Cases in Delirium for Family Physicians

Transcription

1 Friday General Session Cases in Delirium for Family Physicians Dale Moquist, MD Former Geriatric Coordinator Memorial Hermann Family Medicine Residency Horseshoe Bay, Texas Educational Objectives By the end of this educational activity, participants should be better able to:. Discuss the predisposing and precipitating risk factors of delirium. 2. Recognize the different presentations of delirium. 3. Discuss how to evaluate, diagnose, and treat delirium. Speaker Disclosure Dr. Moquist has disclosed that he has no actual or potential conflict of interest in relation to this topic. 4

2 2 Speaker Disclosure CASES IN DELIRIUM Dale C. Moquist, MD TAFP Annual Session & Primary Care Summit November 9, 208 Dr. Moquist has disclosed that he has no actual or potential conflict of interest in relation to this topic. Dr. Moquist is a Diplomate of the American Board of Family Medicine with a CAQ in Geriatrics. 3 8 Learning Objectives By the end of this activity, the participant will be better able to:. Discuss the predisposing and precipitating risk factors of delirium. 2. Recognize the different presentations of delirium. 3. Discuss how to evaluate, diagnose and treat delirium. Case 76 year-old woman is admitted for elective R hip replacement. History includes HTN and DM2 and takes enalapril and metformin. She complains of mild forgetfulness, often misplacing keys or where she has left the mail but otherwise she has been healthy. She was swimming 3 miles a week until 3 months ago but her activities have been limited by R hip pain. Her vital signs are stable with a BMI of 22. On exam she has decreased ROM of R hip with pain. Her SLUMS is 28/ hours post-op she pulls out her IV and wants to go home. 9 0 What is the MOST likely diagnosis?. Normal aging 2. Mild cognitive impairment 3. Major depression 4. Delirium 5. Alzheimer s Disease Other Names for Delirium Acute Confusional State Acute Mental Status Change Altered Mental Status Acute Organic Brain Syndrome Reversible Dementia Toxic or Metabolic Encephalopathy

3 Delirium is an important independent predictor of all of the following except:. Death 2. New institutionalization 3. Dementia 4. Functional decline 5. Delusional disorder Incidence and Morbidity Community prevalence: 2% /3 of inpatients aged 70+ on general medical units Much higher in the ICU 5% in the ER Up to 85% at end-of-life Meta-analysis on 3,000 patients followed for 2 years showed increased risk: 2-fold for death 2.4-fold for institutionalization 2.5-fold for new dementia Persistence of delirium poor long-term outcome 2 DSM-V Delirium Diagnostic Criteria Disturbance of consciousness with reduced ability to focus, sustain, or shift attention Change in cognition or a perceptual disturbance NOT better accounted for by existing dementia Development for a short-time (hours to days) and fluctuation during the day Evidence from history, physical, or labs that the disturbance is a direct physiologic consequence of a medical condition or a drug Difficult to apply but use confusion assessment method Clinically more useful 95% sensitivity and specificity 3 Which of the following is required for diagnosis of delirium using the confusion assessment method?. Acute change or fluctuating course in physical status 2. Hallucinations 3. Lethargy 4. Inattention 5. Delusions Confusion Assessment Method (CAM). Acute change in mental status and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness Requires features and 2 and either 3 or 4. Spectrum of Delirium Hyperactive, agitated, and or mixed delirium 25% of all cases Hypoactive delirium 75% of all cases Less often recognized and appropriately treated Poorer prognosis Special efforts to detect 2

4 7 8 Hyperactive Symptoms ( >3) Hypoactive Symptoms (> 4) Hypervigilance Restlessness Fast or loud speech Irritability Combativeness Impatience Swearing Singing Laughing Euphoria Anger Wandering Easy startling Fast motor responses Distractibility Tangentiality Nightmares Persistent thoughts Uncooperativeness Unawareness Decreased alertness Sparse or slow speech Lethargy Slowed movements Staring Apathy 9 20 Pathophysiology Documented Mechanism: Cholinergic Deficiency Anticholinergic drug overdose, reversed by physostigmine Scales available to measure anticholinergic burden of drug regimens Cholinesterase inhibitors have not been effective in preventing/treating delirium Second Potential Mechanism: Inflammation Postoperative Cancer Infection Elevated C Reactive Protein Predisposing Factors Advanced age Dementia Functional impairment in ADLs Medical comorbidity History of alcohol abuse Male sex Sensory impairment vision and hearing Depressive symptoms Laboratory abnormalities Mild cognitive impairment 2 22 Precipitating Factors Medications (3 meds added in 24 hours) Surgery Anesthesia Uncontrolled pain Low hematocrit level Bed rest Indwelling devices Physical restraints Infections Clinical Prediction Rule Risk Factors Age > 70 Alcohol abuse Cognitive impairment Physical functional impairment Abnormal serum chemistries Aortic aneurysm surgery Noncardiac thoracic surgery Points 2 3

