Delirium and Dementia Paul Kettl, M.D., M.H.A. Summary DELIRIUM Acute brain failure Identify cause (meds, infection) Treat sx Poor prognostic sign DEMENTIA Chronic brain failure AD most common cause Often more than one type of dementia present Treatment: cholinesterase inhibitors and memantine Research dissapointing 1
Delirium Clinical Features Acute onset Fluctuating course Inattention Disorganized thinking Altered level of consciousness Cognitive deficits Clinical Features (cont.) Perceptual disturbances (illusions or hallucinations in 30% of patients) Psychomotor disturbances (hyperactive or hypoactive) Altered sleep wake cycle Emotional disturbances, including labile mood Inouye SK. Delirium in older patients. NEJM. 354:1157 1165 March 16, 2006 2
Clinical Features Acute onset Fluctuating course Inattention Disorganized thinking Altered level of consciousness Cognitive deficits Delirium 20% of inpatients 65 or older 36.8% of surgical pts McDaniel M, Brudney C. Postoperative delirium: etiology and management. Curr Opin Crit Care. 2012 Jun 22. [Epub ahead of print] 50% 80% incidence in ICU Pisani MA, McNicoll L, Inouye SK. Cognitive impairment in the intensive care unit. Clin Chest Med. 2003 Dec;24(4):727 37. Cost of delirium in US: $38 million to $150 milllion McDaniel M, Brudney C. Postoperative delirium: etiology and management. Curr Opin Crit Care. 2012 Jun 22. [Epub ahead of print] Prevalence is 1 2% in the community Inouye SK. Delirium in older patients. NEJM. 354:1157 1165 March 16, 2006 3
Etiology Usually multifactorial Occasionally one prime factor, but usually a combination of: illness (beware infection, sepsis) meds (beware anticholinergic or sedating drugs) labs (glucose, lytes, CBC) Associated with decreased cerebral blood flow: prefrontally, thalamus, basal ganglia; altered cholinergic system; inflammation; chronic stress >hypercortisolism, cytokines Michael A. Fearing, Ph.D.; Sharon K. Inouye, M.D., M.P.H. Delirium. FOCUS 2009;7:53 63. Numerous and widely varying precipitants can activate delirium in susceptible (high baseline vulnerability) patients. In their landmark study, Inouye and Charpentier (1996) separated out baseline risks present at admission (e.g., prior cognitive impairment) from precipitants affecting the patient after admission (e.g., new onset respiratory insufficiency). Robust patients with less baseline vulnerability ( more cerebral reserve ) were more resilient to new precipitants after admission (Figure 8 4). FIGURE 8 4. Interrelationship of baseline and precipitating factors in delirium. Source. Adapted from Inouye SK, Charpentier PA: Precipitating Factors for Delirium in Hospitalized Elderly Persons: Predictive Model and Interrelationship With Baseline Vulnerability. Journal of the American Medical Association 275:852 857, 1996. Copyright 1996, American Medical Association. Used with permission. The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org 8 4
Delirium and Dementia One year mortality rate is 35 40% Dementia pts have 2 5 fold increased risk of developing delirium 2/3 of delirium pts also have dementia Cole MG: Delirium in elderly patients. Am J Geriatr Psychiatry 12:7 21, 2004 Pts who develop delirium after cardiac surgery have lower MMSE score Saczynski JS, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012 Jul 5;367(1):30 9. (those pts. With dementia and delirium die earlier than with dementia alone: Relative risk of death increased 1.8 times) Rockwood, S Cosway, D Carver, P Jarrett, K Stadnyk and J Fisk. The risk of dementia and death after delirium. Age and Ageing, Vol 28, 551 556, 1999 K Research using multivariate and logistic regression analyses has demonstrated that delirium independently increased mortality risk in study samples. For example, Ely et al. (2004a) found a 6 month mortality hazard ratio of 3.2 for ICU patients who had been delirious while on the ventilator (Figure 8 6). FIGURE 8 6. Delirium and mortality in intensive care unit patients. Source. Ely et al. 2004a. The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, Gabbard GO. 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org 10 5
