Delirium in Hospital: Acute Medical Settings

Transcription

1 Delirium in Hospital: Acute Medical Settings Dr. Frank Molnar Co-Chair, Champlain Dementia Network champlaindementianetwork.org Medical Director, Regional Geriatric Program of Eastern Ontario rgpeo.com Co-chair, Champlain Regional Geriatric Advisory Committee Associate Professor of Medicine, University of Ottawa Staff Geriatrician, Division of Geriatric Medicine, The Ottawa Hospital

2 Financial Conflicts of Interest I do not have any actual, potential or perceived financial conflict of interests with respect to this topic. I believe my opinion and behavior (acts of commission or omission) can be influenced by contributions or gifts from the pharmaceutical industry. I decline support (honoraria) and gifts (trips, meals, entertainment) from the pharmaceutical industry.

3 Definition Delirium is a disturbance of consciousness with reduced ability to focus, sustain, or shift attention. It is a change in cognition that occurs over a short period of time and tends to fluctuate over the course of the day. (Milisen et al. 2001).

4 It s common! Estimated prevalence of delirium: % ER attendees over 65 years of age 10-18% on admission to hospital increases to 20-40% during hospital stay 40% of patients admitted to ICU rising to 70-87% during ICU stay 5-10% after elective general surgery 20-30% elective orthopedic but >50% post hip fracture surgery As many as 80% of patients develop delirium near death

5 It s under recognized!! Up to 66% deliriums are unrecognized (Inouye, 1998)

6 It s Relevant!!! CIHI Dementia /delirium resulted in 6x more ALC hospitalisations than diabetes, hypertension and asthma combined.

7 STEP 1 Identify Presence of Delirium

8 Recognize Predisposing Factors Dementia - fivefold increase of risk (Cole, 2004) Increased relative risk during hospitalization due to: vision impairment (RR = 3.5) severe illness (RR = 3.5) cognitive impairment (RR = 2.8) and high urea/creatinine (RR = 2.0) (Inouye,1998) Other predisposing risk factors: dependence in activities of daily living history of depression use of anticholinergic medications medical co-morbidities (Dolan et al., 2000; Marcantonio et al., 2000)

9 RGPEO Dementia Assessment Tool Patient s Name: DOB: Dementia vs. mild cognitive impairment (MCI) 1. Amnesia 2. Aphasia, apraxia, agnosia, executive dysfunction (SHAFT) 3. Progressive 4. Impacts on Function Is the person Cognitively Declining? No Yes CIRCLE POSITIVE FINDINGS Depression M Persistent low Mood S NewSleep disturbance I decreased Interest G Guilty thoughts (multiple Regrets) E decreased Energy C decreased Concentration (decreased focus) A decrease in Appetite P Physical complaints, Psychomotor change (hypoactive vs. Hyperactive agitated) S Suicidal ideation (active vs. passive) Somatization Increased alcohol use MCI (Does not meet all 4 criteria) Dementia (Meets all of criteria 1 4) Delirium Fluctuation (hourly and unpredictable), Hallucinations, Drowsiness, Sudden onset, slow mentation Lewy-Body vs. Parkinson s Dementia Parkinsonism, hallucination, fluctuation, decreased visuospatial Normal Pressure Hydrocephalus Brain, bladder, Balance Alzheimer Progressive decreased short-term memory Decreased word-finding Decreased insight Mixed Vascular Arterial disease Neuro imagine Risk factors Frontotemporal Behaviour frontal lobe Language semantic dementia, primary progressive aphasia Other 1. CJD +++ rapid with balance and swallowing change 2. Brain Injury

10 Delirium vs. Dementia Delirium Dementia Onset Abrupt Gradual Course Short Long Fluctuation Present Absent Hallucinations Present Absent Attention Impaired Normal LOC Altered Normal Psychomotor Altered Normal It is common for Delirium to be superimposed on Dementia!