5 23 24 Risks for Postoperative Delirium No risk factor points: 2% One or two risk points: 0% Three plus risk points: 50% Caused by SUM of predisposing factors and precipitating factors Greater the predisposing factors the fewer precipitating factors are needed Older and frail patients are more susceptible AWOL Tool for Prediction Prospective design for derivation and validation Assign point to each of 4 items Age > 80 Failure to spell WORLD backward Disorientation to place Nurse-Rated Illness: Mild, Moderate, Severe, Moribund Each is assigned point 0 Points: 2% Points: 4% 2 Points: 4% 3 Points: 20 % 4 Points: 64% Easy to do at bedside Vanja D. The AWOL Tool: Derivation and Validation of a Delirium Prediction Rule. Journal of Hospital Medicine. Vol 8: September 203. Which of the following interventions is associated with reduced incidence of delirium after hip fracture surgery?. Strict avoidance of opiate analgesics 2. Using geriatric structured protocols 3. Transfusion to Hgb level > 0 mg/dl 4. Donepezil in the postoperative period 25 Which shortens duration of delirium and associated with improved PX function, less functional decline, shorter hospital stay, and improved -year survival in critically ill older adults?. Reorientation 2. Early exercise and mobility 3. Use of : care for each patient 4. Massage 5. Physical restraints Case 2 An 8 year-old man undergoes evaluation 2 days after cholecystectomy because his daughter is concerned about a change in cognition. When she entered his room he addressed her as his wife who died 3 years ago. She believes he returned to baseline cognition 2 hours later. On exam, vital signs are normal. He is alert and calm. He is oriented to self and place but not to time. Neurological exam is unremarkable. Which one of the following would provide information on whether the patient meets CAM criteria for delirium?. Drawing intersecting pentagons 2. Electroencephalography 3. Digit span task 4. CT of the brain 4

6 29 30 Key Facts of Postoperative Delirium Peak Onset: First postoperative day Peak Prevalence: Second postoperative day Incidence of Delirium Noncardiac Surgery: 5% Aortic Aneurysm Repair: 50% CABG: 50% Hip Fracture Repair: 50% Total dose of anesthetic agents Postoperative Medication RX Do not use benzodiazepines Avoid use of meperidine Adequate pain management is important High levels of pain associated with delirium Use scheduled dosing PCA Regional anesthesia Opioid sparing analgesics Ice packs Case 3 An 86 year-old woman is admitted to the hospital from a NH because of increasing lethargy over the last 2 days and is slow to respond to questions. Normally she is alert and oriented, pleasant, and actively involved in her care. History includes hypertension, Diabetes Mellitus 2, paraplegia from a car accident 30 years ago, and recurrent pressure ulcers On arrival in the ER, temp is 39.3, blood pressure is 88/40, and pulse is 00 beats per minute. Behavior fluctuated between lethargy and mild agitation. She provides no useful history. 3 Which of the following is the most appropriate next step in her care?. Obtain CT of the head with contrast 2. Administer a high-potency, low-dose antipsychotic med 3. Perform physical examination and order laboratory tests 4. Transfer to ICU for observation 5. Obtain psychiatric consultation 32 Case 4 83 year-old woman is hospitalized for pneumonia. History includes Alzheimer s, depression, and urinary urgency. Baseline meds are sertraline 50 mg/d and oxybutynin 5 mg/d. During hospitalization she has become more confused despite initiation of appropriate antibiotics and antipyretic agents. She awakens in the middle of the night demanding that staff bring her lunch, she hallucinates, and engages in conversation with children whom she believes are in the room. 33 Which one of the following would be the most appropriate initial pharmacologic intervention?. Begin donepezil 2. Begin quetiapine 3. Begin ramelteon 4. Discontinue sertraline 5. Discontinue oxybutynin ER 34 5

