Delirium Geriatric Giants Lecture Series Divisions of Geriatric Medicine and Care of the Elderly University of Alberta
Overview A. Delirium - the nature of the beast B. Significance of delirium C. An approach to diagnosis D. Management of delirium E. Prevention of delirium
Case DT Mr. DT, an 83 year old man who was living alone is brought to the emergency room by his neighbor, Mrs. GS. He is obviously confused and does not appear to know where he is or how he arrived. He appears to be drowsy, falling asleep while you are talking to him. Mrs. GS looks concerned and is willing to offer any help that is required. A discharge summary from his last admission two years ago is available. At that time he was not confused and was admitted for an uncomplicated community acquired pneumonia.
Case DT What further information would you like to obtain by history? Thus far, what is your provisional diagnosis? What do you know so far about Mr. DT that might predispose him to this condition? What are the potential precipitating variables in his case?
Delirium The nature of the beast
Question 1 Which of the following are not necessary for the diagnosis of delirium? A. Hallucinations B. Acute cognitive changes C. Cognitive fluctuations D. A disturbance of consciousness
Question 1 - Answer Which of the following are not necessary for the diagnosis of delirium? A. Hallucinations B. Acute cognitive changes C. Cognitive fluctuations D. A disturbance of consciousness
Diagnosis - DSM IV Criteria 1. A disturbance of consciousness 2. A change in cognition 3. The disturbance develops over a short period of time and tends to fluctuate. 4. There is evidence that the disturbance results from a medical condition, substance intoxication or substance withdrawal
Drowsiness A A Disturbance of Consciousness excessive or inappropriate Coma in the extreme Inattention Easily Distracted Disorganized Stream of Thought Clouded Sensorium
A A Change in Cognition Profile of cognitive change is non-specific Memory, Language, Executive Functioning, Judgement,, Insight Importance of establishing a cognitive baseline for comparison Classic behavioral changes are not required for the diagnosis Hallucinations, Delusions, Aberrant Motor Behavior, Sleep disturbances, Aggression
Acute and Fluctuating Delirium is acute in its onset (hours to days) fluctuating in its course hyperactive and hypoactive Severe impairment in consciousness and lucidity Differential Diagnosis Stroke or Seizure - also acute in onset Lewy Body Dementia - also fluctuating
Underlying Etiology Classification of Delirium (DSM-IV IV-TR) Delirium due to a general medical condition Substance intoxication delirium Substance withdrawal delirium Substance induced delirium Delirium due to multiple etiologies Failure to find an etiology should cause re- evaluation of the diagnosis
Delirium Significance
Question 2 Which in-patient population has historically had the highest incidence of delirium? A. General Surgery B. General Medicine C. Orthopedic Surgery D. Cardiac Surgery
Question 2 - Answer Which in-patient population has historically had the highest incidence of delirium? A. General Surgery B. General Medicine C. Orthopedic Surgery D. Cardiac Surgery
Why delirium matters Common Under-recognized recognized Often Iatrogenic Costly
Delirium is common In hospital prevalence at admission 10-22% incidence after admission GIM 7-31% Cardiac Surgery 33% Orthopedic Surgery <50%
Delirium is under-recognized recognized Despite excellent diagnostic criteria, prospective studies consistently show a failure of clinicians to recognize delirium. Why do physicians misread delirium? Misread as something else Fluctuating course Hypoactive subtypes Impairment assumed to be benign
Delirium is often iatrogenic Associations Medications New medications in hospital Unintended Withdrawal syndrome in hospital Process of Care Sensory deprivation/over-stimulation Catheters and restraints Unintended fluid deprivation Careless omission of visual or hearing aides Any iatrogenic illness
Delirium is costly Independent Associations Mortality Prolonged hospital stay Discharge to Nursing Home Functional Decline
Question 3 Which of the following predisposing risk factors for delirium are associated with the greatest relative risk? A. Alcohol use B. Dementia C. Chronic pain D. Number of medications
Question 3 - Answer Which of the following predisposing risk factors for delirium are associated with the greatest relative risk? A. Alcohol use B. Dementia C. Chronic pain D. Number of medications
The Approach to Diagnosis 1. Anticipate it 2. Obtain relevant and reliable information 3. Interview and objective testing 4. Satisfy criteria for Delirium 5. Investigate for underlying cause
1. Anticipate it What sets the table for delirium? Setting Age Dementia Sensory Impairment Co-morbidity Frailty Previous Delirium
