Download Delirium: Evaluation and Management

Delirium in the Elderly
M. Andrew Greganti, MD
March 19, 2009
Outline of Discussion
Case Presentation
Distinguishing characteristics
Prevalence
Etiology/Pathogenesis/Risk Factors
Prodrome
Clinical Presentation
Diagnosis/Evaluation
Prognostic Implications
Prevention and Treatment
Case Presentation
86 yo woman presents with confusion post
hip fracture surgery.
Medical Problems:
– Hypertension
– CHF - compensated
– Sick sinus syndrome S/P pacemaker
– Chronic atrial fibrillation
– Chronic anxiety about health
Case Presentation
Long-term resident of life care community
living in an intermediate care facility
Severe anxiety with tendency to obscess
over health issues
– Increasing anxiety level recently
Less intellectually “sharp” over previous 6
months
Hospital Course
In the ED could not understand that she
had broken her hip
No immediate perioperative complications
Postop day 2: Confused, agitated, waxing
and waning of sensorium
– Difficulty recognizing family
– Misinterpreted environmental stimuli
– “Sundowning” requiring a sitter
Hospital Course
Hypoxia secondary to aspiration
Improved post antibiotics
Confusion and difficulty understanding
directions - effective PT impossible
Poor hearing exacerbated confusion.
Hospital Course
After 10 days, cognition improved but not
back to baseline
Discharged to skilled nursing floor of her
life care community with persisting:
– Confusion
– Disorientation
– Severe anxiety
– Poor recent memory
Post Hospital Course
Fell 2 months post discharge, fracturing R ankle
– Severe delirium postop marked by episodic yelling out
Never returned to baseline:
– Intermittent confusion
– Somnolence followed by agitation
– Repetitive vocalizations
No response to re-orientation – partial response
to clonazepam, then olanzapine
Characteristics of Delirium
Disturbance of consciousness
Abnormal attention
Abnormal cognition
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Orientation
Memory
Thought processing
Executive function
Perception
Acute in onset and fluctuating in course
Precipitated by acute medical illness, medication, or
substance intoxication
Hyperactive, hypoactive, and mixed forms
Other Characteristics
Misdiagnosis is frequent – unrecognized in
up to 70%
May develop over hours to days.
– Abrupt onset more common.
– The line between dementia and delirium is
often unclear.
How common is delirium?
On admission to medical wards, 15 to 20%
of older patients meet criteria for delirium.
– Incidence during medical hospitalization: 5 to
10% - in some studies 30%.
– Prevalence higher in surgical patients:
10 to 15% post general surgery
30% post cardiac surgery
50% post hip fracture
Very common in terminally ill patients –
90%
Etiology
Etiology - Multifactorial in a patient
predisposed by underlying dementia:
– Infections
– Toxins, including drugs
– Substance withdrawal
– Organ failure: heart, liver, kidney, etc.
– Metabolic derangements
– Primary brain disorders
Pathogenesis
No specific structural brain lesion identified
but subcortical and cortical dysfunction
Changes in perfusion pressure
Depleted acetylcholine
Dopamine excess
Dopamine, GABA, serotonin, acetylcholine
imbalance
Cytokine activation
Risk Factors
Dementia: the strongest risk factor – 25 to 75%
Other predisposing brain diseases: stroke,
Parkinson’s
Advanced age
Severe medical illness
Metabolic disturbances: Hyponatremia,
dehydration
Drugs: anticholinergics, sedative hypnotics,
narcotics
Other Risk Factors
Immobility, low activity level
Hearing or vision impairment
Number of hospital room changes
Environmental high noise level
Prodrome
Patients may describe and/or manifest:
– Decreased concentration
– Irritability, restlessness, anxiety, depression
– Hypersensitivity to light and sound
– Perceptual disturbances
– Sleep disturbance - daytime somnolence and
nocturnal agitation
Clinical Presentation
Disorientation to place, time, situation
Impaired consciousness
– Reduced awareness
– Reduced or clouded consciousness with or
without overt hallucinations
Clinical Presentation
Decreased ability to focus, sustain, or shift
attention
– Decreased selective attention
– Distractibility
Cognition is made worse by inattention.
