DELIRIUM. Sabitha Rajan, MD, MSc, FHM Scott &White Healthcare Texas A&M Health Science Center School of Medicine

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1 DELIRIUM Sabitha Rajan, MD, MSc, FHM Scott &White Healthcare Texas A&M Health Science Center School of Medicine

2 Disclosure Milliman Care Guidelines - Editor

3 Objectives Define delirium Epidemiology Diagnose Prevent Treat Counsel

4 Define Delirium Acute state of confusion Sudden onset Progresses during several hours to days Fluctuating course Can alternate between agitation/restlessness and fatigue/indifference Inattention Hallmark of diagnosis forgetful, confused Abnormal level of consciousness at times Hypoactive delirium (25%) Fatigued Hyperactive delirium (25%) Hallucinations Agitated Mixed (50%)

5 AKA Acute confusional state Toxic encephalopathy Organic brain syndrome ICU psychosis

6 In patients aged 70 and older General Medical Inpatient Ward 17% No Delirium 17% 66% Present on Admission Develops during Admission

7 Epidemiology Up to 75% of patients in an ICU Up to 85% at the end of life

8 Important? In the Hospital: Up to ten times the risk of mortality Three to five times the risk of a nosocomial infection Prolonged length of stay Greater chance of nursing home discharge as opposed to a home discharge (73% vs 30% in one study) Increased costs estimated at $ Billion annually

9 After Discharge Once thought to be an acute problem that resolved Prolonged risk for mortality lasts for up to 2 years At risk for poor functional and cognitive recovery

10 Post-operative delirium Saczynski JS et al. N Engl J Med 2012;367:30-39

11 Challenging to Diagnose Index of suspicion Agitation present in less than 25% of cases 50-80% of cases remain undiagnosed Screening SQiD (single question in delirium) Do you think [insert pt name] has been more confused lately? 80% sensitive and 71% specific in hospitalized oncology patients

12 Differential Diagnosis Sundowning If it is a new pattern, assume delirium Established sundowning can be worse in the hospital Neurologic (focal) Wernicke s aphasia Bifrontal lesions Nonconvulsive status epilepticus Facial twitching Nystagmus Automatisms Psychiatric diagnosis Depression Dementia

13 Delirium vs. Dementia Why is it difficult to differentiate? Often co-exist Dementia with Lewy bodies can be associated with fluctuations in mental status and visual hallucinations

14 Delirium vs. Dementia Onset and course Dementia slow onset over months or years Delirium sudden onset over hours or days Speech normal slurred inattentive, easily Attention normal distracted Memory gradual memory loss more forgetful than usual Hallucinations possible common Mood normal or depressed anxious, fearful, suspicious, indifferent General health usual sign of illness or drug side effect

15 Diagnosis Entirely clinical! There is no objective test. Determine the timeline of the mental status changes Are they fluctuating? What is the level of consciousness? What is the ability to pay attention?

16 Multifactorial Risk Assessment Predisposing Factors Age Dementia Stroke Parkinson s Disease Multiple Co-morbidities Impaired Vision Impaired Hearing Functional Impairment (ADL) Males Alcohol abuse Precipitating Factors New acute medical problem Exacerbation of chronic medical Surgery and/or anesthesia New psychoactive medication Acute stroke Pain Change in environment Urinary retention Constipation/Impaction Dehydration Sepsis/Infection

17 Mnemonic for Precipitating Factors Drugs Electrolyte imbalance Lack of drugs Infection Reduced sensory input Intracranial Urinary or fecal problems Myocardial (heart) and lungs medications, recently started or stopped, changes in dosages, over-the-counter medications, herbals, alcohol especially from dehydration stopping medications, alcohol withdrawal urinary or respiratory tract infections; blood or wound infection after an injury or surgery poor or uncorrected vision and hearing stroke inability to empty bladder or bowel heart attack, pneumonia, or other condition causing lack of oxygen in the blood and the brain

18

19 Scales Delirium Observation Screening Scale (DOSS) Delirium Rating Scale (DRS) Delirium Rating Scale-Revised-98 (DRS-R-98) Digit Span Test Global Attentiveness Rating (GAR) Memorial Delirium Assessment Scale (MDAS) Mini-Mental State Examination (MMSE) Nursing Delirium Screening Scale (Nu-DESC) Vigilance A Test

20 Confusion Assessment Method (CAM) The copyright of the CAM is owned by Sharon K. Inouye, Yale University School of Medicine. A training manual and permission to use the CAM are available online at /TheConfusionAssessmentMethod.pdf