2. Information Gathering Review the health record - nursing notes! Interview capable informants family and friends family doctor other formal caregivers nurses on the floor home care nurses who know the baseline
Question 4 Which of the following is the least reliable indication of a clouded consciousness? A. Persistent sleeping B. A mini-mental mental status exam score of 18/30 C. Inability to repeat a set of six numbers D. Distractibility during serial subtractions
Question 4 - Answer Which of the following is the least reliable indication of a clouded consciousness? A. Persistent sleeping B. A mini-mental mental status exam score of 18/30 C. Inability to repeat a set of six numbers D. Distractibility during serial subtractions
3. Objective Findings Observations during encounter Administer simple screening tools Mini Mental Status Exam Bedside Tests of Inattention
Simple Bedside Screening Tests Vigilance A test Digit Span Serial Subtractions An Exercise: Practice each method with a partner
4. Confusion Assessment Method A mental checklist done after contact with patient, family and caregivers There must by evidence of 1. Acute and Fluctuating Course 2. Inattention 3. Disorganized Thinking or Altered LOC
Question 4 Identify the most common precipitant for delirium in the elderly A. Neurological causes B. Infectious causes C. Metabolic causes D. Medication causes
Question 4 - Answer Identify the most common precipitant for delirium in the elderly A. Neurological causes B. Infectious causes C. Metabolic causes D. Medication causes
5. Investigate for precipitant Medications Infectious Metabolic Cardiopulmonary Other pain, stress, sleep deprivation, retention Neurologic
Question 5 Which of the following medication classes bring the highest risk for delirium? A. Fluorquinolones (eg. Levofloxacin) B. Narcotics (eg( eg.. Morphine) C. NSAIDs (eg. Indomethacin) D. Antidepressants (eg( eg. Citalopram)
Question 5 - Answer Which of the following medication classes bring the highest risk for delirium? A. Fluorquinolones (eg. Levofloxacin) B. Narcotics (eg( eg.. Morphine) C. NSAIDs (eg. Indomethacin) D. Antidepressants (eg( eg. Citalopram)
Delirium - The Usual Suspects Narcotics Anticholinergics Benzodiazepines Psychotropics Anti-Parkinsonian Drugs Common Drugs but less likely H2 antagonists, Beta Blockers, NSAIDs
Case DT What would you like to do next? Mr DT is admitted to the hospital with the diagnosis of delirium. Admission orders? You are called by the nursing staff on the medical ward at 3 am because Mr DT is shouting and crawling out of bed. He tried to strike a nurse who came to talk to him. What would you do at this point?
Delirium Management
Approach to Management Specific Supportive Sedative
Question 6 Management of delirium in seniors includes the following except: A. Holding all medications B. Treat bacteruria if cultures>10 8 C. Correct visual or hearing impairments D. Treat dehydration/ hypernatremia
Question 6 - Answer Management of delirium in seniors includes the following except: A. Holding all medications B. Treat bacteruria if cultures>10 8 C. Correct visual or hearing impairments D. Treat dehydration/ hypernatremia
Specific Management Identify and treat or eliminate the underlying causes reduce medications - narcotics, psychotropics,, benzodiazepines, anticholinergics appropriate treatment - infection, metabolic, cardiopulmonary, retention
Supportive Management The right aids: hearing & visual devises. The right environment: light, clocks, & windows geared to normal diurnal patterns. Minimize hospital noises. The right approach: calm, non calm, non-threatening approach by familiar visitors and regular staff. Supervised wandering is preferred to restraints.
Sedative Management Reserved for situations of immediate risk. hyperactive delirium Examples Anti-psychotics Haloperidol 0.5-1.0 mg q2-4h is drug of choice Atypical neuroleptics - less evidence Benzodiazepines in the setting of withdrawal.
Delirium Prevention
Question 7 Which of the following were not included in a successful, well-powered, delirium prevention trial? A. Sleep protocol including back massages B. Rehydration protocol including IV therapy C. Cognitive protocol including reorientation D. Mobility protocol including walking
Question 7 - Answer Which of the following were not included in a successful, well-powered, delirium prevention trial? A. Sleep protocol including back massages B. Rehydration protocol including IV therapy C. Cognitive protocol including reorientation D. Mobility protocol including walking
Prevention of Delirium Simple protocols to prevent delirium appear to be effective and cost neutral Protocols to address Sleep deprivation, immobility, cognitive impairment, visual and hearing impairment, dehydration. Future protocols might also include medication reviews and prevention of infections.
Review A. Delirium - the nature of the beast B. Significance of delirium C. An approach to diagnosis D. Management of delirium E. Prevention of delirium