Renee Flores, MD Division of Geriatrics & Palliative Medicine Department of Internal Medicine

Define AMS and delirium Describe how to recognize and diagnose delirium Identify the predisposing or precipitating risk factors for delirium in elderly patients Demonstrate how to evaluate and treat elderly patients with delirium Evaluate and apply interventions to prevent delirium

Approx. ⅓ of pts. 70 years old admitted to the medicine service experience delirium: ½ of these are delirious on admission while other ½ develop delirium in the hospital. A systematic review found that persistence rates for delirium at hospital D/C and at 1, 3 and 6 months after D/C were 45%, 33%, 26% and 21%, respectively. In SNF, approx. 15% of new admissions meet criteria for delirium.

Literature shows that when delirium persists beyond 6 months, it is likely that the patient will have cognitive decline, resulting condition could be dementia/mild cognitive impairment (MCI), depending on its severity. A meta-analysis of 3,000 patients followed for a mean of 22.7 months found that delirium was independently associated with an increased risk of death (OR 2.0; 95% CI 1.5-2.5), institutionalization (OR 2.4; 95% CI 1.8-3.3) dementia (OR 12.5; 95% CI 11.9-84.2).

Under-recognition of delirium is a major problem, with only 12%-35% of all cases recognized in routine care. CAM is the most useful bedside assessment tool for delirium. 4 key features of CAM are: Acute change or fluctuating course Inattention Disorganized thinking Altered level of consciousness

SAS Score

Underlying co-morbid conditions must be taken into account Depression can sometimes be confused with hypoactive delirium and mania with hyperactive delirium. Hyperactive delirium accounts for only 25% of cases with the remaining being hypoactive quiet delirium. Hypoactive delirium is associated with an equal or poorer prognosis than delirium with hyperactive or normal psychomotor features.

One of the best documented mechanism is cholinergic deficiency. This is classically seen in overdoses of anticholinergic medications like atropine. A second potential mechanism is inflammation, seen classically in post-op patients and in those with cancer or infection. Literature shows an association of delirium with increased levels of CRP, IL-1, IL-6 and TNF-α. Inflammation can break the blood-brain barrier allowing toxic medications and cytokines greater access to the CNS.

Can be classified into 2 groups: baseline factors that predispose patients to delirium and acute factors that precipitate delirium. Baseline factors: Advanced age Preexisting dementia Preexisting functional impairment in ADL Male gender Sensory impairment (hearing and visual loss) Depressive symptoms Medical comorbidity

Acute precipitating factors: Medications (most common) Surgery Uncontrolled Pain Low Hb Bed rest Physical restraints

D Drugs (BNZ, H2 blockers, Opioids, Anticholinergics, antidepressants, Antipsychotics) E Electrolyte imbalance ( Na and Ca), Eyes & Ears L Liver disease I Infection/Intoxication/Insomnia/Intracranial tumor R Retention (urinary or fecal) I Ischemia (MI, CVA, PAD, CAD) U Urea/ARF M Metabolic ( thyroid, B12, cortisol, blood sugar, hypoxia)

Agent AE Agent Adverse Events

Agent AE

The incidence is 15% after elective non-cardiac surgery and up to 50% after high risk procedures such as hip fracture repair, AAA repair and CABG. Total dose of anesthetics used during the procedure also play an important route. It is important to note that high levels of pain have also been associated with delirium.

Strategies to provide adequate analgesia with minimally effective doses of opioids should be used. Low post-op Hb level (<30%) has also been associated with delirium, although transfusions have not been shown to reduce delirium.

Eight strong recommendations: benefits clearly outweighed the risks, or the risks clearly outweighed the benefits. Multicomponent nonpharmacologic interventions delivered by an interprofessional team should be administered to at risk older adults to prevent delirium. Ongoing educational programs regarding delirium should be provided for health care professionals. A medical evaluation should be performed to identify and manage underlying contributors to delirium. Pain management (preferably with nonopioid medications) should be optimized to prevent postoperative delirium. Medications with high risk of precipitating delirium should be avoided. Cholinesterase inhibitors should not be newly prescribed to prevent or treat postoperative delirium. Benzodiazepines should not be used as first line treatment of agitation associated with delirium. Antipsychotics and benzodiazepines should be avoided for treatment of hypoactive delirium.

Step Key Issues Proposed Treatment

Target for Prevention Cognitive impairment Sleep deprivation Immobility Visual impairment Hearing impairment Dehydration Intervention Orientation, board with names, daily schedule, reorientating communication Nonpharm: warm milk/herbal tea, music, massage, noise reduction; melatonin or ramelteon Early mobilization, ambulation or range of motion 3x/d Visual aids and adaptive equipment Amplification, cerumen disimpaction, special communication techniques Early recognition and repletion

Urinary catheters should be avoided unless absolutely required for monitoring fluids or treating urinary retention. Bowel stimulants and stool softeners can be used to prevent obstipation, particularly in those taking opioids. Complete bed rest should be avoided because it can lead to increasing disability through disuse of muscles and development of pressure ulcers and atelectasis in the lungs. Malnutrition can be prevented through use of nutritional supplements and careful attention to intake of food and fluids.

