Kathleen Pace Murphy PhD MS GNPBC Assistant Professor UTHealth Division of Geriatric and Palliative Medicine Deputy Director Consortium on Aging Kathleen Pace Murphy PhD MS GNPBC Assistant Professor UTHealth Medical School ID: 915971
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Slide1
Delirium in Older Adults
Kathleen Pace Murphy, PhD, MS, GNP-BCAssistant Professor, UTHealth Division of Geriatric and Palliative MedicineDeputy Director, Consortium on Aging
Slide2Kathleen 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.
Slide3Delirium 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/
Slide4Delirium 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
Slide5Etiology
Potential causes of delirium include:Inadequate pain controlDrug or toxin
Metabolic disorders
Neurovascular insult
Systemic organ failureComplications from a systemic disease
Slide6Figure 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
Slide7Delirium
Increased mortalityPoorer functional status
Limited rehabilitation
Increased hospital-acquired complications
Prolonged hospital stayIncreased risk of institutionalizationHigher health care expenditures.
Slide8Differential Diagnosis
Hypoactive Delirium Hyperactive Delirium Mixed Delirium (46%)**The main feature differentiating delirium from depression from dementia:
Acute – fluctuating nature of symptoms
Slide9Delirium 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
Slide10Clinical 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
Slide11PATHOPHYSIOLOGY
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.
Slide12MORTALITY
Delirium is a medical emergencyPersons who have delirium have a statistically significant higher risk of death compared to age cohorts who do not.
Slide13Medication 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
Slide14Score 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
Slide15Screening Tools
Richmond Agitation Sedation Scale (RASS)Confusion Assessment Method (CAM)Confusion Assessment Method for ICU (CAM-ICU)Neelon and Champagne Confusion Scale (NEECHAM)
Slide16Slide17E. Wesley Ely, MD MPH and Vanderbilt University, 2002.
Slide18Confusional 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.
Slide19Slide20Delirium Management Listical
Knowledge and addressing the underlying causeBe mindful of the environmentDo not over stimulate Good patient careMedications (hopefully last resort)
Slide21Assessment
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
Slide22Intervention Step 1
Identify and Treat reversible contributorsMedicationsInfectionFluid balance disordersImpaired CNS oxygenation
Severe pain
Sensory deprivationElimination Problems
Slide23Intervention Step 2
Maintain behavioral controlBehavioral interventionsPharmacologic InterventionsNecessary for behavior that is dangerous to patient or others and does not respond to other management strategies
Slide24Intervention 3
Anticipate and prevent or manage complicationsUrinary incontinenceImmobility and fallsPressure ulcersSleep disturbance
Feeding disorders
Slide25Intervention 4
Restore function in delirious patientsHospital environmentCognitive reconditioningAbility to perform ADLFamily education/support/ participation
Discharge
Slide26Prevention
Limit use of medications known to cause deliriumEnsure good nutrition and hydrationCorrect sensory deprivationEncourage normal sleep patternsPromote cognitive stimulation
Slide27Prognosis
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
Slide28References
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.