Delirium in Older Adults - PowerPoint Presentation

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Delirium in Older Adults

Kathleen Pace Murphy, PhD, MS, GNP-BCAssistant Professor, UTHealth Division of Geriatric and Palliative MedicineDeputy Director, Consortium on Aging

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Kathleen Pace Murphy, PhD, MS,

GNP-BCAssistant Professor, UTHealth Medical School

Division of Geriatrics and Palliative Medicine

Deputy Director, Consortium on Aging

Neither I nor members of my immediate family have any financial relationship with commercial entities that may be relevant to this presentation.

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Delirium Incidence

10-24 percent of the hospital patient population Incidence increases with patient complexity 60 percent occurs in older adult patients60-80 percent incidence in those admitted to a Medical ICU80-90 percent in older adults with terminal cancer.

Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment.

Critical Care Clinics.

2008;24:657-722/

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Delirium or Acute Confusional State DEFINITION

SyndromeAcute Brain FailureCharacterized by:AcuteDisturbance in consciousness

Reduced ability to focus, sustain or shift attention

Occur over short period of time Fluctuates over the course of a day

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Etiology

Potential causes of delirium include:Inadequate pain controlDrug or toxin

Metabolic disorders

Neurovascular insult

Systemic organ failureComplications from a systemic disease

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Figure out the trigger

Drug use (hypnotics, anticholinergic) (30%)

E

lectrolyte abnormalities (40%)

Lack of drugs (withdrawal)Infection (40%)R

educed sensory input

(24%)

I

ntracranial problems (stroke)

U

rinary retention and fecal impaction

M

yocardial

or metabolic problems (14- 26%)

Often combination of several of the above.

Francis

 J, Martin D, Kapoor W

: A prospective study of delirium in hospitalized elderly. 

J Am Med Assoc.

 263:1097-1101 1990

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Delirium

Increased mortalityPoorer functional status

Limited rehabilitation

Increased hospital-acquired complications

Prolonged hospital stayIncreased risk of institutionalizationHigher health care expenditures.

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Differential Diagnosis

Hypoactive Delirium Hyperactive Delirium Mixed Delirium (46%)**The main feature differentiating delirium from depression from dementia:

Acute – fluctuating nature of symptoms

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Delirium Differential Diagnosis

Depression

Delirium

Dementia

OnsetWeeks to months

Hours to days

Months to years

Mood

Low

Apathetic

Fluctuates

Fluctuates

Course

Chronic, Responds to treatment

Acute, responds to treatment

Chronic, with deterioration over

time.

Self-awareness

Likely

to be concerned about memory

Maybe aware

of changing cognition

Hide or be unaware of memory

ADLs

May neglect basic self-care

Intact or impaired

Intact early, impaired

as disease progresses

IADLs

Intact or impaired

Intact or impaired

Intact early, impaired before ADLs as disease progresses

Sarutzki-Tucker

& Ferry, 2014

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Clinical Presentation

Clinical manifestations appear over a shorter period of time (few days)Progressive decline in memory, awareness to surroundings or behaviorFluctuate throughout the dayInability to maintain normal sequential thought

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PATHOPHYSIOLOGY

Pathophysiology is unclearWidespread derangement of cerebral metabolism or cerebral insufficiency that leads to decreased synthesis of cerebral neurotransmitters, especially acetylcholine.Brain maladaptive reaction to acute stress (Ham et al, 2014)

The core group of clinical manifestations:

Attention deficitsSleep-wake cycle disturbanceMotor activity changes

May present as psychosis, mood changes, fluctuating LOCs, disorientation, memory impairment, and disturbances in speech and language.

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MORTALITY

Delirium is a medical emergencyPersons who have delirium have a statistically significant higher risk of death compared to age cohorts who do not.

