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Delirium in the Elderly Didactics Lecture Belinda Setters, MD, MS Delirium Learning Objectives: * Define delirium & describe the various forms * Review the pathophysiology of delirium * Utilize objective tools to diagnose delirium * Recognize the risk factors for the development of delirium and measures to take for prevention * Learn pharmacologic and non-pharmacologic treatment of delirium Delirium Delirium Defined: * What is Delirium? * What is “not” Delirium ? Delirium Delirium Delirium Defined: DSM IV Criteria Disturbance of consciousness with reduced ability to focus, sustain, or shift attention Change in cognition (memory deficit, disorientation, language disturbance) or a perceptual disturbance not better accounted for by existing dementia Development over a short time (hours to days) and fluctuation during the day Evidence from history, physical, or labs that the disturbance is a direct physiologic consequence of a medical condition or a drug Delirium Delirium Defined: DSM-IV Criteria for Delirium A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with educed ability to focus, sustain or shift attention. ___yes___no B. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia. ___yes___no C. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day ___yes___no D. 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. ___yes___no Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. Copyright © 2000, American Psychiatric Association. Delirium Delirium Defined: * DSM-IV criteria precise but difficult to apply * Confusion Assessment Method (CAM) Clinically more useful >95% sensitivity and specificity Can be administered by RN or other care provider ICU version available for intubated, critically ill patients Delirium Delirium Defined: Confusion Assessment Method (“CAM”) 1. Acute change in mental status w/ fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness Delirium Delirium Defined: CAM-ICU 1. Acute Onset or Fluctuating Course A. Is there evidence of an acute change in mental status from baseline? (or) B. Did the abnormal behavior fluctuate during the past 24 hours (e.g., tend to come and go, or increase and decrease in severity as evidenced by fluctuation of the VAMASS, GCS or previous delirium assessment)? 2. Inattention ○ ○ Did the patient have difficulty focusing attention as evidenced by scores less than 8 on either the auditory or visual component of the Attention Screening Examination (ASE) Use the 5+5 pictures, or recognize a letter intermixed in a sequence of 10 letters Delirium Delirium Defined: CAM-ICU 3. Disorganized Thinking ○ Does the patient have disorganized or incoherent thinking as evidenced by incorrect answers to 2 or more of the following 4 questions and/or demonstrate an inability to follow commands? Set A 1) Will a stone float on water? 2) Are there fish in the sea? 3) Does 1 pound weigh more than 2 pounds? 4) Can you use a hammer to pound a nail? Set B 1) Will a leaf float on water? 2) Are there elephants in the sea? 3) Does 2 pounds weigh more than 1 pound? 4) Can you use a hammer to cut wood? Delirium Delirium Defined: CAM-ICU 4. Altered Level of Consciousness * Is the patient’s level of consciousness anything other than alert (e.g. vigilant, lethargic or stuporous), or is VAMASS < or > 3 (and not decreased due to sedation)? * Alert: Looks around spontaneously, fully aware of environment, interacts appropriately. * Vigilant: Hyper-alert. * Lethargic: Drowsy but easily aroused. Unaware of some elements in the environment, or no appropriate spontaneous interaction with interviewer. Becomes fully aware and appropriate with minimal noxious stimulation. * Stupor: Becomes incompletely aware with strong noxious stimulation. Can be aroused only by vigorous and repeated stimuli. As soon as stimulus removed, subject lapses back into unresponsive state Delirium Delirium Delirium Defined: An Alias by any other name . . . * Acute confusional state * Acute mental status change * Altered mental status * Organic brain syndrome * Reversible dementia * Toxic or metabolic encephalopathy Delirium Delirium Diagnosis: Nurses document < 50% of cases MD document < 20% of cases Delirium Delirium Defined: Numbers don’t lie . . . * 1/3 of older patients presenting to the ED * 1/3 of inpatients aged 70+ on general medical units, half of whom are delirious on admission * Up to 50% postoperatively will become delirious * 70 – 87% of those in ICU will develop delirium Delirium Delirium Defined: Variations on a theme . . . *Hypoactive *Mixed *Hyperactive hypo hyper Delirium Delirium Defined: Hyperactive * Only 25% of delirium * But most commonly recognized * Heightened response to stimuli * Heightened psychomotor behavior * Hypervigilance, restlessness, excitable * Fast and/or loud speech * Distractable * Irritable * Combative, uncooperative Delirium Delirium Hypoactive * Much less recognized * Reduced response to stimuli and reduced psychomotor behavior * Apathy, lethargy * Sparse or slowed speech * Limited awareness * But usually cooperative with staff * Behaviors often attributed to “old age” or dementia * About 40% of delirium Delirium Delirium Defined: Mixed *Fluctuations between hyperactive & hypoactive states hypo hyper Delirium Pathophysiology: Cholinergic deficiency * Delirium is associated with serum anticholinergic activity * Anticholinergic activity is found in delirious patients taking no anticholinergic drugs * Acetylcholine is an important neurotransmitter for cognitive processes * Delirium: caused by anticholinergic drug poisoning, reversed by physostigmine Delirium Pathophysiology: * Serotonin excess or deficiency: result of altered tryptophan-to-phenylalanine ratio * Cytokines (interleukin-2, tumor necrosis factor), as seen in patients with cancer or infections * Other neurotransmitters: GABA and dopamine * Different mechanisms may pertain in different