Delirium: new insights into an ancient problem David Meagher

Transcription

1 Delirium: new insights into an ancient problem David Meagher Professor of Psychiatry, UL Graduate-Entry Medical School

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3 A Geriatric Deliriumologist

4 Overview } The concept of Delirium is conceptually evolving } Psychiatrists have an important role in delirium care } Delirium is common, commonly missed and independently associated with a range of adverse outcomes } Improved detection is a key target for healthcare } Detection must be aligned to effective intervention based upon growing evidence around treatment

5 BC

6 Clouding of consciousness

7 Clouding of consciousness DSM Criteria (III / IV / 5) Acute onset / fluctuating course Inattention Impairment of wider cognition / thinking Physical etiology

8 MEDLINE CITATIONS WITH DELIRIUM IN THE TITLE ( ) EDA ADS IDS? Time for a World Delirium AssociaNon? Time for WDA Updated: Meagher, Int Rev Psych 2009

9 EDA membership 2012 (n=200) (15%)

10 Meagher, 2002

11 Complex neuropsychiatric syndrome Symptoms rated with DRS-98 Present Score 2 or more Inattention 97% 1 73% Sleep disturbance 97% 2 73% LTM 89% 64% STM 88% 53% Visuospatial 87% 64% Disorientation 76% 4 42% Agitation 62% 3* 27% 94% Retardation 62% 37% Language abn 57% 25% Thought disorder 54% 22% Affective changes 53% 18% Perceptual abn 50% 26% Disturbed thought content 31% 9% Meagher et al, BJP 2007

12 Key Point 1.Delirium is (prognosncally) bad

13 Delirium linked to poor outcomes. LOS: Doubled Costs of care: Doubled Reduced subsequent functional status 3x less likely to return home New LTCI c30%% Increased subsequent new dementia Diagnosis 3x increase in following year Mortality

14 Gonzalez et al, 2009 Mortality Increased by 11 % for every additional 48 hours of delirium

15 Poor outcomes independent of - Age / Frailty - Comorbidity severity - DemenNa status Delirium is NOT just a symptom but is itself a major cause of the poor outcomes And predicted by - Severity of delirium symptoms - Complica>ons of uncontrolled delirium - Dura>on of ac>ve delirium

16 Key Issue Delirium is commonly missed or misdiagnosed

17 Siddiqi (2005): SR 42 Studies Prevalence at admission 10-31% Incidence during admission 3-29% Overall freq per admission 11-42% One in five

18 CUH 36 hour point prevalence 358 inpatients 169 cognitively intact 311 assessed 142 cog problems* 47 Excluded Coma / stupor / severe dysphasia Actively dying Infectious risk Refused n < 10 Psychiatry / paediatrics 55 DSM IV Delirium 55% comorbid demenna 46% documented in case notes

19 Identification of DSM-IV delirium Medical case notes (46%) ß R 2 p DRS- R98 ALen>on score * DRS- R98 Short- term memory score * 0.04 Medical specialty Nurse questioning (64%) DRS- R98 Delusions score * 0.04 DRS- R98 Affec>ve lability score * 0.02 DRS- R98 ALen>on score DRS- R98 Long- term memory score Combining approaches, 43 (77%) identified by at least one of these; 23 false positives Patient self rating (32%) DRS- R98 Sleep- wake cycle disturbance score DRS- R98 Orienta>on score <0.001 DRS- R98 Onset score <0.001

20 Missed, misdiagnosed, diagnosed late } Elie et al (2000) Elderly ER attenders: } Kishi et al (2007) Gen hosp Psych referrals: } Han et al (2009) Elderly ER attenders: } Collins et al (2010) elderly med admission : } Fang et al (2008) Pall care patients: } Ryan et al (2013) Gen hosp point prevalence: 65% missed 46% missed 76% missed 72% missed 55% missed 56% missed

21 WHO??? Age extremes Hypoactive subtype Comorbid dementia Psychiatric history Surgical setting i.e. NOT BENIGN OR TRANSIENT CASES

22 Cognitive Superbug? Inconsistent management practices One in five Ø 50% missed Independent predictor of poor outcomes

23 DELIRIUM DETECTION

24 Why?... we need efficient screening Delirious On-call / Nursing staff Cognitive Screening Inform clinical team Apparent lucidity may intervene Clinical team Respond Consider interventions Ongoing progress monitoring

25 EFFICIENT RECOGNITION: TWO STEP PROCESS STEP ONE Screening Sensitivity+++ All patients (at risk) Nurses / NCHD s Focus on altered MSE / Cognition STEP TWO Formal Diagnosis Specificity++ Positive screened Specialists Context NNB*

26 STEP ONE : WHAT IS NEEDED? } Simple and brief : NCHD / Nurse friendly } Sensitive: false negatives are common } Suitable across pops : elderly / frail / morbid } Easily interpreted : clear cut off scores } Tests delirium-friendly elements (relative specificity) } Distinguishes from dementia } Linked to action

27 Key Issue What elements of delirium are dispropornonately affected AND relanvely preserved in its principal differennals (e.g. what can demented folk do that delirious cannot?)

