DELIRIUM Emiliano Valles, MD - PowerPoint Presentation

Slide1

DELIRIUM

Emiliano Valles, MD

UNM Dept. of Psychiatry

Division of Behavioral Health Consultation and Integration

Slide2

None

Disclosures

Slide3

Delirium

Definition

Clinical Manifestation

Epidemiology

Mortality & CostRisk FactorsDelirium ManagementAssessmentPrevention StrategiesManagement StrategiesEtiology/WorkupBehavioral InterventionsPharmacologic InterventionsPathophysiology

Objectives

Slide4

Encompasses multiple descriptive terms including ‘Acute Confusional State,’ ‘(Toxic Metabolic) Encephalopathy,’ ‘Acute Brain Failure,’ ‘ICU Psychosis,’ ‘Subacute Befuddlement.’

Delirium

BMC Medicine

2014

12

:141

Slide5

The state of full awareness of the self and one’s relationship to the environment.

Reduced LOC = Global reduction in level of behavioral response

Two components

Content

& Arousal Consciousness

Slide6

Two components

Content

– sum of all functions mediated at a cerebral cortical level (cognitive and affective)

Focal deficits may exist without reduced level of consciousness

Arousal – Responsiveness of brain systems responsible for cognitive functionReduced LOC: Diffuse cortical impairment or specific brainstem/diencephalic pathwaysConsciousness

Slide7

Clouding of Consciousness

– minimally reduced wakefulness or awareness

Delirium

– DSM

Obtundation – Mental blunting or torpidity. Mild to moderate reduction in alertness, accompanied by a lesser interest in the environment.Stupor – Condition of deep sleep or similar behavioral unresponsiveness from which the subject can be arouse only with vigorous and continuous stimulation. LOC may be impaired even when maximally aroused.Coma – State of unresponsiveness in which the patient cannot be aroused to respond appropriately to stimuli even with vigorous stimulation.

Acutely Altered States of Consciousness

Plum and Posner’s Diagnosis of Stupor and Coma

Delirium By Convention

BMC Medicine

2014

12

:141

Slide8

Disturbance of Attention & Awareness

focusing, sustaining and shifting attention

maintaining conversation or following commands

Disturbance of Psychomotor Activity

Hypoactive Delirium (more frequent in the elderly, often unrecognized)Lethargy, decreased level of motor activityHyperactive DeliriumAgitation and VigilanceClinical Manifestation

Slide9

Disturbance in Level of Arousal

Sleep-cycle disturbances/complete reversal

Daytime drowsiness, nighttime insomnia

Fragmented sleep

Acute Change from Baseline and FluctuatesLucid IntervalsIncreases/decreases in severity over 24 hoursClinical Manifestation

Slide10

Disturbance of Cognition

Disorganized thought

Incoherent speech/Illogical flow of Ideas

Rambling/Irrelevant conversation

DisorientationMemory DeficitsPerceptual disturbancesIllusions and HallucinationsEmotional DisturbanceFear, paranoia, anxietyDepression, apathyIrritability, angerEuphoria

Clinical Manifestation

Slide11

Prevalence

1-2% community, increases with age to 14% of those >85yo

Incidence

hospital admission ranges from 14-24%

Post-operative older patients 15-53%general hospitalization ranges from 6-56%.critical care settings 70-87% 83% of all patients at the end of lifeOften under diagnosedEpidemiology

Journal of Psychiatric Practice 18;6. 2012. 413-19

n

engl

j med 354;11. 2006. 1157-65

Slide12

In 10-30% of older patients presenting to ER, delirium is a symptom that heralds life-threatening conditions

Mortality rates among hospitalized 22-76% (similar to MI or sepsis)

One year mortality rates 35-40%

Duration may be robust predictor of death

One of the most common preventable adverse events among older patientsMortality & Cost

Slide13

Strongly influences ICU Length of Stay

May result in distrust, fear, PTSD

May increase hospital costs up to 31%

Estimated annual cost to US healthcare $38-152 billion

May take weeks to months to resolveMay herald permanent cognitive decline, hasten loss of functional status & independenceMortality & Cost

Slide14

Relation between delirium and

6-month survival

Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 291(14): 1753-1762, 2004

independently associated

with:

higher

6-month

mortality (

HR) =3.2 (1.4-7.7),

P=0.008

longer

hospital stay (HR)=2.0

(1.4-3.0), P<0.001 longer

post-ICU (ward) stay (adjusted P=0.009)fewer

days alive and free of mechanical ventilation (adjusted P=0.03),higher

incidence of cognitive impairment at hospital discharge (adjusted P=0.002)

Slide15

Risk Factors & Insults

n

engl

j med 354;11. 2006. 1157-65

Slide16

Risk Factors

Slide17

Risk Factors & Insults

n

engl

j med 354;11. 2006. 1157-65

Like, all of your patients

Lots of your patients

Slide18

Hospitalized patients >65yo

Have a high degree of suspicion for Delirium if:

Psychotic/agitated/irritable/paranoid (Nursing staff will tell you they are delirious)

Not sleeping overnight

Lethargic, napping, non-participatory with PT/OT, flat, anxious (Confused with depression)Assume the patient is a poor historianBeware lucid intervalsBeware intact social gracesIf delirium present, patient cannot reliably endorse subjective complaintsAssessment

Slide19

Establish Baseline Cognitive Function (if none, assume delirium)

Rely heavily on collateral sources

OSH, SNF, ALF records

Family & Caregivers, Sitters

Medical RecordED TriageED PhysicianHPINursing/PT/OT/Speech NotesAssessment

Slide20

Brief, formal Cognitive Screening

CAM-ICU

MMSE

MOCA

Or Orientation with Attention TestingDays of week backwardsMonths of year backwardsDigit span backwardsVigilance testing (if non-verbal)If unable to participate in attentional testing, consider treating as Delirium until proven otherwise

Assessment

Slide21

Assessment

J Neurol Neurosurg Psychiatry 2014;85:1122–1131.