situations * Bottom line: pathophysiology remains unknown Delirium Meds Med/Sx Illness Meds ETOH w/d Meds Stroke Cholinergic Activation Cholilergic Inhibition Benzos ETOH w/d Reduced GABA Activity Dopamine Benzos Liver failure Cytokine Excess Delirium Serotonin Activation Meds Subst w/d Med/Sx Illness Serotonin Deficiency Cortisol Excess Cushings/Stroke Sx/Stroke GABA Activation Glutamate Activation Liver Failure ETOH w/d Delirium Pathophysiology: The sum is greater than the individual parts . . . * Delirium “caused” by “sum” of predisposing and precipitating factors * The more predisposing factors present, the fewer precipitating factors required to cause delirium Delirium Predisposing Factors: “Honey, what do you expect . . . I’m 85.” * Advanced age * Dementia * Functional impairment in ADLs * Medical comorbidity * History of alcohol abuse * Male sex * Sensory impairment ( vision, hearing) Delirium Predisposing Factors (Etiologies): Acute cardiac events Acute pulmonary events Bed rest Drug withdrawal (sedatives, alcohol) Fecal impaction Fluid or electrolyte disturbances Indwelling devices Infections (esp. respiratory, urinary) Medications Restraints Severe anemia Uncontrolled pain Urinary retention Delirium Evaluation: * History * Focus on time course of cognitive changes, esp. their association with other symptoms or events * Medication review, including OTC drugs, alcohol * Physical examination * Vital signs * Oxygen saturation * General medical evaluation * Neurologic and mental status examination Delirium Evaluation: Based on history and physical * Include CBC, electrolytes, renal function tests * Also helpful: UA , LFTs, serum drug levels, arterial blood gases, chest x-ray, ECG, cultures * Cerebral imaging rarely helpful, except with head trauma or new focal neurologic findings * EEG and CSF rarely helpful, except with associated seizure activity or signs of meningitis Delirium Delirium Treatment: Prevention is still the best medicine . . . * Maximize Prevention / Minimize Risk Environment Medications Predictors Family & RN Support “Restraints” Delirium Treatment: * Interventions for cognitive impairment, sleep deprivation, immobility, sensory impairment, dehydration * Focus on nonpharmacologic approaches (eg, sleep protocol involving warm milk, back rubs, soothing music) * Limit or avoid psychoactive and other high-risk medications Delirium Treatment: * Treat the underlying disease * Address contributing factors * Avoid the complications of delirium: Remove indwelling devices ASAP Prevent or treat constipation and urinary retention Encourage proper sleep hygiene, avoid sedatives * Optimize medication regimen Delirium Meds, Meds, Meds . . . * Alcohol Barbituates * Anticholinergics Benzodiazepines * Anticonvulsants Chloralhydrate * Antidepressants (anticholinergic only) Opiods * Antihistamines (anticholinergic only) Antipsychotics * H2-blocking agents Parkinson meds Delirium Treatment: * Provide “social” restraints consider a sitter or allow family to stay in room * Avoid physical or pharmacologic restraints * If absolutely necessary, use haloperidol Mild delirium: 0.25–0.5 mg po or 0.125–0.25 mg IV/IM Severe delirium: 0.5–2 mg IV/IM Additional dosing q 60 min, as required Assess for akathisia and extrapyramidal effects Avoid in older persons with parkinsonism Monitor for QT interval prolongation, torsade de pointes, neuroleptic malignant syndrome, withdrawal dyskinesias Delirium Delirium Outcomes: * Marker for poor prognosis * Not an independent risk factor for outcome * Problems * Increased costs of hospitalization * Longer length of stay (LOS) * Increased risk of functional decline * Predisposing factors (present on admission) * Dementia Depression Altered Na+ level * Decreased basic functional level (ADLs) * Precipitating factors (occur during hospitalization) * Medications Immobilization Catheters * Infection Restraints Metabolic disturbance Delirium Delirium Outcomes: Financial Disclosures. . . * Delirium increases hospital costs on the average by about $2500 * Which expands to about $6.9 billion in Medicare hospital expenditures Delirium Delirium References 1. 2. 3. 4. 5. 6. 7. Castle C, Leipzig R, Cohen HJ, Larson E & Mier DE. Geriatric Medicine. Springer. New York, 2003. Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. CMAJ 1993; 149:41–6 Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29(7):1370-9. Ferreira FL, Bota DP, Bross A, et al. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001;286(14):1754-8. Gunther ML, Morandi A, Ely EW. Pathophysiology of Delirium in the Intensive Care Unit. Crit Care Clin 2008;45-65. Hazard W, Blass JP, Halter JB. Delirium. Principles of Geriatric Medicine & Gerontology. McGraw Hill, York, PA. 2003: 1503-15. Inouye SK, Viscoli CM, Horwitz RI, et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993;119:474–81 Delirium References 8. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275:852–7 9. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999;106(5):565-573. 10. Inouye SK, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941–8. 11. McNicoll L, Pisani Margaret et al. Detection of Delirium in the Intensive Care Unit: Comparison of Confusion Assessment Method for the Intensive Care Unit with Confusion Assessment Method Ratings. JAGS 2005;53:495–500. 12. Pandharipande P, costabile S, Cotton B, et al. Prevalence of delirium in surgical ICU patients. Crit Care Med 2005;33(12)A45. Delirium References 13. Pandharipande P, Ely EW,. Sedative and analgesic medications: risk factors for delirium and sleep disturbances in the critically ill. Crit Care Clin 2006;22(2):313-327. 14. Pompei P, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42:809–15. Pompei P, et al. 15. Pompei P, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42:809–15. Pompei P, et al. Delirium in hospitalized older persons: outcomes 16. and predictors. J Am Geriatr Soc 1994;42:809–15.