28 Complex neuropsychiatric syndrome Symptoms rated with DRS-98 Present Score 2 or more Inattention 97% 1 73% Sleep disturbance 97% 2 73% LTM 89% 64% STM 88% 53% Visuospatial 87% 64% Disorientation 76% 4 42% Agitation 62% 3* 27% 94% Retardation 62% 37% Language abn 57% 25% Thought disorder 54% 22% Affective changes 53% 18% Perceptual abn 50% 26% Disturbed thought content 31% 9% What else causes this clinical picture? Meagher et al, BJP 2007

29 WHAT IS DISPROPORTIONATELY AFFECTED? Visuospatial Fxn Attention Thinking / Language (comprehension)

30 Serial assessment Across populations

31 So: In assessing for delirium } Attention / visuospatial and higher order thinking are disproportionately and consistently affected } Disorganised thinking is notoriously difficult for nonpsychiatrists to consistently identify } Common bedside tests of visuospatial ability are too hard for delirium and lack specificity } Attention is the element that is most suited to reliable assessment at the bedside. } BUT WHAT ABOUT DEMENTIA?

32 Simple tests of attention can assist in delirium detection and distinction from dementia DSF DSB Controls Delirium D-D Dementia DSB scores readily distinguished both deli and dem from cog intact patients DSF was relatively preserved in dementia group and more specific to delirium With deli and D-D significantly lower than dementia group at p<0.01 Meagher et al, 2010: JNNP

33 Simple tests of a\ennon and vigilance disnnguish delirium in elderly medical panents with delenna DSF DSB Vigilance MonthsB Controls Delirium D-D Dementia DSF and months backwards dis>nguishes delirium from rest Vigilance tests dis>nguish delirium and comorbid Dd from rest Unpublished data

34 What should we use as the brain s vital sign?.. efficient screening (primarily) for ina\ennon by defininon, all delirious panents have ina\ennon

35 Bedside tests of attention } WORLD backwards.. ( Whirled? tongue tied?) } Serial sevens / threes...(?nasty maths teacher) } Months backwards test } Days of week in reverse test.(too simple infantilising?) } Digit Span forwards } Digit Span Backwards (working memory) } Spatial span tests (F/B) (visual for those with speech issues) } Vigilance A test (?) } Digit cancellation test } SAVEAHEART / Letter vigilance.(?attention) } Delbox

36 A comparison of SSF, MBT and subjective confusion in a general hospital population Screening method Sensitivity* (95% CI) Specificity* (95%CI) General hospital inpatients (n=265) Single test Simultaneous tests MOTYB MOTYB / SSF4 (either failed = positive) 83.3% ( ) 93.8% ( ) 90.8% ( ) 81.1% ( ) Older inpatients, 69 yrs (n= 133) Single test MOTYB 83.8% ( ) 89.6% ( ) Younger inpatients, 69 years (n= 132) Single test Simultaneous tests Evidence of confusion SSF4 / MOTYB (either positive = positive) 90.9% ( ) 100% ( ) 92.5% ( ) 86.8% ( ) Patients with known dementia (n= 31) Single test MOTYB 87.5% ( ) 71.4% ( )

37 What is the correct way of administering and interpreting the MBT? What defines a pass or a fail?

38 MAY DECEMBER MARCH JANUARY SEPTEMBER JULY NOVEMBER APRIL OCTOBER AUGUST FEBRUARY JUNE

39 MBT verbal vs computerised in elderly medical and final year medical students

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41 ADVANTAGES OF COMPUTER-ASSISTED TESTING } Increased test reliability } Reduced tester skill requirement } Ease of testing } Readily linked to action: decision-support } Accessibility in ipad-tablet-smartphone era Versus: } Reduces clinical common sense for untestables both hyper and hypoactives } Intimidating to older patients

