Delirium in the Older Adult - Boston University

Delirium in the Older Adult Matt Russell,MD, MSc Assistant Professor of Medicine Boston University School of Medicine Slide show courtesy of Drs. Lisa Caruso and Serena Chao Objectives To elicit key features of and define delirium To review epidemiology, risk factors, and precipitants of delirium To discuss management strategies around delirium. Case: 2pm Admission

Agnes D: 88 year old female ALF resident with history of Dementia( MMSE 21/30), HTN, CAD, hearing loss, history of GI bleed (diverticulosis), hyperlipidemia, and COPD presents with a 3 day history of progressive dyspnea, purulent sputum, and wheezing. Per nursing home flow sheet, oxygen saturation was in the low 80s% on room air. She is admitted with COPD exacerbation. At baseline, she is AAOx2. She is minimal assist with some ADLs (dressing and toileting) and ambulates independently. What is your first thought? What could possibly go wrong? A case for contingency planning

Case continued Agnes is admitted to the inpatient medical service. She is placed on 2 liters NC. Her other admission medications are as follows: ciprofloxacin, Solumedrol IV, Donepezil

Famotidine for GI prophylaxis Advair 500/50 Spiriva zolpidem prn D5 NS at 75 cc/hour Case contd Because of history of GI bleed, the team puts her on venodyne boots for DVT prophylaxis. She is placed on telemetry and continuous oxygen saturation monitoring The patient is settled in and the medical team goes home Beep Beep! Dear Dr.Nightfloat.

Hi, are you covering for Agnes D?.... Delirium: She is OFF THE WALL!! Delirium Definition? Delirium = Syndrome Definition: An acute disorder of attention and cognition; acute confusional state Delta MS or Mental Status Changes are vague, inappropriate terms and should not be usedCALL IT WHAT IT IS! Your next step is.

MEDICAL EMERGENCY! Next steps Go to bedside and see patient Approach in comforting fashion-NOT GUNS A BLAZIN!! Obtain history of baseline mental status from all available sources Perform bedside testing for delirium screening Recognition Delirium is unrecognized by physicians in 32-67% of cases in hospitalized patients Reasons for this include

lack of awareness of syndrome as important cognitive assessment not done misdiagnosed or not detected Inouye SK. The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994; 97:278-88. Diagnosis: Confusion Assessment Method (CAM) 1. Acute change in mental status with a fluctuating

course 2. Inattention 3. Disorganized thinking OR 4. Altered level of consciousness Sensitivity AND > 94%; specificity > 90% ; gold standard used was ratings of psychiatrists Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion. The Confusion Assessment Method: A new method for detection of delirium. Ann Intern Med 1990; Assume it is delirium until proven otherwise: Delirium may be the only

manifestation of a lifethreatening illness in the elderly patient. Please complete Agnes Delirium Map Agnes Delirium Map Risks: Precipitants: Your interventions: Epidemiology

Complicates hospital stays for more than 2.3 million persons 65 years of age and older per year Prevalence on admission to the hospital is 1424% Incidence of new cases arising during hospitalization is 6-56% Independent predictor of mortality up to 1 year after occurrence; mortality in patients who develop delirium in the hospital is 2533% $$$ Etiology Biology is poorly understood The development of delirium involves

the interrelationship between a vulnerable patient and noxious insults.1 1 Inouye SK. Delirium in older persons. NEJM 2006;354:1157-65. Approaches to Clinical Problem Solving simpler explanations are, other things being equal, generally better than more complex ones" Agnes Delirium Map Risks:

Precipitants: Age Dementia Medical illnesses Hearing impairment- no hearing aids!! Change in setting

Hidden restraints (IV tubing, venodynes, oxygen) Medications (solumedrol, cipro, ambien,famotidine) Interventions: Treat underlying process Eliminate restraints Maximize sensory input (hearing aids) Eliminate unnecessary and/or harmful meds: d/c famotidine and use PPI

d/c ambien Additional Non-pharm: family presence, orient, remove overt and hidden restraints, soothing tones, reassurance Pharm: haldol if necessary. Start low Agnes case continued Agnes daughter comes in to help settle her mother down. She asks to speak to the doctor.. What the hell are you people doing to my mother??!!! A brief skills practice. Management and Treatment

Treat medical illness, as possible Always try non-pharmacologic treatment first dont change room if possible encourage family visits.EDUCATE FAMILY MEMBERS!! quiet room with low level lighting make sure patients have their glasses and hearing

aides limit IVs, catheters, other restraints Management and Treatment Pharmacologic management indicated if the patient is endangering him- or herself or others AVOID BENZODIAZEPINES except for

alcohol withdrawal (delirium tremens) mainstay is the antipsychotic, haloperidol (Haldol); start with 0.5-1 mg, check vitals in 20 min, repeat dose as needed olanzapine (Zyprexa) may be a useful alternative How to distinguish Delirium from Dementia Features both: seen in Key features of delirium:

Disorientation Acute onset Memory Impaired attention impairment Altered level of Paranoia consciousness Hallucinations Emotional lability

Sleep-wake cycle Slide courtesy of Serena Chao, MD reversal Management and Treatment Haldol: advantages Haldol: readily available disadvantages extrapyramidal PO, IM, IV SE quick onset of contraindicated in action pts with high therapeutic

Parkinsons index disease or parkinsonism Conclusions Identify risk factors Implement prevention strategies Recognize syndrome when occurs Determine etiology and treat if possible When in acute fevers, pneumonia, phrenitis, or headache, the hands are waved before the face, hunting through empty space, as if gathering bits of

straw, picking the nap from the coverlet, or tearing chaff from the wall--all such symptoms are bad and deadly. Hippocrates, [460-375 BC] Acknowledgements Dr. Lisa Caruso Dr. Serena Chao Thank You Some drug classes that are associated with delirium Medications with psychoactive effects: 3.9-fold increased risk

