POST STROKE DELIRIUM Dr Janet Ballantyne
Delirium de: away from/off lira: ridge between ploughed farrows/tracks off the tracks Acute confusional state Acute brain syndrome Acute brain failure Metabolic encephalopathy
What Is Delirium? 1. Disturbance of consciousness (attention) 2. Change in cognition or perception not better accounted for by dementia 3. Develops over short period and fluctuates 4. Caused by direct physiological consequences of medical condition/substance intoxication or withdrawal
Prevalence General community > 85yo community ED O/A to hospital During admission Post op ICU NH End of life 1-2% 14% 10 30% 14-24% 6-56% 15-53% 70-87% Up to 60% Up to 85%
Incidence ACH: patients > 85 yo 25% admissions due to delirium Incidence rate for developing delirium 55% # NOF 60% Incidence post stroke Limited studies Meta-analysis10-48%
Huge impact Unrecognised in up to 2/3 cases mortality 10-25% length of stay ($$) risk of residential care admission Some fail to recover baseline cognition Traumatic experience for patient & family risk: early identification, assessment and Rx
Pathogenesis Not fully understood Different mechanisms final common pathway Disruption of neurotransmission Deficiency of acetylcholine Excess of dopamine
Case study 87 yo man. Lives alone Found on floor by care giver L) hemiparesis, multiple bruises and skin tears PMH: Hypertension BPH Meds: Felodipine 5mg OD Oxybutynin 5mg BD
Collateral history Sensory impairment Poor hearing, no hearing aid Poor vision OA limits mobility. LWF Cognitive decline over last 12/12 STM loss Needing assistance with ADLs
Which of the following are risk factors for developing delirium? A. Old age B. Hearing/Visual Impairment C. Poor pre stroke functional status D. Underlying cognitive impairment E. All of Above
Which of the following are risk factors for developing delirium? A. Old age B. Hearing/Visual Impairment C. Poor pre stroke functional status D. Underlying cognitive impairment E. All of Above
Risk factors Dementia/cognitive impairment Previous delirium Old age Frailty Sensory impairment Polypharmacy Alcohol, opiod or BDZ withdrawal Palliative care population
Risk factors Pain IDC: 2x risk Restraints: 4x risk Multiple room changes No glasses/hearing aid No clock/watch ICU admission
Risk factors Multiply risk not just additive Modifiable Drugs (addition/withdrawal), pain, intercurrent illness, dry, sleep deprived, restraint Non modifiable Dementia, previous delirium, age, male
70yo, best predictors: Cognitive impairment Previous delirium Visual impairment Hearing impairment Sleep deprivation Immobility Dehydration
Case study Orientated on admission Overnight: agitated, picking cotton, pulls out IV Speech slurred and incoherent Next morning sleeping, difficult to rouse, refused breakfast
What s the most likely diagnosis? A. Dementia B. Delirium C. Extension of stroke D. Seizure E. Depression
What s the most likely diagnosis? A. Dementia B. Delirium C. Extension of stroke D. Seizure E. Depression
What is delirium? 1. Disturbance of consciousness (attention) 2. Change in cognition or perception not better accounted for by dementia 3. Develops over short period and fluctuates 4. Caused by direct physiological consequences of medical condition/substance intoxication or withdrawal
Cardinal Features Disturbance in attention Disorganised thinking Disorientation Memory impairment Perceptual disorders Increased or decreased psychomotor activity Disturbed sleep/wake cycle Fluctuates and is worse at night
Delirium vs dementia vs depression
Clinical Assessment Collateral history Onset & course of confusion Baseline cognitive function & functional capacity Medication history OTC drugs, alcohol, benzodiazepines Clinical examination MMSE, MOCA, ACE-R not appropriate
Confusion Assessment Method - CAM 1. Acute onset & fluctuating course and 2. Inattention and either 3. Disorganised thinking Course Attention Muddled or 4. Altered level of consciousness Sensitivity 94%, specificity 90%
Diagnosis post stroke No specific screening tool Assessment limited by Dysphasia Brain injury/oedema Collateral hx?pre-existing cognitive impairment IQCODE: Informant questionnaire on cognitive decline in the elderly GPCOG
Attention Unable to generate, sustain, and shift attention Distractible & lose thread of conversation Disorientation 20 1 backwards Serial 7s Months of year/days of week in reverse
Memory Memory disturbance largely due to inattention On recovery typically an amnesic gap for the period of the illness if fluctuation marked, islands of memory may remain
Thinking Organisation and content of thought processes impaired by delirium History muddled, illogical, disjointed Problem solving & planning impaired Concept formation impaired Delusions - paranoid & persecutory content Difficulty with basic ADLs
Disorders Of Perception Disturbance of hearing and vision common Attention: crucial role in perception of sensory information Depersonalisation and unreality common Illusions misinterpretation of stimuli Hallucinations visual, auditory, tactile
The Sleep Wake Cycle Disruption Consistent feature Insomnia with daytime sleepiness Difficulty distinguishing between dreams and reality Abnormal day and night EEGs Disruption to the neurotransmitter system making up the reticular activating system promotes and maintains cortical arousal
