BGS Autumn Delirium: Recognition, prevention, management

Delirium: Recognition, prevention, management Dr Tizzy Teale Senior Clinical Lecturer and Honorary Consultant Geriatrician University of Leeds and Bradford Teaching Hospitals NHS Trust

How common is delirium? Delirium is the commonest complication of hospitalisation in older people Large point prevalence study (Italy) 108 acute and 12 rehabilitation wards Delirium assessments with the 4AT within a pre-determined 24 hour period ( Delirium Day ) 1867 patients assessed Bellelli G, Morandi A, Santo et al BMC Medicine 2016;14:106 Overall point prevalence of delirium in hospital inpatients over 65 was 22.9% Over 50% of patients with delirium have a diagnosis of dementia Ryan DJ, O Regan et al BMJOpen 2013;3;e001772

Prevalence varies by ward type Bellelli G, Morandi A, Santo et al BMC Medicine 2016;14:106 Between 1 in 4, and 1 in 5 older people in hospital have delirium This estimate is consistent across prevalence studies In some settings (palliative care, ICU) rates are much higher The remainder are likely to be at risk of developing delirium

How often is delirium missed? Up to 2/3 of cases of delirium are missed or misdiagnosed by acute medical teams Collins et al Age Ageing 2010; 39(1):131-135

People remember being delirious Recall of delirium experiences is common after recovery (>50%) Those with more severe delirium and with underlying cognitive impairment less likely to recall This doesn t make their distress any less at the time Commonly recalled symptoms are of visual hallucinations Misinterpretation of real sensory experiences also common Source of fear and anxiety Delusions common (often threatening) Descriptions of incomprehensible situations / time distortion common Trying to make sense of situation There may be longer lasting neuropsychiatric sequelae O Malley et al J of Psychosomatic Res 2008;65:223-228

Poorer longer term outcomes following Poor cognitive outcomes delirium Delirium is associated with incident dementia OR 8.7 95%CI: 2.1-35 Acceleration of cognitive decline Two-fold increased rate in the first 12 months Davis et al Brain 2012; 135:2809-2816 Gross et al 2012; Arch Int Med;2012;172(17):1324-1331 Institutionalisation OR 2.41 95%CI: 1.77-3.29 (average follow up 15 months) Mortality HR 1.95 95%CI: 1.51-2.52 (average follow up 23 months) Witlox et al JAMA 2010;304(4):443-51

Setting Delirium is poorly coded in the UK health service Prevalence from reported studies % (range) General / geriatric medicine 23.6% (15-42) 0.39 Critical care 48 (29.8-83.3) 0.23 Emergency Department 9.8 (9.6-11.1) 0.14 Orthopaedics 44.8 (29-68.1) 0.05 Delirium rate (%) from UK HES data 2006-7 (>65s) Clegg A, Westby M, Young J Age Ageing 2011;40(2):283-286 Even if we diagnose it, the bigger picture is invisible as we are not coding for delirium at hospital discharge.

Recognising delirium Based on DSM 5 criteria Diagnosis of delirium requires all DSM 5 criteria to be met Criteria operationalised into screening or diagnostic algorithms A degree of subjectivity / inconsistently applied criteria Delirium is a complex syndrome features can be difficult to spot

Disturbance in attention Key features (DSM 5 criteria) Reduced ability to direct, focus, sustain and shift attention AND Disturbed level of awareness Reduced orientation to the environment Acute / subacute onset Representing a change from baseline attention and awareness A tendency to fluctuation Over hours or days An additional disturbance in cognition Memory deficit, disorientation, language, visuospatial, perception Criterion A Criterion B Criterion C

Not better explained by an existing or evolving neurocognitive disorder Not in the context of severely reduced arousal e.g. coma Physiologically attributable to a medical condition History, examination, lab findings Substance intoxication or withdrawal Exposure to a toxin Multiple aetiologies Criterion D Criterion E

Inattention Difficulty maintaining / shifting focus between tasks Easily distracted by sounds, objects, own thoughts Perseveration May be poor eye contact May seem vague

Detection of delirium superimposed on dementia (DSD) is particularly challenging Impaired attention is a key feature of delirium May help distinguish delirium from dementia But patients with dementia struggle to complete tests of attention Rutter et al EDA Conference Abstract 2016; #13

