Jacinta Lucke Resident Emergency Medicine PHD Gerontology & Geriatrics

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2 Jacinta Lucke Resident Emergency Medicine PHD Gerontology & Geriatrics

3 TAKE HOME MESSAGE When managing confusion in older patients: Routinely screen for impaired cognition Patients with impaired cognition either have delirium or are at risk of developing it and should be treated as such Use a structured approach Aggressively treat causes of delirium and start nonpharmacological treatment Remember: delirium has higher mortality rates than STEMI and stroke

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5 CASE

6 Use standardized approach for all acute patients Broad differential diagnosis Manage acute problems - safety ABCDE

7 Airway Breathing Circulation Disability Exposure Airway Hypoxia Shock (sepsis) Hypo/hyper glycemia Trauma obstruction Hypercarbia Infection (pneumonia/uti) Stroke Hypothermia Dehydration Meningitis Pain Electrolyte disturbances Encephalitis Medication Endocrine disease Intracranial hemorrhage Withdrawal Seizures/postictal Encephalopathy (wernicke/hypertensive) CNS mass lesion Psychiatric Overdose (J Stephen Huff, 2015)

8 DIFFERENTIAL DIAGNOSIS Dementia

9 (Inouye, Westendorp, & Saczynski, 2014)

10 Acute onset Altered level of consciousness Fluctuating course Inattention Cognitive deficits Perceptual disturbances Psychomotor disturbances Disorganized thinking Altered sleepwake cycle Emotional disturbances (Inouye 2006)

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12 (Inouye, Westendorp, & Saczynski, 2014)

13 (Wilber and Ondrejka 2016) Predisposing risk factors for delirium Demographics Comorbid Disease Drugs Advanced age Number of comorbidities Polypharmacy Male gender Severity of comorbidities Psychoactive medication use Visual impairment Alcohol abuse Hearing impairment Drug abuse Dementia Depression History of delirium Cerebrovascular disease Falls Functional impairment Terminal illness Malnutrition

14 (Wilber and Ondrejka 2016) Precipitating causes of delirium Systemic disease Primary CNS disease Drugs Environmental Infection/sepsis Stroke Polypharmacy Prolonged ED stay Dehydration Meningitis Withdrawal Sleep deprivation Hypoxia Encephalitis Drugs or alcohol use Physical restraints Hypercarbia Subdural hemorrhage Anticholinergics Indwelling urinary catheter Shock Epidural hemorrhage Sedative-hypnotics Pain Hypo/ hyperglycemia Hypo/ hyperthermia Trauma Acute myocardial infarction Electrolyte abnormalities Intracerebral hemorrhage Seizures/postictal state Opoids Surgery or procedures

15 (Wilber and Ondrejka 2016) Chief complaint: altered mental status Assess level of consciousness: RASS Assess cognition: Six Item Screener If above steps normal=stop If abnormal: bcam If bcam abnormal: patient has delirium

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18 REMOVE PRECIPITATING FACTORS

19 TREATMENT NON PHARMACOLOGICAL

20 PHARMACOLOGICAL TREATMENT Drug Dose Notes Haloperidol (oral) Haloperidol (parental) Risperidone Olanzapine mg twice daily and every 4h as needed mg IM every min as needed 0.5 mg orally twice daily mg orally once daily IM dosing preferred over IV due to short duration of action IV. Usually patients respond to <3 mg Quetiapine mg orally twice daily Recommended in Parkinson s disease (Kahn, 2014)

21 DIFFERENTIAL DIAGNOSIS Dementia

22 CONTROVERSY DELIRIUM IS A MARKER OF VULNERABILITY FOR DEMENTIA DELIRIUM ITSELF LEADS TO DEMENTIA (Inouye, Westendorp, & Saczynski, 2014)

