Delirium in the Older Adult - PowerPoint Presentation

Slide1

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 ChaoSlide2

Objectives

To elicit key features of and define delirium

To review epidemiology, risk factors, and precipitants of delirium

To discuss management strategies around delirium.Slide3

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.Slide4

What is your first thought?Slide5

What could possibly go wrong?

A case for contingency planning…Slide6

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 ½ NS at 75 cc/hour Slide7

Case cont’d

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 homeSlide8

Beep Beep!

Dear Dr.Nightfloat….Slide9

“Hi, are you covering for Agnes D?....”

Delirium: She is OFF THE WALL!!Slide10

Delirium

Definition?Slide11

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 used—

CALL IT WHAT IT IS!Slide12

Your next step is….Slide13

MEDICAL EMERGENCY!Slide14

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 screeningSlide15

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.Slide16

Diagnosis: Confusion Assessment Method (CAM)

Acute change in mental status with a fluctuating course

Inattention

AND

3. Disorganized thinking

OR

4

.

Altered level of consciousness

Sensitivity > 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; 113:941-8.Slide17

Assume it is delirium until proven otherwise:

Delirium may be the only manifestation of a life-threatening illness in the elderly patient.Slide18

Please complete Agnes’ Delirium MapSlide19

Agnes’ Delirium Map

Risks:

Precipitants:

Your interventions:Slide20

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 14-24%

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 25-33%

$$$ Slide21

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.Slide22

Approaches to Clinical Problem Solving

“simpler explanations are, other things being equal, generally better than more complex ones" Slide23
Slide24
Slide25

Agnes’Delirium Map

Risks:

Age

Dementia

Medical illnesses

Hearing impairment- no hearing aids!!

Precipitants:

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 Slide26

Agnes’ case continued

Agnes’ daughter comes in to help settle her mother down. She asks to speak to the doctor…..Slide27

What the hell are you people doing to my mother??!!!

A brief skills practice….Slide28

Management and Treatment

Treat medical illness, as possible

Always try

non-pharmacologic

treatment first

don’t 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 IV’s, catheters, other restraintsSlide29

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 alternativeSlide30

How to distinguish Delirium from Dementia

Features seen in both:

Disorientation

Memory impairment

Paranoia

Hallucinations

Emotional lability

Sleep-wake cycle reversal

Key features of delirium:

Acute onset

Impaired attention

Altered level of consciousness

Slide courtesy of Serena Chao, MDSlide31

Management and Treatment

Haldol

: advantages

readily available

PO, IM, IV

quick onset of action

high therapeutic index

Haldol

: disadvantages

extrapyramidal SE

contraindicated in pts with Parkinson’s disease or parkinsonism

neuroleptic malignant syndromeSlide32

Conclusions

Identify risk factors

Implement prevention strategies

Recognize syndrome when occurs

Determine etiology and treat if possibleSlide33

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]Slide34

Acknowledgements

Dr. Lisa Caruso

Dr. Serena ChaoSlide35

Thank YouSlide36

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)Slide37

Etiology: Medications

Cardiac (digoxin, lidocaine)

Antihypertensives (beta-blockers, Aldomet)

Miscellaneous

H2-blockers

steroids

metoclopramide

lithium

anticonvulsants

NSAIDSSlide38

Evaluation

Recognize syndrome

History

establish patient’s cognitive and functional baseline

thorough medication review: drug toxicity may account for up to 30% of all cases of deliriumSlide39

Evaluation

Physical Exam

vital signs including O

2

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 backwardsSlide40

Evaluation

Individualized work-up

Metabolic: CBC, electrolytes, BUN/Cr, glucose, Ca

2+

, phosphate, LFT’s, 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, EEGSlide41

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 base-line 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.Slide42

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, recurrenceSlide43

Prevention: Modify Risk Factors

OUTCOME

INTERVENTION

(Experimental Event Rate)

USUAL CARE

(Control Event Rate)

MATCHED

Number Needed to Treat (NNT)

(unmatched)

1

ST

episode of delirium (number of pts)

42 (9.9%)

64 (15%)

OR,

0.60 (95% CI 0.39-0.92);

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.Slide44

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.Slide45

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.Slide46

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.Slide47

Etiology

1940’s: Cortical function on EEG characterized by abnormal slow-wave activity.

Exception: alcohol and sedative withdrawal showing predominately low-voltage, fast-wave activity

Subcortical structures important, also.

Patients with subcortical strokes and basal ganglia abnormalities are more susceptible to delirium.Slide48

Etiology

Role of Acetylcholine (Ach)

Neurotransmitter involved in multiple aspects of cognitive functioning including memory

Anticholinergic medications are frequent causes of delirium

Patients with Alzheimer’s 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