11 The Devil is in the Detail This table oversimplifies so let us look at exceptions to the rules as well as the most reliable signs of Delirium

12 Onset & Duration (exceptions) Delirium May have prolonged low grade delirium with chronic ETOH, BDZ, Narcotic, Anticholinergic (e.g. TCA, Ditropan) use Dementia Can have rapid onset with strokes or CJD (see Health Canada CJD website)

13 Fluctuation Delirium New onset unpredictable fluctuation (hour by hour not day by day) Depression Predictable diurnal variation (worse in morning) Dementia Predictable diurnal variation (worse in afternoon or evening)

14 Hallucinations Delirium Especially if family describe new onset hallucinations Dementia / Psychiatric Disorders Long-standing hallucinations E.g. Lewy Body disease, Psychotic Depression, Bipolar disease

15 Attention, Concentration, LOC Delirium Attention, Concentration and altered Level of Consciousness (i.e. drowsy, somnolent) Depression Can alter Attention, Concentration but not LOC Dementia Normal Attention, Concentration, LOC

16 Patterns of Psychomotor Change in delirium Hyperactive ("wild man!"); 25% Hypoactive ( out of it!, snowed, pleasantly confused ); 50% Mixed delirium (features of both), with reversal of normal day-night cycle ( sundowning ); 25%

17 Confusion Assessment Method (CAM) AND AND EITHER 1. History of acute onset of change in patient s normal mental status & fluctuating course? 2. Lack of attention? Sensitivity: % Specificity: 90-95% Kappa: Disorganized thinking? 4. Altered Level of Consciousness? Inouye SK: Ann Intern Med 1990;113(12):941-8 Arch Intern Med. 1995; 155:301

18 STEP 2 Diagnosis, Treatment & Management Of Underlying Cause(s)

19 Causes of Delirium? I WATCH DEATH

20 I WATCH DEATH I Infection: Most common are pneumonias & UTI in elderly, but sepsis, cellulitis, SBE and meningitis can also occur

21 I WATCH DEATH I Infection W Withdrawal: benzodiazapines, ETOH, typical neuroleptics, anticholinergics

22 I WATCH DEATH I Infection W Withdrawal A Acute metabolic: electrolytes, renal failure, acid-base disorders, abnormal glycemic control, pancreatitis

23 I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma: head injury (SDH, SAH), pain, vertebral or hip fracture, concealed bleed, urinary retention, fecal impaction

24 I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma C CNS pathology: tumor, AVM, encephalitis, meningitis, abscess

25 I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia (or increased CO2) from COPD exacerbation, CHF

26 I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia D Deficiencies: B-12, folate, protein, calories, water

27 I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia D Deficiencies E Endocrine thyroid, cortisol, cancer cytokines

28 I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia D Deficiencies E Endocrine A Acute vascular/mi : stroke, intracerebral bleed

29 I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia D Deficiencies E Endocrine A Acute vascular/mi T Toxins-drugs Really anything; anticholinergics (TCA, Ditropan), benzos (especially longacting), narcotics, seizure meds and other psychotropics are common culprits

30 Decrease or stop drugs that can cause Delirium Is the patient on delirium inducing drugs : Benzodiazepines (valium = diazepam, ativan = lorazepam, serax = oxazepam, temazepam, flurazepam) Narcotics (morphine, MS Contin, Dilaudid codeine ) Alcohol Neuroleptics (Antipsychotics) Haldol, Respiridone, Olanzepine Anticonvulsants (Seizure medications) Dilantin (Phenytoin), Gabapentin, Pregabalin Anticholinergics (see next slides) Many of these also cause decreased Balance and Falls (another cause of ED / ALC)

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32 A Memory Tool for Health Care Workers ACUTE CHANGE IN MS (Mental Status), mnemonic A ntiparkisonian C orticosteroids U rologic (antispasmodics) T heophylline E mesis (antiemetics) C ardiac(antiarrhythmics) H 2 blockers ( cimetidine) A nticholinergics N SAID s G eropsychotropic E toh I nsommia meds N arcotics M uscle relaxants S eizure meds

33 How can one sort through this daunting list of medications? Look for a time-based relationship Confusion worsened after starting this medication (or increasing the dose). Ask Pharmacist to review drugs that may be impairing cognition (generic or theoretical perspective) and then apply a practical lens based on personal knowledge of patient to develop a tailored personalized plan for medication adjustments.