42 Step Two - Actual Diagnosis? } A systematic means of applying DSM IV or 5 criteria is lacking (and not provided by DSM manual) } CAM / CAM-ICU:? Sensitivity when not in expert hands? } NUDESC / DOS: if observed behaviours are preferred but? Both really screening tools } CTD: Score < 19 need training and takes minutes } DRS-R98 score 18.training and takes minutes } DRS-R98 algorithm for DSM-IV (vs clinical Dx) = 89%

43 DSM-5 Delirium Algorithm A A disturbance in attention DRS-R98 item 10 Attention score 1 B The disturbance develops over a short period of time (usually hours to a few days)represents a change from baseline attention and awareness, OR tends to fluctuate in severity during the course of a day DRS-R98 item 14 Temporal Onset 1 or DRS-R98 item 15 Fluctuation score 1 C D E An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability, or perception The disturbances in Criteria A and C are not better explained by a pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma. There is evidence from the history, physical examination or linvestigations that the disturbance is a direct physiological consequence of another medical condition, substance, or exposure to a toxin, or multiple etiologies Any of the following: score of 1 on DRS-R98 item 11 Short term memory, item 9 Orientation, and Score of 2 on DRS-R98 item 5 Language, item 13 Visuospatial, item 2 Perceptual disturbance. Where dementia is present, a total DRS-R98 score of 18 denoted presence of comorbid delirium AND RASS -2 DRS-R98 item 16 Etiology score 1

44 DSM-5 maintains status quo if interpreted liberally No delirium

45 Emerging technologies

46 The weight of evidence increasingly supports proactive pharmacotherapy

47 Drug Prevention of Delirium Hakim et al (2012) Risperidone Cardiac Surgery RCT, Risperidone vs placebo 101 >65 Reduced SSD Schroder et al (2014) Haloperidol Cardiac Surgery Before/ After design 240 >18 No effect Hatta et al (2014) Ramelteon Gen med / ICU RCT, Ramelteon vs placebo 67 >65 Beneficial effect

48 Errrrr?!? What % of the Variance in this heterogenous syndrome can be modified pharmacologically? And how does this work for individual patients

49 Perceived primary MOA of antipsychotics in delirium treatment 40 How might drugs work? % sedation antipsychotic anti-delirium Other 0 1 *anxiolysis / treating nursing staff Meagher, Int Psychogeriatrics, 2009

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51 Note: total 34 prospective studies; patient N circa 1000!!! No great difference wrt effectiveness

52 The 46a syndrome Tahir et al (2010) } PCRCT } Old gen hospital inptts mean age 85y/o (n=42) } Quetiapine (25-175mg) vs plb x one week } Faster response rate x 82% in Q grp } Non-cognitive > cog } 7 deaths NS Devlin et al (2010) } PCRCT } ICU ptts (n=36) } Quetiapine (50-200mg) vs plb x 10 days } Faster response and shorter duration delirium in Q grp (p=0.001) } Q grp more likely to be discharged to home (p=0.06)

53 From detection to treatment: the Milford three-step algorithm Protocolised care is the way forward

54 1. Can the patient take medications orally? YES NO *As for oral except omit suggestions that include atypicals and *reduce to 50% oral dose 2. Is the patient predominantly hyperactive or hypoactive? Hyperactive 3. What is the primary aim of treatment? Hypoactive Avoid Benzodiazepines 1. Low dose Haloperidol (0.5-1mg bd) 2. If EPS-prone or other haloperidol contraindications use Olanzapine (2.5-10mg) or Risperidone (0.5-2mg) Reduced Agitation Combination with benzodiazepine useful. Otherwise use similar approach to improving cognition box. Some cases may require high dose combination Rx titrated as per tolerability Improved Cognition Avoid benzodiazepines. Sedation is best achieved with antipsychotics* 1. Haloperidol 2. If agitation persists consider Quetiapine or 3. Methotrimeprazine *See guidance notes for daily dosing

55 Cogometer: an integrated solution for diagnosis and treatment Formalised Delirium-Specific Automated Cognitive testing Preventative strategies No Delirium SSD* Pharmacological and other interventions for delirium treatment Evidence-Based Guidelines For Delirium Prevention and Management Delirium *SSD = Subsyndromal delirium

56 Conclusion } The DSM-5 concept of Delirium maintains key elements of DSM-IV acute generalised neurocognitive syndrome } Psychiatrists have skills relevant to delirium care } Delirium is common, poorly identified and independently associated with a range of adverse outcomes } Improved detection requires systematic formalised effort } Effective intervention is possible by applying the growing evidence around treatment

57 European Delirium Association 9 th Annual Meeting.