Objectives Delirium in Older Persons ELITE 2018 Liza Isabel Genao, MD Division of Geriatrics Describe rate, cost, complications of delirium Effectively diagnose the syndrome Describe multicomponent model to approach delirium Name non-pharmacological interventions to treat and prevent delirium Name 1-2 pharmacological regimen for treating symptoms of delirium Describe pearls for communicating with the agitated patient Delirium is common Delirium is deadly Emergency Department: 8-17% prevalence (present on admission) Surgical wards: Cardiac (11-46% incidence), non-cardiac (13-50% incidence) and orthopedic (17% prevalence, 12-51% incidence) Medical ward:18-35% prevalence, 11-14% incidence ICU: 7-50% prevalence, 19-82% incidence Post acute care: 14% prevalence, 20-22% incidence End of life: up to 88% present at the time of death General medicine wards: RR=1.5-1.9 risk for death ICU: RR=1.4-13 risk for death If after a stroke: RR= 2 or in the setting of dementia RR= 5.4 risk for death Post-acute care: RR= 4.9 risk for death ED: RR=1.7 risk for death American Journal of Hospice & Palliative Medicine 28(1) 44-51ª The Author(s) 2011 Delirium leads to high disease burden and disability Functional decline: RR=1.9 (cardiac surgery), RR=2.1 (non-cardiac surgery), RR=1.5 (general medicine ward) Need for LTC placement: RR=5.6 (orthopedic surgery), RR=2.5 (gen med ward), RR= 9.3 (if dementia present) Cognitive impairment: RR=1.7 (cardiac surgery), RR=2.1 (noncardiac surgery), RR=6.4-41.2 (ortho) Increased length of stay: RR= 1.4-2.1 (ICU) Higher costs: US$164 billion/year (USA), $182 billion/year (18 European countries combined) Delirium is preventable & under-recognized Delirium is preventable in 30 40% of cases Delirium is under-recognized: missed in 22% to 50% of cases. Factors that contribute to under detection: Preexisting dementia, depression, Sensorial alterations, the hypoactive presentation, its fluctuating nature the lack of formal cognitive assessment as part of routine screening across care settings, ageist attitudes toward older people with an expectation of confusion. In hospice the moaning, groaning, and grimacing that often accompany delirium in the last few days of life may lead to its missed diagnosis and may instead be interpreted as physical pain. American Journal of Hospice & Palliative Medicine 28(1) 44-51ª The Author(s) 2011 1
The American Psychiatric Association's Diagnostic and Statistical Manual, 5th edition criteria for DELIRIUM Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness. The disturbance develops over a short period of time (usually hours to days), represents a change from baseline, and tends to fluctuate during the course of the day. An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception) The disturbances are not better explained by another preexisting, evolving or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma Diagnosis cont.. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect. Additional features that may accompany delirium and confusion include the following: Psychomotor behavioral disturbances such as hypoactivity, hyperactivity with increased sympathetic activity, and impairment in sleep duration and architecture. Variable emotional disturbances, including fear, depression, euphoria, or perplexity Linking level of consciousness and Delirium Surveillance CAM-ICU flowsheet Sensitivity: 94-100%, Specificity: 90-95% Inouye SK et al. Ann Intern Med. 1990; 113: 941-948 Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved Copyright 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved Delirium versus Dementia Condition Time Course Distinguishing Features Delirium Acute onset, lasting days to weeks (though could be longer) Impaired attention Altered level of consciousness Dementia Progressive worsening, permanent Unimpaired attention and level of consciousness until severe stages However, there are features that are common in both: Disorientation Sleep-wake cycle reversal Memory impairment Hallucinations 11 Assume it is Delirium until Proven Otherwise Delirium may be the only manifestation of lifethreatening illness in the elderly patient It is a medical emergency! 12 2
