Download Delirium

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.