Ensure safety Use families or sitters as first line Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Use soft restraints or mitts only as a last resort to maintain pt safety (eg to prevent pt from pulling out tubes or catheters)

The lowest dose of the least toxic agent should be used for the shortest time possible. Except in unusual cases (alcohol withdrawal), antipsychotics have a more risk:benefit ratio than BNZ or other sedatives. Use of antipsychotics for delirium is off-label there are no FDA-approved drugs for the indication of delirium.

Haloperidol and Risperidone have the least sedation but the greatest risk of EPS. Quetiapine is most sedating and has the least EPS effects.

It is important to point that many cognitive deficits associated with delirium can continue, abating weeks and even months after the illness. Careful monitoring of mental status and providing adequate functional supports during this period are necessary to give the patient maximal chance of returning to his or her baseline level.

The first key step in delirium management is accurate diagnosis; several brief diagnostic assessments are available that operationalize the Confusion Assessment Method diagnostic algorithm after administration of a brief mental status examination that includes testing attention All delirious patients require a thorough evaluation for reversible causes; all correctable contributing factors should be addressed. In addition to the established associations of delirium with death, functional decline, and nursing home placement, new evidence shows that patients with delirium are at increased risk of prolonged cognitive decline and dementia. Pharmacologic intervention should be reserved for key target symptoms that cannot be adequately managed with nonpharmacologic interventions; low-dose, high-potency antipsychotics are usually the treatment of choice. Proactive, multifactorial interventions have reduced the incidence, severity, and duration of delirium.

GRS 9 th Edition AGS Expert Panel on Postoperative Delirium. Clinical Practice Guidelines for Postoperative Delirium in Older Adults. New York: American Geriatrics Society; 2014. Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512 520. Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911 922. Marcantonio ER, Ngo LH, O Connor M, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium. Ann Intern Med. 2014;161(8):554 561.

PMH. Mrs. Tufts is 75 year old retired school teacher who comes to the hospital for acute confusion. she lives in a small, older home. She has HTN, DM, hyperlipidemia, CAD s/p stent in 2000, CHF, atrial fibrillation, CKD, GERD, migraines, osteoarthritis, COPD, & hypothyroidism.

MEDS. MEDICATIONS : Lisinopril 40 mg po qday Metoprolol tartrate 50 mg po qday Atorvastatin 40 mg po qday Aspirin 325 mg po qday Coumadin 3 mg po qhs Omeprazole 40 mg po qday Glyburide 10 mg po qday Metformin 1000 mg po bid Pioglitazone 45 mg po qday Ntg 0.4 mg SC prn chest pain Digoxin 0.25 mg po qdaily Amitriptyline 25 mg po qhs Ibuprofen 400 mg po tid Meloxicam 7.5 mg po bid Naproxen 250 mg po bid Citalopram 20 mg po qday Sertraline 25 mg po qday Furosemide 20 mg po qday KCL 20 meq po qday Clopidogrel 75 mg po qday Atrovent 17mcg /actuation 1 puff bid Combivent 1 puff every 6hrs prn Advair 250/50 mcg 1 puff bid Ambien 10 mg o qhs Levothyroxine 50mcgpo qhs.

MEDICATIONS : Lisinopril 40 mg po qday Metoprolol tartrate 50 mg po qday Atorvastatin 40 mg po qday Aspirin 325 mg po qday Coumadin 3 mg po qhs Omeprazole 40 mg po qday Glyburide 10 mg po qday Metformin 1000 mg po bid Pioglitazone 45 mg po qday Ntg 0.4 mg SC prn chest pain Digoxin 0.25 mg po qdaily Amitriptyline 25 mg po qhs Ibuprofen 400 mg po tid Meloxicam 7.5 mg po bid Naproxen 250 mg po bid Citalopram 20 mg po qday Sertraline 25 mg po qday Furosemide 20 mg po qday KCL 20 meq po qday Clopidogrel 75 mg po qday Atrovent 17mcg /actuation 1 puff bid Combivent 1 puff every 6hrs prn Advair 250/50 mcg 1 puff bid Ambien 10 mg o qhs Levothyroxine 50mcgpo qhs. MEDS that can cause delirium.

Allergies: Latex, sulfas SOCIAL : 30 pack year, quit 5 years back. No alcohol or illicit drug use Surgeries: Cholecystectomy Stents VITALS: BP 110/70 mm Hg Pulse :60 RR:14 Temp 98 F Standing up 100/70 mm Hg

Which one of the following is the most appropriate next step in her care? A. Obtain computed tomography of the head with contrast. B. Administer a high-potency, low-dose antipsychotic agent. C. Perform physical examination and order laboratory tests. D. Transfer to ICU for observation. E. Obtain psychiatric consultation.

Which one of the following classes of medication is the most common cause of delirium in hospitalized older adults? A. Angiotensin-receptor blockers B. H2-receptor antagonists C. Selective serotonin-reuptake inhibitors D. H1-receptor antagonists E. HMG-CoA reductase inhibitors

Strong evidence suggests that delirium is an important, independent predictor of all of the following EXCEPT: A. Death B. New institutionalization C. Dementia D. Functional decline E. Delusional disorder