Delirium A Geriatric Syndrome Jonathan McCaleb, MD, CMD, HMDC UNSOM, Assistant Professor of Medicine Geriatrics / Hospice & Palliative Medicine
Introduction Common Serious Unrecognized: a medical emergency made worse by late recognition by clinicians Delirium not to be confused with dementia Acute onset, variable course, usually reversible and preventable Dementia is chronic, progressive, irreversible with minor variations.
Definition (DSM V) Acute onset or fluctuating course And Inattention And Disorganized thinking Or Altered level of consciousness
Case Report 92 year old male with profound hearing loss and visual impairment admitted to VA CLC awaiting placement after prolonged hospitalization. Initially admitted to the acute medical ward for altered mental status, confusion and psychosis with behavioral instability after coming into the ER reporting being chased by giant rocks and hearing nothing but loud marching music. PMH: BPH with obstruction with chronic indwelling Foley Bilateral Sensorineural hearing loss Visual Impairment Arthritis
Hospital Course TSH, CBC, B12, B9, UA, CMP, CT scan of brain normal. Mental health assessments concluded he was demented and without capacity to make decisions. Transferred to the skilled nursing facility to await placement and possible guardianship. Hearing aids and glasses replaced. Repeat cognitive assessment revealed capacity. At our request came up with a plan for discharge so he bought a bus ticket to San Francisco and went on vacation.
Discussion Delirium can have varying presentations with multiple etiologies and risk factors. This elderly man experienced an unfortunate cascade of events: lost glasses and broken hearing aids contributed to confusion and visual and auditory hallucinations; hallucinations led to aggressive behavior which resulted in hospitalization. Cognitive assessments were performed in the setting of impaired vision and hearing, resulting in the determination of incapacity for medical decision making. He was transferred to the SNF to pursue guardianship and placement with the potential loss of autonomy. When glasses and hearing aids were replaced, the hallucinations resolved. A repeat cognitive assessment revealed intact decisional capacity. Auditory and visual hallucinations can result from hearing and vision loss, respectively and can be mistaken as symptoms of psychiatric disorder in the setting of a complex presentation.
Incidence Incidence increases with age, co-morbidity and severity of acute illness. 1/3 elderly patients admitted to hospital experience symptoms of delirium* delirium occurred in 15-53% of geriatric patients postoperatively and 50-80% of ICU patients** * 1994 article by Sumner in Cleveland Clinic J Med ** Inouye in 2006 article NEJM and Pisani 2003 Clin Chest Med
Incidence Additional settings include Long Term Care and Assisted Living Facilities Outpatient Delirium in all settings carries an increased risk of mortality
Prognosis Delirium in geriatric patients has a 10x increase in-hospital mortality and 3-5x increased acquired complications* All leading to requirement for Nursing Home Placement. *Geriatric Review. 8 th ed. AGS; 2016.
Cost People are living longer Financial pressure on health systems to allocate resources Delirium is prevalent in hospitalized patients, prolonging length of stay and necessitating Nursing Home placement, translating into higher cost of care. $16-64,000 per patient/yr. vs. No Delirium* *Leslie, et al. Arch Intern Med. 2008;168:
Clinical CAM (Confusion Assessment Method) 1 of 2 Major: acute change in mental status, fluctuation of the mental status, inattention.3/3 Minor: disorganized thinking or altered level of consciousness. ½ Use in coordination with patient s history and baseline cognitive level: MMSE Hypoactive: psychomotor retardation Hyperactive: psychomotor agitation Mixed: alternating signs
Clinical CAM confusion assessment method 2 of 2 Terminal: last hour to days of life and frequently irreversible Hyperactive presentation often leads to interventions that prolong or worsen Delirium: restraints, psychotropic medication while diagnosing the underlying cause is neglected or delayed
Risk Factors Intrinsic Risk (Mostly fixed factors) - Age, cognitive impairment, chronic illness, sensory impairment. Extrinsic Risk (Modifiable factors) - Infectious, Pharmacologic, Neurologic, Cardiac, Renal/Urologic, Endocrine, Metabolic.
Risk Factors Infection: UTI, Pneumonia Pharmacy/Medications: Antipsychotic, Benzodiazepines, Antidepressants, Opioid analgesics, OTC Diphenhydramine, Sedatives for sleep, Urinary Incontinence meds. Cardiac: Acute MI, CHF, Arrhythmia Neurologic: stroke, fall with intracranial hemorrhage or subdural, seizure. Renal Failure, Urinary retention
Risk Factors Dehydration, Hypernatremia, fecal impaction, hyponatremia SIADH, hypercalcemia, Diabetes with hyperosmolar hyperglycemia, DKA, Hypoglycemia. Psychiatric Disorders: History is important, diagnosis by exclusion.
Prevention Strategy: Identify modifiable risk factors to prevent occurrence. Educate caregivers and family to contribute to prevention with reorientation, hearing and vision devices.
Evaluation History and Physical Exam Laboratory: CBC, CMP, Urinalysis ECG Urine Drug Screen Chest X-ray CT, MRI if suspect focal neurologic findings
Management Pharmacologic: If necessary for dangerous agitation. Nonpharmacologic always preferred