7 Case 5 The daughter of an 82 year-old woman calls because her mother has suddenly become more agitated, confused, and psychotic. Her mother has a 4-year history of Alzheimer s. Psychotic symptoms and agitation have been well-controlled on quetiapine 50 mg po HS. Which of the following is the most appropriate next step?. Increase quetiapine to 75 mg/day 2. Discontinue quetiapine and initiate risperidone 3. Stop all meds and reevaluate in week 4. Arrange urgent physical and laboratory evaluation 35 Evaluation History focuses on the time course of changes and association with other symptoms or events Fever Shortness of breath Change in medication Brown Bag Test: Do not forget OTCs Vital signs with oxygen saturation Careful general medical exam Neuro exam for new focal findings Identify acute medical problems or exacerbations of chronic medical problems Laboratory Studies Selected based on history and exam findings Minimum: CBC, electrolytes, and kidney function Other tests in selected situations Urine: UA, UC, and toxicology for drugs Liver Function Tests Serum Medication Tests ABGs CXR EKG Appropriate cultures Cerebral imaging is overused except for head trauma or new focal neurologic findings What is the Source? Drugs: Change in meds and OTC Electrolyte disturbance Lack of drugs including poorly controlled pain Infections Reduced Sensory Input: Hearing and vision Intracranial Urinary retention and fecal impaction Myocardial/Metabolic/Pulmonary Drugs to Reduce or Eliminate Alcohol Anticholinergics Oxybutynin and Benztropine Anticonvulsants Primidone, Phenobarbital, and Phenytoin Antidepressants Amitriptyline and Imipramine Antihistamines Diphenhydramine H2 blocking agents Antiparkinsonian agents Barbiturates Benzodiazepines Zolpidem Opioids Prevent or Manage CX Implement scheduled toileting program Avoid physical restraints Mobilize with assistance Use physical therapy Implement nonpharmacologic sleep regimen Avoid sedatives Minimize nighttime awakenings Assist with feedings with aspiration precautions Do not forget nutritional supplementation 6

8 4 42 Restore Function Reduce clutter and noise at night Provide adequate lighting Familiar objects from home Reorient at least three times a say With improvement match performance to ability: ADLs Educate family Discuss family s role in restoring function On discharge provide increased ADL support Follow mental status changes Disruptive Behaviors Teach hospital staff appropriate interaction Encourage family visitation Pharmacologic intervention Only if necessary Harm themselves Use low-dose high potency antipsychotics What About Intervention with Meds? Antipsychotics have a more favorable risk benefit ratio than benzodiazepines or sedatives All use of antipsychotics for delirium is off-label Many studies are not blinded and outcomes are difficult to interpret Use the lowest effective dose for the shortest duration Only use if agitated Do not use benzodiazepines as first-line RX Adding cholinesterase inhibitors does not work! Antipsychotics in Delirium Drug Daily Dose Adverse Events Quetiapine Ziprasidone mg Max: 50 mg/ mg po/im Max: 20 mg/24 Sedation, Hypotension, Eye Exam Q 6 Mo Can Be Used in Parkinson s, Fewer EPS Mild Sedation, Mild Hypotension Haloperidol mg Relative Nonsedating, EPS, First Generation Agent Olanzapine mg Q2H No IV Sedation, Falls, Gait Disturbance, Fewer EPS Risperidone.25-.5mg hs Sedation, Hypotension, EPS With Doses > mg/day Care Transitions in Delirium Diagnosis requires knowledge of patient s baseline Presence of delirium at discharge to a SNF is risk factor for hospital readmission Prolonged cognitive and functional disability make care planning more difficult: Increased resources Care transitions are risk factors for delirium particularly in highly vulnerable individuals Consider keeping in hospital extra day or two to allow discharge to home instead of SNF Proactive Management Hospital Elder Life Program: Decrease 40% Cognitive impairment Sleep deprivation Immobility Visual impairment Hearing impairment Dehydration Proactive geriatrics consultation in hip fracture Promote Sleep Hygiene Melatonin Warm milk Back rubs Soothing music Avoid Diphenhydramine! 7