2 or more meds: 4.5-fold Sedative-hypnotics: 3.0 to 11.7-fold Narcotics: 2.5 to 2.7-fold Anticholinergic drugs: 4.5 to 11.7-fold antihistamines (Benadryl, Atarax) antispasmodics (Lomotil) tricyclic antidepressants antiparkinsonian agents (Cogentin, Artane) antiarrhythmics (Quinidine, Norpace) Etiology: Medications Cardiac (digoxin, lidocaine) Antihypertensives (beta-blockers, Aldomet)

Miscellaneous H2-blockers steroids metoclopramide lithium anticonvulsants NSAIDS Evaluation

Recognize syndrome History establish patients cognitive and functional baseline thorough medication review: drug toxicity may account for up to 30% of all cases of delirium Evaluation Physical Exam

vital signs including O2 saturation search for signs of infection neurological exam include cognitive evaluation (ex. MMSE) other tests for attention forward digit span (able to repeat 5 digits forward) months of the year or days of week backwards Evaluation Individualized work-up Metabolic: CBC, electrolytes, BUN/Cr, glucose, Ca2+, phosphate, LFTs, magnesium. Consider also TSH, drug levels, tox screen, ammonia.

Infection: urine cx, CXR, blood cultures, consider LP If no obvious cause, ABG, ECG, brain imaging, EEG Prevention: It can be done! Objective: To evaluate the effectiveness of a multicomponent strategy for the prevention of delirium Design: Controlled clinical trial. Randomization not possible but pts meeting criteria admitted to intervention unit were prospectively matched by age, sex and baseline risk of delirium (meaning for number of risk factors). Subjects: 852 patients >70 yrs old admitted to general

medicine service at a teaching hospital 426 usual care, 426 intervention Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76. Prevention: Modify Risk Factors Intervention was standardized protocols to manage six risk factors for delirium Risk factors targeted were: cognitive impairment, sleep deprivation, immobility, vision impairment,

hearing impairment, dehydration Intervention unit staffed by a trained team (geriatric nurse specialist, two specially trained Elder Life specialists, a certified therapeutic-recreation specialist, a physical therapy consultant, a geriatrician and trained volunteers.) Outcomes: Delirium by Confusion Assessment Method, severity, recurrence Prevention: Modify Risk Factors OUTCOME INTERVENTION (Experimental Event Rate) USUAL CARE

(Control Event Rate) MATCHED Number Needed to Treat (NNT) (unmatched) 1ST episode of delirium (number of pts) 42 (9.9%) 64 (15%) OR,

0.60 (95% CI 0.390.92); P=0.02 19.4 (10.4-134.2) Total days of delirium 105 days 161 days P=0.02 Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.

Prevention: Modify Risk Factors Intervention did not change the severity of the delirium episode. Rates of recurrence of delirium did not differ in the two groups. Adherence rates high; lowest in non-pharm sleep protocol at 71%. Cost of intervention per case of delirium prevented was $6,341. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.

Risk Factors Risk Factor Studies/Pts in analysis (n/n) Combined Odds Ratio (95% Confidence Interval) P Value: Test of Homogeneity Dementia 12/289

5.2 (4.2, 6.3) .01 Medical illness 4/3 3.8 (2.2, 6.6) .47 Medications (narcotics)

2/128 1.5 (0.9, 2.3) .096 Male gender 6/103 1.9 (1.4, 2.6) .32

Depression 5/78 1.9 (1.3, 2.6) .01 Alcohol 3/27 3.3 (1.9, 5.5) .90

Abnormal sodium 2/23 2.2 (1.3, 4.0) .03 Hearing impairment 3/122 1.9

(1.4, 2.6) .17 Visual impairment 3/112 1.7 (1.2, 2.3) .05 Diminished ADL 2/33

2.5 (1.4, 4.2) .60 Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. J Gen Intern Med. 1998;13:204-12. Risk Factors Risk Factor Studies/Pts in analysis (n/n) Combined Odds Ratio (95%

Confidence Interval) P Value: Test of Homogeneity Dementia 12/289 5.2 (4.2, 6.3) .01 Medical illness 4/3

3.8 (2.2, 6.6) .47 Medications (narcotics) 2/128 1.5 (0.9, 2.3) .096 Male gender

6/103 1.9 (1.4, 2.6) .32 Depression 5/78 1.9 (1.3, 2.6) .01

Alcohol 3/27 3.3 (1.9, 5.5) .90 Abnormal sodium 2/23 2.2 (1.3, 4.0)

.03 Hearing impairment 3/122 1.9 (1.4, 2.6) .17 Visual impairment 3/112 1.7

(1.2, 2.3) .05 Diminished ADL 2/33 2.5 (1.4, 4.2) .60 Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. J Gen Intern Med. 1998;13:204-12. Etiology

1940s: Cortical function on EEG characterized by abnormal slow-wave activity. Exception: alcohol and sedative withdrawal showing predominately low-voltage, fastwave activity Subcortical structures important, also. Patients with subcortical strokes and basal ganglia abnormalities are more susceptible to delirium. Etiology Role of Acetylcholine (Ach)

Neurotransmitter involved in multiple aspects of cognitive functioning including memory Anticholinergic medications are frequent causes of delirium Patients with Alzheimers disease are particularly susceptible Serum anticholinergic activity (SACA) is increased in older pts with delirium and in postoperative delirium Some evidence that certain patients with delirium improve with administration of acetylcholinesterase inhibitors, such as physostigmine and donepezil

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