Detecting inattention Months of the year backwards (MOTYB) Ask to say forwards Jan to Dec. Then ask to recite backwards from Dec. If able to reach July without error, attention likely intact MOTYB in >69yo without dementia 84% sensitivity 90% specificity for delirium O Regan JNNP 2014;85:1122-1131

MOTYB in those with dementia Poor specificity for delirium Patients with dementia may struggle to complete? Is inattention a feature of dementia, or is this measuring something else? O Regan JNNP 2014;85:1122-1131 Patterns of errors may help to discriminate between delirium and dementia (more work needed) omissions / repetitions / self-correction Rutter et al EDA Conference Abstract 2016; #13 Duncan et al EDA Conference Abstract 2016 # 35 Use of informant instruments can help to identify pre-existing dementia (e.g. the IQCODE-SF) Jackson et al Age Ageing 2016;45(4):505-11

Consciousness, arousal and attention Altered consciousness (DSM-IV) changed to disturbance in attention and awareness in DSM-5 Consciousness is a hierarchical construct Level of consciousness = arousal Content of consciousness = attention Consciousness therefore includes implicit assessment of arousal Removed in DSM-5

It is important not to miss delirious patients in whom attention cannot be assessed due to alterations in arousal (e.g. too sleepy) Those with sudden onset of altered arousal (over, or underactive) not attributable to existing or evolving condition (e.g. stroke) should be considered to meet DSM-5 criterion A for delirium EDA and ADS BMC Medicine 2014; 12:141

Acute onset and fluctuating course Aim to identify a change from baseline SQiD (single question in delirium) Do you think [patient] has been more confused lately? 80% sensitivity for delirium 71% specificity Sands et al. Palliat Med 2010; 24: 561-565 Have there been fluctuations over the course of days or hours?

Additional cognitive disturbance Disorganised thinking, incoherent speech, perceptual problems, disorientation Problems making sense of what is going on Misinterpreting the environment Asking abstract questions can help identify May be hallucinations or persecutory ideas Do you feel frightened by anything or anyone? Are you concerned about anything going on here? Health Improvement Scotland Delirium toolkit 2014 Mumbling, slurred or rambling speech which may be difficult to understand

Hypoactive delirium Most common subtype (39%) Withdrawn, quiet, sleepy, poorly rousable Little interest in environment, poor oral intake Slurred speech Often missed need to consider the diagnosis Associated with particularly poor outcomes Hyperactive delirium Delirium subtypes Less common (21%) Agitated, wandersome, hyper-alert Behavioural disturbances Mixed delirium fluctuates between these subtypes (27%) 13% have no motor symptoms

Alertness (normal / abnormal) AMT4 (Age, DOB, Place, Current Year) Attention (MOTYB) Acute change or fluctuating course (yes / no) 4AT can be used in those untestable with other methods e.g. stupor Does not rely on skilled assessment of attention Previous validation study (Italy) Sensitivity 89.7% Specificity 84.1% Bellelli Age Ageing 2014;43(4):496-502 Utility in non-english speaking patients Sensitivity 91% Specificity 71% De et al Int J Geriatr Psych 2016; epub ahead of print 4AT (the4at.com)

Abnormal hand movements Carphology aimlessly picking at Uncommon behaviours clothes or bedding (12.5% of delirium episodes) From carphologia (Greek): Highly specific for delirium (98%) Karphoi: bits of twig, wool or straw Poor sensitivity Lego: I gather (14%) High likelihood ratio (positive) 6.8 Floccilation plucking at the air Seems unrelated to delirium subtype From floccus (Latin) If you see it Think Delirium Tufts of wool or hair Holt et al Age Ageing 2014

Strong predictors: Frailty Dementia Visual impairment Dehydration Severe illness Who gets delirium? Modifiable vs non-modifiable risk factors

Lucid Delirious Who gets delirium? Decompensation is more pronounced for the same insult Minor illness (e.g. UTI) Recovery may be protracted (persistent delirium) Recovery may be incomplete (lasting cognitive impairment) Decompensation threshold Those with frailty and dementia are closer to the threshold of decompensation (limited reserve) Modified from Clegg, Young, Iliffe, Olde-Rikkert, Rockwood. Frailty in elderly people. Lancet 2013; 381: 752-762

Delirium prevention strategies: Up to one third of delirium is preventable through multicomponent delirium prevention interventions Siddiqi et al Cochrane Review 2016 DOI: 10.1002/14651858.CD005563.pub3 Personalised care delivered in a ward environment geared for delirium prevention What don t we know? Which are the most important / effective components of a multicomponent intervention and how should these best be delivered?