Slide22

Management Strategies

n

engl

j med 354;11. 2006. 1157-65

Slide23

Orientation & Therapeutic activities for cognitive impairment

Early Mobilization

Interventions to prevent sleep deprivation

Communication methods and adaptive equipment for vision/hearing impairment

Early intervention for volume depletionNon-pharmacologic approaches to minimize psychoactive drug usePrevention Strategies

Slide24

Optimize Oxygen Delivery to brain

Optimize Electrolyte balance

Optimize Nutrition

Optimize Pain management

Optimize Bowel and Bladder FunctionPrevention of Post-op ComplicationsTreat symptoms of Delirium30-40% of cases may be preventablePrevention Strategies

Slide25

Search for and Treat underlying medical illness

Targeted History (OPQRST, SUD, Meds) with emphasis on recent changes

Complete ROS (Urinary retention, constipation, pain)

Vitals, EKG, CXR

Physical & Neuro examSelected Labs (CBC, Chem 10, LFT’s, TSH, B1, B12, U/A, UDM, Utox, EtOH, HIV, Trep pallidum)Clinically indicated labs (ABG, cultures, Therapeutic Drug levels, ESR, ANA, NH3,

porphyrins

)

Consider broadening workup if clinically indicated

Imaging, LP, EEG (may help discern delirium from psych)

Management Strategies – Etiology/Workup

‘Laboratory Approach to Specific Clinical Situations in Psychiatry’, Chapter 4

of the American Psychiatric Publishing Textbook of Psychiatry, 6th Ed

n engl j med 354;11. 2006. 1157-65

Lancet 2014; 383: 911–22

Slide26

Delirium Precautions

Calm, comfortable environment

Orientation materials (clocks, calendars, familiar objects) and regular re-orientation

AIDET

Family involvement in careLimit room and staff changesEncourage daytime wakefulness and mobilityCluster care, minimize disruptions of sleepSupportive careAddress predisposing & precipitating factorsPrevent falls, wandering, violence, intentional and unintentional self-harm

Management Strategies - Behavioral

n

engl

j med 354;11. 2006. 1157-65

Lancet 2014; 383: 911–22

Slide27

Currently, there are

no medications with U.S. Food and Drug Administration (FDA) approved indications for the management of delirium

no published double-blind, randomized, placebo-controlled trials to guide the pharmacological management of delirium

no consensus between oncologists, geriatricians, psychiatrists, and palliative medicine specialists about how to pharmacologically treat delirium

No evidence meds improve prognosisReserve for patients with severe agitation, interference with medical care, severe psychosisPharmacologic Interventions

n

engl

j med 354;11. 2006. 1157-65

Lancet 2014; 383: 911–22

Slide28

Pathophysiology

Crit

Care

Clin

24 (2008) 789–856

Slide29

Discontinue

deliriogenic

agents and anti-cholinergic agents

Avoid

GABAergic agents to control agitation, if possible (unless CNS depressant w/d)Adequately assess & treat painAvoid Opioids for behavioral control of agitationPharmacologic Interventions

Slide30

Consider: (

with LOTS of hand waving

)

Acetylcholinesterase Inhibitor for correction of central anticholinergic syndrome

Rotate opioids from morphine/meperidine to fentanyl or hydromorphoneSerotonin antagonist to control toxic elevations of 5HT usually associated with (hypoactive) deliriumMelatonin or Melatonin agonists for sleep cycle regulationNMDA-receptor antagonist (memantine, amantadine) to minimize glutamine induced neuronal injuryAlpha-2 agonist (dexmedotomidine, clonidine) for protection against acute NE release 2/2 hypoxia/ischemia

Depakote for management refractory hyperactive delirium

Dopamine

antagonists

for theorized abnormally elevated levels of dopamine

Pharmacologic Interventions

Crit

Care Clin 24 (2008) 657–722

J Neuropsychiatry Clin Neurosci 2015; 00:1–6

Psychosomatics 2015; 56:615–625

Slide31

Slide32

Excited Delirium Syndrome

Altered Sensorium

Aggressive/agitated behavior

Superhuman strength, lack of willingness to yield to overwhelming force

Diaphoresis, hyperthermiaOften UDM positive for sympathomimetic agent (meth, PCP, LSD, cocaine)Often described retrospectively after patient death, sudden cardiac arrestNecessitates available supportive care for managementSpecial Cases

Journal of Forensic and Legal Medicine 19 (2012) 7e11

Slide33

Irreversible Delirium

Delirium considered irreversible if:

Diagnostic efforts fail to discover etiology

Therapeutic trials fail to reverse delirium even with help of expert consultants.

Underlying etiology is irreversiblePalliative Care optionsGoals of Care guide workup and managementSpecial CasesJOURNAL OF PALLIATIVE MEDICINE

16;4. 2013. 423-435