21 Tests for Attention Squeeze or raise hand when they hear a letter in a list: G D H A U A I W P A Spell WORLD backwards Recite serial 7 s or 3 s Show pictures or objects and ask for recall in one minute Days of the week (or months) backwards Digit span - up to 5 forwards and 4 backwards

22

23

24 Labs and Imaging Tailored to history and exam Electrolytes CBC if anemia is considered LFT s, ammonia if hepatic encephalopathy is considered ABG for hypercarbia Toxicology screen and drug levels Cultures and UA CXR MRI Brain EEG Lumbar Puncture

25 Prevention and Management of Delirium in the Older Hospitalized Patient. Inouye SK. N Engl J Med 2006;354:

26

27 Delirium Management Make diagnosis Support/educate patient and family Non pharmacologic interventions Establish goals (need prognosis) Consider work up/treatment of potentially correctible etiologies Aggressively treat distressing symptoms

28 Non-pharmacologic Interventions Cognitive Orientation (calendar, caregiver names) Activities (cognitively stimulating) Sleep Regular routine Sleep aids (relaxing music, massage) Environmental (eliminate noise, night time meds) Mobility (range of motion, limit IV s, etc) Visual Aids (glasses, large dial phones, etc) Hearing Aids (check ear wax) Volume repletion for dehydration (beverage of choice available and offered frequently)

29 Pharmacologic Treatments No medication is FDA approved for the treatment of delirium No published double blind, randomized, placebo controlled trials Few controlled trials Small numbers Various patient populations post op, ICU, cancer, AIDS, hip fractures

30 Haldol vs. Benzodiazapenes Double blind RCT 244 AIDS patients 30 (12%) patients developed delirium Haloperidol (n =11) Chlorpromazine (n = 13) Lorazepam (n = 6) Haloperidol equivalent to chlorpromazine > lorazepam

31 Inouye SK. N Engl J Med 2006;354:

32 Antipsychotics Typicals (haloperidol, chlorpromazine) have greatest evidence base, are cheaper, and have multiple routes of administration

33 Antipsychotics & Black Box Mortality increased in dementia with antipsychotics Black Box Warning Issued in 2004 Consistent across all antipsychotics Relative risk = Absolute risk = 3.5% vs. 2.3% with placebo Number Needed to Harm = 83 Number need to treat = 5 14 For every 9 25 persons helped, 1 death associated with use Delirium No evidence that mortality is increased Not examined closely

34 Prevention Prospective matched trial of usual care vs ELP (Elder Life Program) in 852 enrolled patients Inouye SK. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. N Engl J Med. N Engl J Med 1999; 340: Geriatric Consult Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49: Antipsychotics Kalisvaart KJ, de Jonghe JF, Bogaards et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53:

35 Risk Factors for Delirium and Intervention Protocols. Inouye SK et al. N Engl J Med 1999;340:

36 Cumulative Incidence of Delirium According to Study Group. Inouye SK et al. N Engl J Med 1999;340:

37 Prevention ELP intervention The cost of intervention per case of delirium prevented was $6,341 No difference in LOS or mortality HELP (Hospital Elder Life Program)

38 Prevention Geriatric Consult Geriatric Consultation 126 patients aged 65 and older admitted emergently with hip fracture Randomized trial of Usual care vs Geriatric consults Average of 10 (!) recommendations with 77% compliance Delirium in consult group reduced by over 1/3 Severe delirium in consult group reduced by over 1/2

39 Prevention - Medication High risk patients with hip fractures received haloperidol 0.5mg three times daily Reduced severity and duration of delirium but not incidence All three approaches were preventative

40 Delirium at end of life Up to 85% At end of life, etiology varies 42% dehydration 29% liver failure 25% medication Why treat? QOL Time for patient and family Can help 50% of the time Constipation, Retention Adjust medications Hydrate as per family and patient wishes

41 Guidelines and Resources PIER from ACP American Psychiatric Association National Institute for Excellence (NICE) Vanderbilt University ICU (Pocket cards can be downloaded here)

42 Patient and Family information

43 Selected References Marcantonio ER. In the clinic. Delirium. Ann Intern Med Jun 7;154(11):ITC6-16. Lonergan E, Britton AM, Luxenberg J, Wyller T. Antipsychotics for delirium. Cochrane Database Syst Rev. 2007:CD Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:

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