Plan before Pills
• Prevention of delirium
• Correction underlying causes
• Non-pharmacologic intensify
• Pharmacologic (agitation)
Management: Non-pharmacologic
HELP Prevention
• Cognition: orientation board (carry pen!), (day) open
drapes, clock, calendar, family photos
• Sleep: min deprivation (d/c 2am labs & o/n BD/vitals;
meds when awake); warm drink; limited pm awake
• Mobility: Early OOBchair ; PT/OT; no foley/restraints
• Vision: glasses
• HOH: get aids; adapt environment (stethoscope!)
• Dehydration: po fluids; observe at mealtime
• Feeding: assist with meals
• Activity: Involve family (rotate members) or get sitter;
move pt to room close to RN station, current events
Inouye, SK. JAGS 2006; 54: 1492-1499.
Management: Non-pharmacologic
Restraint Use
• AVOID!
• 4x increased risk protracted delirium
• Increase risk of falls, injury, & delirium
• Use only in emergency, for as short a
duration as possible with frequent reevaluations, and d/c asap
• Absolutely no “sheeting”
Inouye, SK. Arch Intern Med 167 (13): 1406-12.
Management: Pharmacologic
• 30/244 AIDS patients admitted to hospital with
AIDS related illness, developed delirium
• Double blind randomization to lorazepam,
chlorpromazine or haloperidol
• Early cessation of lorazepam arm due to
worsening sedation, confusion & ataxia
• Chlorpromazine & haldoperidol arm
improvement in delirium per DRS score, limited
EPS and improved MMSE in chlorpromazine
group @ 2d
Breitbart, W. Am J. Psych, 1996; 153: 231-237.
Management:
Pharmacologic Anti-psychotics
Typical: Haldol
Advantages: min sed
Disadvantages: lower sz thrshld; more EPS (even at low
dose); not FDA-app for IV; can incr QTc; Torsades
Dose: 0.25-0.5mg po, IM, IV; can repeat in 30 mins x1; then
dose q4h
t1/2=21h (10-38)
APA 1999
Management:
Pharmacologic Antipsychotics
Atypical:
Advantages: min sed, less EPS, hyperglycemia
Disadvantages: take time to work, no evidence in short-term;
recent Black Box warning: vascular events!
Risperidone 0.25-0.5mg po bid
t1/2=20-30h
EPS with high dose
Olanzapine (Zyprexa) 2.5-5mg po qd
t1/2=30 (21-54h)
more anticholinergic
Quetiapine (Seroquel) 12.5-25mg po bid
t ½=6h
less EPS risk
Van Zyl. Geriatrics 2006; 61(3): 18-21.
Management: Pharmacologic
Benzodiazepines
Used best in w/d
Lorazepam 0.5-1mg po, IM, IV q6-8
(no first-pass, no renal adjustment)
t1/2=12h
Conclusion:
1. Prevent delirium.
–
–
Evaluate risk factors pre-admit, during and
post hospitalization.
Adjust admit orders
2. It is important to develop a systematic
approach for diagnosis of delirium, THEN
(DOCUMENT!).
3. First use non-pharmacologic measures,
then pharmacologic, to treat delirium.
Case Revisited:
• Mrs. Fleming is a 75 year old female with htn,
OA, dm, cri (1.3) baseline and chronic AF. She
lives alone in a 3 story home.
• Meds: (Home)
Lisinopril 20mg qam
Asa 81 mg
Celebrex 200mg qam
Metformin 500mg bid
Hctz 25mg qam
Elavil 50 mg qhs
Medicines In-hospital:
•
•
•
•
Lisinopril 10mg qam
Hctz 25mg qam
Regular Insulin SS
0.9NS 150 cc/hr x
36hr
• Elavil 50mg qhs
• ASA 81mg qam
• Darvocet N 1 q 6hr
• Prosom 15mg qhs prn
• Benadryl 25mg q 6hr
itching, sleep
• Vicodin 5/500mg q
4hr prn
• Morphine 2-4 mg iv q
4hr
• Zofran 4mg q 6hr prn
n/v
Case revisited:
• Currently, pt is quietly sitting in chair, picking at
skin.
• When asked what is she doing she notes, “ It is a
shame you can’t afford extermination in this
place!”
• She then returns to her activity.
• Her daughter notes she has not slept in 3 days and
was incontinent of urine 2 days PTA.
• Roommate notes she was lethargic and not
answering questions a few moments ago.
CAM Assessment: Is she Delirious?
• Acute/fluctuating?
• Inattentive?
• Disorganized thinking?
• Decreased level of consciousness?
An Algorithm to Remember!
Delirium
Evaluation
Management
History
(h/o dementia?)
Physical exam ("head to toe")
Treat Findings
(Reassure,
d/c restraints)
focal exam
non-focal
Do appropriate next step
(eg, fever-->cx;
neuro abnl-->head CT)
Review meds
Order addn'l tests
Treat Findings
Treat Findings
non-agitated
Non Pharmacologic
agitated
Non Pharmacologic
& Pharmacolgic
Review Dementia?
• Dementia
–
–
–
–
Get further hx from family of baseline
Was dx missed or never made?
Prior hx of delirium during hospitalization?
Do serial cognitive assessment: MMSE
Review Other Risks for Delirium:
• Recent physical symptoms? Cough, chills,
SOB
• Psychiatric symptoms? None
• Alcohol/Illicit drug use? 1 Highball
nightly
• Recent CNS trauma? No trauma other
than hip
• Recent stroke symptoms? No
Case Revisited: Exam
•
•
•
•
•
•
•
•
Sat 88% ra, rr 28, p 100, bp 100/50, pain grimace
HEENT: Dry mucosa, no evidence cns contusion
Neck: No adenopathy or thyromegaly or jvd
Lungs: Increase fremitus and percussion dullness rt.
base no use acc muscles
Heart: Irregular rhythm, rate 100, no murmur, rub or
gallop
Abdomen: +bs, soft non distended, non tender
GU: +foley, no evidence retention
Neuro: Inattentive, disoriented, poor recall of hospital
events, hyperalert at times, motor strength symmetric,
normal sensory function, no hyper-reflexia, antalgic gait
Case, cont’d
• Labs:
10.5
13.2
192
33.0
148 110
56
128
5.2 30
1.8
UA: +LE, nitrite, 1.025, bacteria, rbc
ECG: A. Fib rate 60s, no acute ST changes
CXR:
Case Revisited: What factors
predisposed this patient for delirium?







Foley
Poor po intake
Poor vision
> 3 new medications
Sensory impairment
Use of restraints
Bed bound status
>30 bun/creatinine
ratio
Baseline cognitive
deficits
Lack of pain control
Poor sleep
Case Revisited:
What factors precipitated delirium?
Stroke
UTI
Pneumonia
Anti-cholinergics
Dehydration
Hypoxia
Anemia
Hypotension
Metabolic
derangements
Alcoholism
Illicit drugs
Cardiac ischemia
Case Revisited:
How should we treat this patient?
Add lorazepam
Initiate sleep orders
Stop elavil
Stop lisinopril
Schedule tylenol
Add vicodin schedule
Stop combo analgesic
Explain condition to
daughter
Zosyn 3.25 mg q 6h
Initiate oral hydration
protocol
Start IVF
Reorientation
protocol
Remove foley
Oxygen therapy
THANK YOU