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CHAMP Delirium Part 2: Evaluation & Management Andrea Bial, M.D. University of Chicago Goals 1. Develop a plan for teaching a Systematic Approach to the Evaluation of hospitalized older patient with delirium. 2. Develop a plan for teaching an appropriate Treatment Plan for the hospitalized older patient with delirium Overnight Events: Morning Rounds at the Bedside • 75yo W admit 2d ago w/ COPD, bronchitis • Intern reports: o/n she pulled out her IV, thought she was at home • X-cover ordered Prosom 1mg & po abx Overnight, cont’d • Currently, pt w/o c/o. Doesn’t recall events of previous night. • PE: sleepy, arouseable 37.6 148/62 88 20 93%2L Lungs w/ faint wheeze bilat Rest w/o change Labs WBC 13.2, diff P; H/H stable Na 133, BUN 26, Cr 1.2 Overnight, cont’d • A/P #1) COPD—cont nebs, steroids, po abx #2) HTN—stable on meds #3) Confusion—add risperdal 1mg QHS prn #4) Disp—await PT/OT Systematic Approach to the Evaluation of Delirium • No one “gold standard” approach • Multiple Mnemonics (e.g., Delirium) & algorithms • Need individualized, systematic approach to avoid missing potential causes • Few studies exist specifically looking at causes Evaluation of Delirium: Causes • Francis (1990) – – – – Large teaching hospital General medicine patients (n=229) Delirium developed in 22% (n=50) Determined cause(s) as: definite, probable, or possible • 18 (36%) w/ one definite cause (Drug toxicity, then infection=fluid/lyte imbalance) • 10 (20%) w/ one probable cause • 22 (44%) w/ >1 cause; 62 possible etiologies (2.8/pt) DELIRIUM Evaluation History (dementia?) and Physical Exam (head to toe) Management NON-AGITATED PATIENT: Non-Pharmacologic treatment FOCAL EXAM: Do appropriate next step (e.g.,fevercx) THEN, review meds& Order other tests Treat Findings & Manage symptoms NON-FOCAL EXAM: Review meds Order addn’l tests Treat Findings & Manage symptoms AGITATED PATIENT: Non-Pharmacologic & Pharmacologic tx Evaluation: Dementia Teaching Points 1. 2. 3. 4. Hx of dementia? Hx of sundowning? Agitated dementia ≠ delirium Importance of considering dx: DEMENTIA DELIRIUM Evaluation: Physical Exam • Head to toe: – – – – – – – – Vitals (temp, HR, RR, BP, pulse ox, pain) Head (CVA, bleed, meningitis, sz, blind, deaf) Lung (pneumonia, PE, CHF) Chest (ischemia, CHF, arrhythmia) Abd (ischemia, impaction, bleed) GU (UTI, retention) Extrem (pain, volume status, CVA) Skin (pressure ulcer, volume status) Evaluation: Head CT? • No evidence to support routine ordering • Order if: – – – – new focal finding(s) on exam head trauma suspicion of encephalitis no other identifiable causes found Evaluation: Medication Review • Too little (alcohol or other drug w/d) – Francis (1990) 1/50pts (2%) – Lawlor (2000) 4/71pts (6%) • Too much – narcotics, neuroleptics, anticholinergics, antiemetics Francis 1990, Schor 1992, Lawlor 2000 Evaluation: Medication List • • • • • • • • • • • • • 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: Medication List • • • • • • • • • • • • • 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: Medications, cont’d Anticholinergic properties frequently overlooked: 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) Quinidine Evaluation: Additional tests • Labs – CBC, lytes, liver, renal – Consider TSH, B12, cortisol, ammonia, abg • Drug levels (digoxin, etc) • Urine tox, UA • CXR • EKG • EEG Evaluation: EEG • Since 1950’s, recommendations for EEGs • Usually: generalized slowing • Sensitivity 75% Management: Non-Pharmacologic • Cognition: orientation board (carry