Delirium and Dementia Survey of 263 hospitalized pts with AD 56% developed delirium; rate of deterioration BEFORE hospitalization was not different BUT Those with delirium had twice the rate of deterioration in the year following admission, AND the increased rate of deterioration continued for FIVE YEARS Gross AL, et al. Delirium and Long term Cognitive Trajectory Among Persons With Dementia. Arch Intern Med. Published online August 20, 2012. doi:10.1001/archinternmed.2012.3203 Delirium Evaluation Evaluate meds (sedating meds, anticholinergic meds) Infection: Vital signs, u/a, chest x ray Labs: CBC, lytes, BUN, Cr, LFT s, ammonia, glucose, EKG, O2 sat MMSE can be widely varying 6
From: 3D-CAM: Derivation and Validation of a 3-Minute Diagnostic Interview for CAM-Defined Delirium: A Cross-sectional Diagnostic Test Study3D-CAM: Derivation and Validation of a 3-Minute Interview for Delirium Ann Intern Med. 2014;161(8):554-561. doi:10.7326/m14-0865 Date of download: 10/22/2014 Copyright American College of Physicians. All rights reserved. Etiology (cont.) Also consider weakened state (dementia) substance abuse sensory impairment Post op care Sleep deprivation (in hospital) Inouye SK. Delirium in older patients. NEJM. 354:1157 1165 March 16, 2006 7
Delirium Treatment FIND THE ETIOLOGY!! (But, half the time, there is not one etiology) Maintain patient safety Manage the environment (reorient pt, clock, calendar are helpful); maintain hearing aids, glasses Prevent hypoxemia, infection, constipation Manage agitation (behaviorally, meds) Remember EtOH or drug (including prescribed) drug withdrawal Treat pain TAKES DAYS TO WEEKS TO CLEAR Management Check med list Check labs Any treatable cause? Tune up? Treat pain Adequate nutrition Supportive environment 8
B 52 Combination of Haloperidol 5 and lorazepam 2mg Can be put in the same syringe Less likely to develop EPS (6%) Currier GW. Standard Therapies for acute agitation. Journal of Emergency Medicine, 27: suppl 1, S9 S12, 2004. Combination Rx superior to either alone Yildiz A. et al. Pharmacological management of agitation in emergency settings. Emerg Med J. 20:339 346, 2003. Meds for Agitation Geri s Haloperidol 1 2 mg IM or PO Atypicals (quetiapine 50 50 bid) commonly used, generally well tolerated, but no double blind trials Peritogiannis V, Stefanou E, Lixouriotis C, Gkogkos C, Rizos DV. Atypical antipsychotics in the treatment of delirium. Psychiatry Clin Neurosci. 2009 Aug 10 Lorazepam 0.5 to 1 mg IM or PO or IV 9
Prevent Delirium? Good nutrition (pts with low albumin more likely to get delirium) Tune up (cardiac condition, DM) Meds? melatonin 0.5 mg hs Al Aama T, et al. Melatonin decreases delirium in elderly patients:a randomized,controlled clinical trial. Int J Geriatr Psychiatry. 26:687, 2011 risperidone 1 mg hs one time in PACU reduced delirium from 32% to 11% Prakanrattana U and Prapaitrakool S. Efficacy of risperidone in preventing delirium in cardiac surgery. Anaesth Intensive Care 35(5):714 9, 2007 olazepine also reduces incidence Friedman JI, et al. Pharmacological Treatments ofnon Substance Withdrawal Delirium:A Systematic Review of Prospective Trials. Am J Psychiatry 2013;:. doi:10.1176/appi.ajp.2013.13040458 donepezil, rivastigmine not helpful (in 5 separate trials) Prevent Delirium? 67 elder patients admitted to ICU given either ramelteon 8 mg hs x7 days (a melatonin agonist) or placebo 3% of those on ramelteon became delirious compared to 32% (!!) on placebo (p=0.003) Melatonin, released by the pineal gland, helps to regulate sleep/wake rhythms Hatta K, et al. Preventive Effects of Ramelteon on Delirium: A Randomized Placebo Controlled Trial. JAMA Psychiatry. Published online February 19, 2014. 10