34 I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia D Deficiencies E Endocrine A Acute vascular/mi T Toxins-drugs: H Heavy metals Neurology consult Lead, manganese, bismuth, mercury, solvents, arsenic, thallium

35 DELIRIUMS

36 Or go for the Money! Drugs, drugs, drugs, drugs Prescription, OTC, using someone else s, illicit, alcohol, withdrawal Infection Pulmonary, Urinary, Skin (PUS) Metabolic Cardio/respiratory Pain including discomfort from retention and constipation

37 Physical Exam Vitals: normal range of BP, HR (unexplained sinus tachycardia), Spo2, Temperature (some older patients do not become febrile with infections)? Good physical exam: particular emphasis on cardiac, pulmonary and neurologic systems Hydration status Also rule out fecal impaction (DRE) urinary retention (bladder U/S, in-and-out catheter) Infected decubitus ulcer

38 Delirium workup: Lab testing Basic labs most helpful! CBC, electrolytes, BUN/Cr, glucose TSH, B-12, LFTs Calcium, & albumen Infection workup (Urinalysis, CXR) +/- blood cultures

39 Other Investigations selected additional testing; drug levels, toxic screen, ABG EKG CT Head if focal signs? EEG (if suspect seizure)? role for LP (do last, and only if history suggests)

40 STEP 3 PREVENT occurrence, recurrence, worsening or prolongation of delirium

41 Interventions for preventing or treating delirium in hospital The Hospital Elder Life Program (HELP) reduced incidence of delirium (30%), improved patient functional outcomes (30%), reduced length of stay (25%) and saved an average of $831 per intervention patient for acute hospital costs and $9,446 per patient per year in long-term nursing home costs. At a dissemination site in a large community hospital, HELP was evaluated using administrative data, and saved $1.25 million per year in 704 patients on one 40-bed unit. A follow-up study involving 7,000 patients per year on six hospital units resulted in annual net savings of $6.9 million.

42 HELP s Non-Pharmacological Approach Inform and educate staff and family Optimise vision clean glasses, lighting Optimise hearing hearing aids Treat all precipitating causes including pain! Optimise hydration, nutrition, sleep Early mobilization Stabilise environment and re-orientate Encourage presence of family members for reassurance Low stimulation - avoid excessive noise or frequent moves Normalize sleep Avoid restraints (physical and chemical)

43 STEP 4 Be prepared to treat urgent / emergent symptoms where the patient is an imminent risk to themselves or others

44 Pharmacological Approach Avoid chemical restraints if possible Use sedation only if severely agitated and restless Avoid prn use of medication if possible Use a SINGLE medication rather than two to decrease the potential for side effects/drug interactions: start with a low dose choose a drug with low anticholinergic activity try to stop the medication as soon as possible, focusing on correcting the underlying cause for the delirium continue with non-pharmacological interventions

45 Canadian Coalition for Seniors Mental Health Guidelines on the Assessment and Treatment of Delirium (2006) Haloperidol: low doses ( mg per dose or 1-2 mg per day) as short a period of time as possible (days) during acute delirium not for delirium due to withdrawal from alcohol or benzodiazepine Acute alcohol or benzodiazepine withdrawal delirium: use a shorter acting benzodiazepine (Lorazepam is recommended) Atypical antipsychotics: limited data on their use for agitation due to delirium alternate agents for those with: Parkinson s Disease Lewy Body dementia a history of severe side effects with haloperidol Cholinesterase inhibitors effects are variable

46 STEP 5 - Call for HELP if you feel you are missing something. Who are you going to call? Care of the Elderly Geriatric Medicine Geriatric Psychiatry Psychiatry Neurology Internal Medicine