Psychomotor Behaviour & Emotion Hyperactive -30% heightened arousal restless, agitated and aggressive Hypoactive -25% withdrawn, quiet and sleepy Mixed - 45% Hypoactive & mixed difficult to recognise
Case Study Exam: Temp 37.8 Crepitation at left base L) hemiparesis 1-2 whiskeys/night at home Medication chart: Not in pain currently Sevredol 10-20mg Q2H/ PRN 40mg Tramadol 100mg QID/PRN 300mg
Case Study Na 132, K 3.2, Cr110 CSU: +ve WBC and RBC
What s the most likely cause of his delirium? A. Dehydration B. Drugs C. Electrolyte imbalance D. Infection E. Alcohol Withdrawal
Whats the most likely cause of his delirium? A. Dehydration B. Drugs C. Electrolyte imbalance D. Infection E. Alcohol withdrawal Most deliriums are multifactorial in aetiology 30% cause not found
Common causes of delirium: Drugs 30% of delirium Analgesics Narcotics: Tramadol and morphine Benzodiazepines Antiparkinsonian agents (Sinemet) Medication withdrawal: eg narcotics, SSRIs, TCAs, BDZ, EtOH
Anticholinergic drugs Acetylcholine Attention/cognition Deficiency associated with delirium Anti-Ach drugs can cause/worsen delirium Oxybutynin, TCAs, Benztropine, Antihistamines, Antispasmodics Low activity: Prednisone, Digoxin,Frusemide, Theophylline, Ranitidine, Codeine Cumulative effect
Common causes of delirium Sepsis Vascular event Stroke, MI Fluid balance (dry/ccf) Electrolyte disturbance Immobility (restraint, IDC) Malnutrition Pain Urinary retention Constipation
Stroke and delirium No predictive model > risk of delirium Large stroke BUT risk of medical complications ICH
Examination & Investigations Bloods Electrolyte disturbances Septic screen CT brain Head injury, fall, focal neurological signs Lumbar Puncture Meningism, headache and fever EEG Non convulsive status epilepticus
Back to the case Calling out repeatedly Refusing IV line Disturbing the other patients on the ward Pulling at his catheter
What s the best next management? A. Haloperidol 0.5 mg stat. Rpt in 30 mins prn B. Lorazepam 2 mg IV stat C. Move to side room, pull curtains turn off the light D. Review opiods and remove IDC E. Use restraints to stop pulling out IDC and allow the IV to be replaced.
What s the best next management? A. Haloperidol 0.5 mg stat. Rpt in 30 mins prn B. Lorazepam 2 mg IV stat C. Move to side room, pull curtains, turn off the light D. Review opiods and remove IDC E. Use restraints to stop pulling out IDC and to allow the IV to be replaced
Management Identify and treat underlying cause Management of the confusion Non drug management Drug management
Non drug management Support and educate the family Remain calm & avoid confrontations Avoid restraint Assist with reorientation Consistency of staff Clocks, calendars Familiar photos and visitors Minimise level of stimulation Appropriate lighting
Non drug management Hearing aids/glasses available and work Avoid complications immobility, malnutrition, pressure sores, over-sedation, falls, incontinence Adequate hydration Mobilise Sleep hygiene Liaise with Older Peoples Health/Psychiatry
Drug Management Stop what you can Reduce doses Assess anticholinergic load Avoid starting drugs unless clear indication Wandering & disorientation are NOT indications for drug treatment
Drug Management Distressing symptoms Dangerous behaviour Essential investigations or treatment Lowest dose for shortest time
Anti psychotics: Haloperidol Less sedating, high potency DA blockade, minimal anticholinergic activity, no active metabolites Reduce level of arousal, perceptual disturbance, persecutory ideas PO/IM/IV Haloperidol 0.5mg IM/IV=1mg PO 0.25mg BD plus 0.25mg prn 2 doses Review daily Wean morning dose first Avoid in Parkinson s disease and LBD Monitor for EPSE
Antipsychotics Risperidone 0.25mg BD/PRN Increased mortality OR 1.61 (95% CI 0.88 2.96) risk of stroke > risk with age, dementia, short duration, higher dose
Antipyschotics PD and LBD Quetiapine Low incidence EPSE Sedating Hypotension
Benzodiaepines Not recommended as first line agents Exception: drug and alcohol withdrawal Useful if anxiety symptoms are prominent Use if additional sedation required especially at night Worsen confusion and sedation Can cause paradoxical agitation Lorazepam 0.25mg BD
Prevention: Modifiable risk factors Targeting modifiable risk factors prevents some case of delirium Sleep deprivation Immobility Dehydration Visual/hearing/cognitive impairment delirium episodes (15% 9.9%) No effect on severity or rate of recurrence N Engl J Med 1999;340:669-676
Outcome Persistent 1/52: 60% 2/52: 20% 4/52: 5% May be present at 12/12
Outcome Poorer cognitive and functional outcomes LOS dx to residential care mortality Acute and at 12/12
Outcome: Mortality Estimated mortality 1/12: 14% 6/12: 22% 2x that of patients without delirium. Remains when adjusted for dementia and underlying illness. Delirium > 6 months: mortality J Am Geriatr Soc. 2009;57(1):55
Incidence of dementia following delirium 65yo admitted to Medical services 203 patients Followed for 3 years Delirium: 18.1% per year No delirium: 5.6% per year Age and Aging 1999;28:551-556
If delirium does not resolve Re-evaluate for underlying causes Follow-up and assess for possible underlying dementia
Take Home Points Common & serious illness Often missed think about it Collateral history vital Non pharmacological treatment essential Risk of delirium can be reduced with careful attention to risk factors