Metabolic Oxygenation Glucose Perfusion Electrolytes Infections Environmental Ambient noise Signage Re-orientation Early mobilisation Avoid ward moves Attention to sleep pattern Individual Avoid catheters if possible Bowel Care Hydration Nutrition Treat pain (avoid opiates if possible ) Is early discharge possible / appropriate / safe? Sensory Ensure hearing aids work and have batteries in Modify these factors where you can Specs! (are they clean?) Medication Avoid deliriogenic drugs Simplify meds as much as possible

Non-pharmacological treatment of delirium It is important to be aware of, and modify potential triggers in non-delirious patients, as well as targeting contributing factors in those who are delirious Delirium episodes shorter and less severe if occur in the context of a multicomponent delirium prevention intervention Marcantonio JAMA 2001;49(5):516-22 O Hanlon et al JNNP 2014;85(2):207-213 No convincing evidence that multicomponent interventions are beneficial for the treatment of established delirium

Drugs and delirium Drugs implicated in development of delirium Drugs for delirium prevention Drugs for delirium treatment Drugs for management of delirium symptoms

Drugs implicated in delirium In general avoid Drugs with anticholinergic properties Antihistamines TCAD Treatments for OAB Benzodiazepines Opioids (but treat pain) Medication review is a key aspect of delirium prevention / management Pay attention to the number, and type of medication

Drugs to prevent delirium (outside ICU) Drugs investigated for prophylaxis Antipsychotics Melatonin / melatonin agonists Acetylcholinesterase inhibitors Citicoline Gabapentinoids No evidence to support the use of any of these drugs for prevention of delirium Siddiqi et al Cochrane Review 2016 DOI: 10.1002/14651858.CD005563.pub3

Pharmacological treatment of delirium Evidence remains limited No convincing benefit for pharmacological therapies for treatment or prevention of delirium in non-icu settings There is a need for further trials to identify agents that are safe for older people, and that have efficacy in the treatment / prevention of delirium

Management of delirium symptoms Identify and manage the underlying cause Symptoms should be managed through verbal and non-verbal deescalation techniques If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term (usually for 1 week or less) haloperidol or olanzapine Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson's disease or dementia with Lewy bodies No drugs have a UK license for treatment or prevention of delirium https://www.nice.org.uk/guidance/cg103/chapter/1-guidance#treating-delirium

Delirium recovery Persistence of delirium beyond hospital discharge is common Discharge 44.7% (half of these will have recovered by 3/12) 1 month 32.8% 3 months 25.6% 6 months 21% Cole et al Age Ageing 2009; 38:19-26 Outcomes for people with persistent delirium are worse than for those who recover Those with dementia are more likely to develop persistent delirium 38% of people presenting with delirium have undiagnosed cognitive impairment Jackson et al Age Ageing 2016;45(4):493-499

Follow up People who have had delirium are more likely to develop incident dementia Follow up after an episode of delirium is useful: For education / give the opportunity for patients to make sense of their experience if they want to To identify features of persistent delirium To identify / signpost those with incident dementia

Resources Bradford Teaching Hospitals NHS Foundation Trust delirium patient information leaflet http://johnscampaign.org.uk/docs/external/bra dford-teaching-hospitals-deliriumprevention.pdf Please contact BTHFT for copyright permissions if you wish to use / adapt Medical.Illustration@bthft.nhs.uk

NICE Delirium: Diagnosis, Prevention and Management of delirium guidelines (CG103) July 2010 http://www.nice.org.uk/guidance/cg103 The 4AT http://www.the4at.com/ The Scottish Delirium Association Delirium Management Comprehensive Pathway Dec 2013 http://www.scottishdeliriumassociation.com Healthcare Improvement Scotland http://www.healthcareimprovementscotland.org E-modules Information for patients and carers TIME delirium care bundle