Predisposing factors or vulnerability Vulnerability A model for Delirium Precipitating factors or insults Noxious Insult A model for Delirium continued VULNERABILITY Age 75+ (RR= 3.3-6.6) Dementia (RR= 2.3-4.7) Prior delirium (RR= 3.0) Functional impairment (RR= 2.5-4.0) Visual impairment (RR= 1.1-3.5) Hearing impairment (RR= 1.3) Depression (RR= 1.2-3.2) Prior TIA or CVA (RR= 1.60) Alcohol misuse (RR= 1.4-5.7) NOXIOUS INSULTS Medications (sedatives/psychoactives) (RR= 2.9-4.5) Indwelling bladder catheters (RR= 2.4), or physical restraints (RR= 3.2-4.4) Fluid/electrolyte abnormalities (RR =3.4) Infections (RR = 3.1) Surgery admission (RR = 3.5-8.3) Trauma admission(rr= 3.4) Urinary retention and fecal impaction, uncontrolled pain, interrupted sleep, noise, etc. ETOH/drug withdrawal Hospital Elder Life Program Risk Factor Intervention Orientation protocol, cognitively stimulating Cognitive impairment Outcome Intervention Control activities 3x/day 1 st delirium Non-pharmacologic protocol, noise reduction, Sleep deprivation 9.9% 15% schedule OR= adjustments 0.39-0.92 episode Ambulation or active ROM exercises; minimize Total delirium Immobility 105 161 equipment P=0.02 days Glasses or magnifying lens, adaptive # delirium Visual impairment 62 90 equipment P=0.03 episodes Hearing impairment Dehydration Portable amplifying devices, earwax disimpaction Early recognition and volume repletion Prevention is Key Current evidence does not support the use of antipsychotics for prevention or treatment of delirium 7 studies antipsychotics with placebo or no treatment for delirium prevention after surgery: (OR = 0.56, 95% CI = 0.23 1.34). 19 studies antipsychotic use was not associated with change in delirium duration, severity, or hospital or ICU LOS, with high heterogeneity among studies. No association with mortality was detected (OR = 0.90, 95% CI = 0.62 1.29). Doing Harm in Delirium. Lancet Psychiatry 2014; 1: 312-5 Inouye SK et al. NEJM. 1999;340:669-76 Antipsychotics in the prevention and treatment of delirium in hospitalized older adults: and systematic review and meta-analysisi. J Am GeriatrSoc 64:705 714, 2016. Older Patient on Admission Treat symptoms of delirium Assess for vulnerability for delirium High risk for delirium Implement multicomponent prevention strategies Identify & treat noxious insults History, physical Examination, medication review, basic labs, targeted infection screen. If not identified TSH, vitamin B12, HIV, CT head, Chest xr, EKG, etc. Assess baseline cognitive function Screen frequently for DELIRIUM DELIRIUM confirmed Prevent Complications Prevent aspiration/protect airway, prevent pressure ulcers, DVT & UTI, ensure euvolemia, adequate nutrition, monitor for urinary retention & constipation Treat symptoms Determine severity & change overtime Modified from Delirium in Older persons. JAMA. Sept 2017 Non pharmacological multicomponent intervention Environmental modifications: Blinds open during the day/closed at night, reduce noise or white noise Early mobility/avoid restrains/remove lines and catheters as early as possible Family involvement, orientation, cognitive stimulation Ensure patient wears glasses and hearing aids while awake Sleep promotion protocols: avoid interruptions overnight, ear plugs, herbal tea, massage, etc. Pharmacological Management of sleep-awake cycle: Melatonin 3-5 mg po QHS or Ramelteon 8 mg po QHS Management of severe agitation: start with low dose of one of the drugs below, keep at steady dose for 2 days, then taper off: Risperidone 0.5-1 mg po qd or bid Olanzapine 2.5-5 mg po/im qd or bid Quetiapine 12.5-25 mg po QHS or bid Haloperidol 0.25-0.5 mg po/iv/im q4h Avoid benzodiazepines except in BDZ or ETOH withdrawal Modified from Delirium in Older persons. JAMA. Sept 2017 Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD05594) 3
Approach to the agitated patient Provide quiet environment (to improve hearing), minimize glare (improve vision), graduate room temperature to patients comfort. Keep the space tidy and clutter free (minimize distraction). Approach from the front (face-to-face), with a gentle voice (lower tone/pitch instead of yelling) and light touch Say what you are going to do before and while you do it Provide simple, one-step directions Ask simple, yes or no questions or questions with 2 choices. Verify the response. If needed use simple writing while you talk Give at least 10 seconds for a response- count silently Do not argue; Use positive statements Find the missing word Reminiscence therapy, folding cloths, painting, cards, etc. In summary A multifactorial syndrome: predisposing vulnerability and precipitating insults Delirium can be diagnosed with high sensitivity and specificity using the CAM Prevention should be our goal If delirium occurs, treat the underlying causes Always try non-pharmacologic approaches Use low dose antipsychotics in severe cases, use for short periods Modified from Helpful communication tips. Duke Speech Pathology and Audiology. 2010. Pathophysiology of Delirium Antipsychotics do not prevent Delirium Antipsychotics do not shorten Delirium Duration Antipsychotics do not reduce the severity of Delirium 4
Antipsychotics do not shorten LOS Antipsychotics (typical or atypical) do not improve survival 5