9 47 48 One Last Case 66 y/o WF awakens at 2 a.m. with severe pain in L foot. It is exquisitely tender, red, and swollen. She is seen by her orthopedist and admitted to hospital for cellulitis. History reveals a pedicure 2 weeks earlier and steroid injection in L foot 8 days earlier. Remote HX of hysterectomy and total R knee. Total L knee 4 months previous. Asthma, HTN, controlled DM2, hypothyroidism, OSA, and hyperlipidemia. She had a tachycardia of 05, BP=48/84, temp > 02, and a new heart murmur. X-ray and CT scan of L foot showed no abscess. Blood cultures were positive for methicillin sensitive staph aureus. This Case Continues Initially on IV clindamycin, then IV vancomycin WBC=3.9, Hgb=0., AlkP=204, SGOT=9, Glu=204, C-Reactive Protein=320, ESR > 00. CT scan of chest showed infected nodules, head scan showed no abnormalities, and L foot scan no abscess. Blood cultures continued to be positive despite appropriate IV antibiotics. She was transferred to a medical center because of need for TEE and infectious disease consult. TEE was normal. Her blood cultures became negative on day 8. She continued with continuous IV nafcillin at 2 grams/hr for 5 weeks More on This Case PET Scan: R psoas abscess, abscess around L knee, activity L foot and osteomyelitis of L-2 Wash out surgery was done on L knee with negative cultures She was on scheduled hydrocodone and started on PT Her husband noted She would forget if her family had called her She could not remember her neighbors and friends visiting her in the hospital She did not remember her two sons and daughter-in-law visiting her Discharged 8 weeks and 4 days after admission using a walker, oral antibiotics, oral pain meds, and PT Post Discharge Continued with oral antibiotics for osteomyelitis Obtained OP physical therapy Graduated from walker to cane after one month After one month hung up the cane Her C-reactive protein is 5. (normal <3.0) ESR is 3 Was able to organize medications SLUMS is Strong AGS Clinical Practice Guidelines. Multicomponent nonpharmacologic interventions. Cognitive reorientation 2. Sleep enhancement 3. Early mobility 4. Correct visual and hearing impairment 5. Proper nutrition and fluid repletion 6. Adequate oxygenation 7. Prevention of constipation 2. Educational programs to reduce hospital delirium 3. Medical evaluation to identify and manage contributing factors Strong Recommendations Continued 4. Pain management should be optimized 5. Avoid high risk meds precipitating delirium 6. Cholinesterase inhibitors DO NOT prevent or RX postoperative 7. Benzodiazepines should not be first-line Rx of agitation 8. Do not use antipsychotics and benzodiazepines for hypoactive form 8

10 54 55 More on AGS Guidelines Weak: Evidence/risks do not support strong recommendation. Multicomponent nonpharmacologic interventions implemented by interprofessional team for postoperative delirium 2. Injection of regional anesthesia at time of surgery 3. Lowest dose of antipsychotics for shortest time interval for severe agitation or substantial harm Insufficient evidence recommendation: Use of EEG monitors during anesthesia Insufficient evidence to recommend for or against. Prophylactic use of antipsychotic med to prevent delirium 2. Specialized hospital units for inpatient care of older adults with postoperative delirium SUMMARY Very common geriatric problem in ER and hospitalized Predisposing and precipitating factors are important Greater predisposing than fewer precipitating factors Frail older adults are more susceptible Remember the mnemonic DELIRIUM Brown Bag test to review ALL meds If needed use antipsychotics not benzodiazepines Anticipate complications Restore function Involve the family Be careful about transitions Remember AGS Guideline Recommendations References QUESTIONS? Chapter on Delirium. Geriatric Review Syllabus. Updated February 208. Accessed online in July 208. Marcantonio E. Delirium in Hospitalized Older Adults. NEJM. 377;5: October 2, 207 Marcantonio E. A Clinical Prediction Rule for Delirium After Elective Noncardiac Surgery. JAMA. 27: January 2, 994. Oh E. Delirium in Older Persons Advances in Diagnosis and Treatment. JAMA. 38:6-72. September 26, 207 Inouye S. Delirium A Framework to Improve Acute Care for Older Persons. JAGS. 66: March References Douglas V. The AWOL Tool: Derivation and Validation of a Delirium Prediction Rule. Journal of Hospital Medicine. Vol 8: September 203. Kalish V. Delirium in Older Persons: Evaluation and Management. American Family Physician. August, 204; Vol 90:

11 Medication Index Cases in Delirium for Family Physicians The following medications were discussed in this presentation. The table below lists the generic and trade name(s) of these medications. Generic Name Amitriptyline Benztropine Diphenhydramine Donepezil Enalapril Haloperidol Hydrocodone Imipramine IV Clindamycin IV Nafcillin IV Vancomycin Meperidine Metformin Olanzapine Oxybutynin Phenobarbital Phenytoin Primidone Quetiapine Ramelteon Risperidone Sertraline Ziprasidone Zolpidem Trade Name None Cogentin Benadryl Aricept Epaned, Vasotec Haldol Hysingla, Norco, Reprexain, Zohydro ER Tofranil Cleocin Nallpen Vancocin Demerol Fortamet, Glucophage, Glumetza, Riomet Zyprexa Ditropan XL, Oxytrol Solfton, Luminal Cerebyx, Dilantin, Phenytek Mysoline Seroquel Rozerem Perseris Kit, Risperdal Zoloft Geodon Ambien, Edluar, Intermezzo, Zolpimist

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