Speech:
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Tangential
Poorly organized
Slowed, slurred
Word finding difficulties: dysnomia, paraphasia,
aphasia
Clinical Presentation
Impaired registration, recent/remote
memory with associated confabulation
Perceptual abnormalities:
– Micropsia
– Macropsia
– Frank auditory or visual hallucinations,
distortion of body image
– May take action in response to hallucinations
Diagnosis
History from family and/or caregivers
Bedside observations
Diagnostic errors are common in:
– Hypoactive form
– The setting of rapid fluctuations of cognition.
Those with the patient the entire day
(nurses) or less likely to be deceived.
Reliable diagnostic instruments
– Confusion Assessment Method (CAM)
Confusion Assessment Method
Are these features present?
– Acute onset and fluctuating course
– Inattention, distractibility
– Disorganized thinking, illogical or unclear
ideas
– Alteration in consciousness
Differential Diagnosis
Dementia
– Alzheimer dementia
– Lewy body dementia
Delusional psychosis
– Psychosis is associated with normal attention,
orientation, and sleep/wake cycle
– Schizophrenia has a more chronic hx with highly
systematized delusions.
Depression and Mania
– Misdiagnosed as depression in as many as 40% of
cases
Evaluation
Search for causative medication is
especially important – up to 40% of cases.
– Psychotropics, narcotics, anticholinergics
– Digoxin, prednisone, furosemide, cimetidine
have anticholinergic properties.
Evaluation
CBC, electrolytes, BUN, Cr, glucose, LFTs
O2 Saturation
Urinalysis
TSH, B12
Toxin screen
CXR
CNS imaging
LP in febrile patient with meningeal signs
Cause not identified in 15 to 25%
Prognosis
Delirium is independently associated with:
– Increased functional disability
– Increased LOS
– Admission to long-term care
Hospital mortality of 22 to 76% - one year mortality of 35
to 40%
– Highest in the hypoactive subtype
May persist for months or indefinitely – more likely in
dementia
Two factors related to better outcomes:
– Admission from home
– Better premorbid functioning
Preventive Measures
Supportive overall approach with constant
reorientation
Effective management of anxiety
Effective management of pain
Early mobilization
Focus on assuring optimal vision and
hearing.
Haloperidol and donepezil prophylaxis not
effective
Treatment
Recognize and treat the prodromal stage
Focus on re-orientation – bedside sitter
Reduce or discontinue psychotropic,
anticholinergic, sedative, and narcotic
meds.
Optimize nutrition.
Physical therapy to increase mobility
Treatment
Nonpharmacologic measures:
– Increase interpersonal contact and
environmental support.
? use of around the clock sitters
– Provide clocks, calendars, soft lighting.
– Place family pictures in clear view.
– Reduce noise levels.
– Maximize visual and auditory acuity.
– Minimize room changes in the hospital.
Treatment
Use medications only as a last resort:
– Antipsychotics: haloperidol
– Atypical antipsychotics: risperidone,
aripiprazole, ziprasidone, quetiapine,
olanzapine
– Benzodiazepines - lorazepam
Treatment
Future therapies:
– Cholinergic drugs: donepezil, rivastigmine,
physostigmine
– Selective dopamine antagonists
– Benzodiazepine receptor (GABA) antagonists
– Antiplatelet and anti-inflammatory agents
Summary of Key Points
Delirium is an acute or subacute change in
mental status marked by a waxing and waning
course.
The etiology is multifactorial superimposed on
dementia and precipitated by acute medical
illness.
Risk factors include age, drug Rx, and metabolic
derangements.
It is associated with increased LOS,
institutionalization, and increased mortality.
Summary of Key Points
Evaluation should focus on ruling out
infection, medication toxicity, neurological
events, metabolic abnormalities, and new
cardiorespiratory problems.
Prevention is the best therapy – focus on
interpersonal and environmental support.
Use medications as a last resort.