pen!) & open drapes during day • Sleep: minimize deprivation (no 2am labs, no o/n BS/vitals if able, give meds when awake) • Mobility: OOBchair asap, PT/OT, no foley/restraints • Vision: glasses • HOH: get aids; adapt environment; stethoscope trick • Dehydration: po fluids; observe at mealtime; avoid “Boost at nightstand” • Observation: Involve family (rotate members) or get sitter; move pt to room close to RN station Management: Non-Pharmacologic Restraint Use • Avoid whenever possible • 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” Management: Pharmacologic • No RCT of treating delirium in hosp pt • Extrapolation from other populations studied (AIDS, NHs, outpatient AD, …) • See Table in handout Management: Pharmacologic Antipsychotics Typical: Haldol, (Chlorpromazine) Advantages: Disadvantages: Dose: min sedating less ↓BP ↑ sz risk more EPS side effects ↑ QT ↑ risk of Torsades 0.25-0.5mg po, IM, IV can repeat 30 mins x1, then q4h t1/2=21h (10-38); peak 4-6h (IV not FDA-approved; short duration of action) APA 1999 Management: Pharmacologic Antipsychotics, cont’d Atypical Antipsychotics Advantages: Disadvantages: less EPS +/- sedation ↓ BP weight gain ↑ BS no evidence: short-term ↑mx (infection, CVS) Management: Pharmacologic Antipsychotics, cont’d Atypical Antipsychotic Doses: Risperidone: 0.25-0.5mg po bid t1/2=20-30h Olanzapine/Zyprexa: 2.5-5mg po qd t1/2=30 (2154h) Quetiapine/Seroquel: 25mg po bid t1/2=6h (better in PD pts) Management: Pharmacologic Benzodiazepines Used best in w/d of EtOH or benzo’s (also consider use in PD, NMS) Lorazepam 0.5-1mg po, IM, IV q4-6 t1/2=12h (no adjustment needed for liver or renal dz) Management: Pharmacologic Bottom Line • Try to avoid meds, but if needed: – Use Haldol in acute settings – Use risperidone for regular use (unless PD: quetiapine) – Use lorazepam for w/d Back to case! • • • • • 75yo W admit 2d ago w/ COPD, bronchitis Intern reports: o/n she pulled out her IV, thought she was a home X-cover ordered Prosom 1mg & po abx Currently, pt w/o c/o. Doesn’t recall events of previous night. PE: sleepy, arouseable 37.6 148/62 88 20 93%2L Lungs w/ faint wheeze bilat Rest w/o change Labs WBC 13.2, diff P; H/H stable Na 133, BUN 26, Cr 1.2 • A/P #1) COPD—cont nebs, steroids, po abx #2) HTN—stable on meds #3) Confusion—add risperdal 1mg QHS prn #3) Disp—await PT/OT Teaching Points 1. Ask: What do you think caused last night’s events? – Was a h/o dementia missed? (dementia/delirium relationship; role of MMSE; further family hx) – Was her PE different at the time x-cover was called? (systematic evaluation/head-to-toe) – Did we start or alter dose of any medications? (nebs, steroids, abx) Teaching Points, cont’d 2. Ask: Is she delirious now? – Discuss use of CAM (comfort of tool; dx of delirium in chart) – Discuss outcomes of delirium (increases: LOS, healthcare costs, mx, d/c to LTCF) – Discuss use of Prosom (and other benzo’s) in delirium Teaching Points, cont’d 3. Ask: Is there anything we should do today to follow-up on her confusion? – Discuss further studies that may or may not be needed (CXR? UA? Repeat Na?) – Discuss the non-pharmacologic measures that should be put into place (orient board, fluids, mobility, drapes, HS nebs & labs) – Discuss use of risperidone (and other antipsychotics) in delirium Recommended Reading • Inouye SK. Delirium in older persons. NEJM 2006;354:1157-65 • Schneider LS et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. NEJM 2006;355:1525-38. • Sink KM et al. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA 2005;293:596-608.