23 DIFFERENTIAL DIAGNOSIS Dementia

24 RISK FACTORS DEPRESSION Loss of partner Alone with memories Loss of ADL Somatic illness (Cole and Denduk 2003)

25 Delirium Dementia Depression Onset Acute Insidious Gradual Duration Hours/days Years Weeks/months Course Fluctuates, sundowning Progressive (stepwise for VaD) Alertness Fluctuates Normal Normal Orientation Always impaired May be normal Normal Memory Impaired Impaired recent, maybe intact remote Thoughts Paranoid, bizarre, disjointed, occur early Delusion common in late stage Perceptions Illusions, hallucination Hallucinations occur late Worse in morning Recent maybe impaired but remote good Slow response, negative thoughts Mood congruent psychosis Emotions Irritable, fearful Shallow, apathetic Sad, may be agitated Sleep Nocturnal confusion Disturbed diurnal rhythm Early morning awakening Other features Organic cause Past h/o mood do

26 HISTORY

27 ASSESSING LEVEL OF CONSIOUSNESS

28 3. About what time is it (within 1 hour) 4. Count backwards from 20 to 1 5. Say the months of the year in reverse 6. Repeat address phrase John, Smith, 42, High St, Bedfor ASSESSING COGNITION 1. What year is it? 2. What month is it? Give the patient an address phrase to remember with components, eg John, Smith, 42, High St, Bedford

29 NEUROLOGIC EXAMINATION

30 GENERAL PHYSICAL EXAMINATION

31 DIAGNOSTIC TESTING

32 ASSESSMENT OF DECISION- MAKING CAPACITY

33 DISPOSITION 2x longer ED stay 2x longer hospital stay 6% vs 1% 30-day mortality rate Delirium has higher mortality rate than STEMI and stroke Accidental falls Cognitive and functional decline

34 SCREENING (Van de Meeberg et al., 2016)((NICE), 2010)(Pendlebury et al., 2016)

35 Multicenter prospective follow-up study The Netherlands Prospective multi-center study 2014/2015/2016 Inclusion: 70 years and older Exclusion: clinically unstable 12 weeks: 24/7 LUMC & 12/7 Alrijne/Bronovo Follow up 3 months and 1 year Patient interviews & medical records

36 SCREENER

37 Multicomponent interventions Cognitive stimulation Physical therapy Avoidance of dehydration Promotion of good sleep patterns Nutritional support Family involvement Pain management Medication review Incident delirium RR 0.73 (95% CI , p<0.001) Accidental falls RR 0.39 (95% CI , p=0.003) (Martinez, Tobar et al. 2015)

38 Remember: delirium has higher mortality rates than STEMI and stroke TAKE HOME MESSAGE When managing confusion in older patients: Routinely screen for impaired cognition Patients with impaired cognition either have delirium or are at risk of developing it and should be treated as such Use a structured approach Aggressively treat causes of delirium and start nonpharmacological treatment

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40 REFERENCES Cole, M. G. and N. Dendukuri (2003). "Risk factors for depression among elderly community subjects: a systematic review and meta-analysis." Am J Psychiatry 160(6): Inouye, S. K. (2006). "Delirium in older persons." N Engl J Med 354(11): Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383(9920), doi: /S (13) Kahn, J. H., Magauran, B.G., Olshaker J.S. (2014). Geriatric Emergency Medicine - Principles and Practice. Padstow, UK, Cambridge University Maclullich, A. M., Anand, A., Davis, D. H., Jackson, T., Barugh, A. J., Hall, R. J., Cunningham, C. (2013). New horizons in the pathogenesis, assessment and management of delirium. Age Ageing, 42(6), doi: /ageing/aft148 Martinez, F., et al. (2015). "Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature." Age Ageing 44(2): NICE, (2010). Delirium: Diagnosis, Prevention and Management. London. Pendlebury, S. T., Lovett, N., Smith, S. C., Cornish, E., Mehta, Z., & Rothwell, P. M. (2016). Delirium risk stratification in consecutive unselected admissions to acute medicine: validation of externally derived risk scores. Age Ageing, 45(1), doi: /ageing/afv177 Siddiqi, N. (2016). Predicting delirium: time to use delirium risk scores in routine practice? Age Ageing, 45(1), doi: /ageing/afv183 Van de Meeberg, E. K., Festen, S., Kwant, M., Georg, R. R., Izaks, G. J., & Ter Maaten, J. C. (2016). Improved detection of delirium, implementation and validation of the CAM-ICU in elderly Emergency Department patients. Eur J Emerg Med. doi: /MEJ Wilber, S. T. and J. E. Ondrejka (2016). "Altered Mental Status and Delirium." Emerg Med Clin North Am 34(3):