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Medication Hierarchy

Level 1 - NeurolepticLevel 2 -Level 3

Level One - Neuroleptics

Level Two – Analgesics; Sedatives-Hypnotics; Dopamine agonists

Level Three – Antihistamine; anti-inflammatory; anticholinergic; antidepressants; cardiac glycosides

Level Four – H2 Antagonist, Dihydropyridine; Tricyclic antidepressants; anti-Parkinson; antimicrobials

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Score 3- High ACA

Score 2 – Moderate

ACA

Score 1 – Mild ACA

AmitriptylineAmantadine

Alprazolam

Atropine

Belladonna

Atenolol

Clozapine

Carbamazepine

Bupropion

Darifenacin

Cyclobenzaprine

Captopril

Desipramine

Cyproheptadine

Chlorthalidone

Diphenhydramine

Loxapine

Cimetidine

Doxepin

Meperidine

Clorazepte

Hydroxyzine

Methotrimeprazine

Codeine

Imipramine

Molindone

Colchicine

Nortriptyline

Oxcarbazepine

Diazepam

Olanzapine

Pimozide

Digoxin

Oxybutynin

FentanylParoxetineFurosemideQuetiapineHaloperidolTolterodineMetoprololImipraminePrednisone

ANTICHOLINGERGICMEDICATIONSPlay a major role in delirium developmentCumulative anticholinergic burden**ACA= anticholinergic activity

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Screening Tools

Richmond Agitation Sedation Scale (RASS)Confusion Assessment Method (CAM)Confusion Assessment Method for ICU (CAM-ICU)Neelon and Champagne Confusion Scale (NEECHAM)

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E. Wesley Ely, MD MPH and Vanderbilt University, 2002.

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Confusional Assessment Method (CAM)

Delirium if you have 1 + 2 +[either 3 or 4].

Diagnostic Features

Definitions

and Characteristics1. Acute Onset

Fluctuating

Course

Is

there evidence of an acute change in mental status from baseline?

Did the abnormal behavior fluctuate during the day, does it come and go, or increase and decrease in severity?

2. Inattention

Did the patient have difficulty focusing attention (easily

distracted) or have difficulty keeping track or what was being said?

3. Disorganized Thinking

Was the patient’s thinking disorganized or incoherent, e.g. rambling, irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching

from subject to subject?

4. Altered LOC

LOC – alert (normal), vigilant (hyper alert), lethargic (drowsy

but easily arousable), stupor (difficulty to arouse) or coma (unarousable)

Inouye SK, vanDyck 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.

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Delirium Management Listical

Knowledge and addressing the underlying causeBe mindful of the environmentDo not over stimulate Good patient careMedications (hopefully last resort)

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Assessment

Vital Signs: BP, P, HR, T, Pulse Ox, Pain

Physical Examination

Urinalysis

Cr, Na, K, Ca, Glucose

CBC with differential

Review old and new anticholinergic medications

Review old and new sedating

medications

Review the need for Foley catheters, IV lines, and other tethers

Apply

glasses, insert hearing aides

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Intervention Step 1

Identify and Treat reversible contributorsMedicationsInfectionFluid balance disordersImpaired CNS oxygenation

Severe pain

Sensory deprivationElimination Problems

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Intervention Step 2

Maintain behavioral controlBehavioral interventionsPharmacologic InterventionsNecessary for behavior that is dangerous to patient or others and does not respond to other management strategies

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Intervention 3

Anticipate and prevent or manage complicationsUrinary incontinenceImmobility and fallsPressure ulcersSleep disturbance

Feeding disorders

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Intervention 4

Restore function in delirious patientsHospital environmentCognitive reconditioningAbility to perform ADLFamily education/support/ participation

Discharge

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Prevention

Limit use of medications known to cause deliriumEnsure good nutrition and hydrationCorrect sensory deprivationEncourage normal sleep patternsPromote cognitive stimulation

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Prognosis

Delirium is usually reversible.Take several weeks for mental function to return to normal levelsThe longer the delirium goes untreated – there is worsening global cognition and executive function worsening.Pathophysiological evidence – inflammation – neuronal apoptosis – brain atrophy

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References

Catic AG. Identification and management of in-hospital drug-induced delirium in older patients. Drugs Aging. 2011:28(9):737-748.

Clegg A, Young JB. Which medications to avoid in people at risk of delirium: a systematic review.

Age and Ageing. 2011. 40:23-29.Gatewood M. Managing delirium among elderly patients in the ED.

Physician’s Weekly, 2013.Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Critical Care Clinics. 2008;24:657-722.Reade MC, Finfer S. Sedation and delirium in the intensive care unit.

New England Journal of Medicine

2014;370(5):444-454.

Sarutzki-Tucker A, Ferry R. Beware of delirium.

The Journal for Nurse Practitioners

2014:10(8); 575-581.