Delirium in the hospital

Susan Cox, DOChief ResidentJuly 2014Delirium GoalsUnderstand the different presentations of deliriumKnow the most common causes of delirium in the hospitalLearn a diagnostic approach to the delirious patientObtain skills to minimize and manage delirium in your patientsCase 1Any elderly woman is admitted for sepsis secondary to UTI. At baseline she has mild dementia, but is pleasant and functional. Yesterday she was doing well. Today, hospital day #4, she is talking to herself, and it is difficult to understand what she is saying. She is anxious, yelling at you, and repeatedly pulling at her clothes. She argues with the nursing staff and refuses blood draws.What is this patient displaying?DeliriumPsychosisDementiaDepression with psychotic features

What is this patient displaying?DeliriumPsychosisDementiaDepression with psychotic features

Delirium: DSM 5Disturbance in attention or cognitionAcute onsetChange from baselineFluctuating severityNot fully explainable by chronic psychiatric disorderLevel of impairment does not occur in the context of coma6Delirium: Confusion Assessment Method (CAM)1. Acute Onset and Fluctuating Course2. Inattention

3. Disorganized thinking4. Altered Level of consciousness

To diagnose delirium by CAM you need 1 and 2 with either 3 or 4.

EpidemiologyDelirium complicates at least 25% of all hospitalizations in the elderlyFong et al 2009Prevalence of delirium8Consequences12 month mortality post-dischargeMcCusker et al 2002Hospital length of stay (days)McCusker et al 2003In ONE THIRD of patients, it will take >8 weeks for delirium to completely resolveDelirium can initiate a cascade of events that lead to functional decline, loss of independence and deathCase 2An elderly man is on your team for a hip fracture. Previously he was independent and active. He is POD #1 s/p ORIF and you have not heard any calls from the RN overnight. On your morning rounds, he is sleepy and falls asleep as you talk to him. You return to his room at 2:00 PM and he is napping again. He missed his breakfast and lunch because he was asleep. He has not used any of his prn medications.What is this patient displaying?DepressionStatus epilepticusDeliriumHes just tiredWhat is this patient displaying?DepressionStatus epilepticusDeliriumHes just tiredTypes of deliriumHyperactiveRestlessness, agitation, hallucinations, delusionsHypoactiveLethargy, sedation, responds slowly, little spontaneous movementMixedComponents of bothMore than half of elderly patients with delirium present with hypoactive or mixed type

Which ones do you get called about?Fong et alIts up to you!You must have a high index of suspicion for delirium in your elderly patientsRemember, 25-80% of your patients will suffer from this depending on your location in the hospitalMost of the time they will just appear sleepy and the RN wont call you about itDo not normalize lethargy

Delirium predicts your patients mortalityDelirium is a SYMPTOMThat means you must recognize it and decide what is causing it NOT just treat it

What are some of the causes of delirium in the hospital?Causes of deliriumYour patient brings along his/her own non-modifiable risk factorsAdd an acute illnessAdd the stressful hospital environmentAdd medication side effects

Patient risk factorsCase 3 Whats going on?An 86 year old man presents to the ER brought in by his son because he is not responding appropriately for the last day. He is inattentive and wont follow commands. He keeps asking for his wife; she died 15 years ago.On exam he appears frail and he has a hearing aid.His son doesnt know his medications, but knows he takes 15 pills daily.You dont have any labs back yet.What is the cause of his delirium?WBC 15, Hgb 19, Plt 300k. 80% N, 10% BandsSodium 153, K 4.3, Cl 105, CO2 15, BUN 30, Crt 1.9LFTs and coags normal

Lactate 6UA 1.022 pH 5, 30WBC +nitrite +LE

Delirium in this patientElderlyFrailPolypharmacyHypernatremiaSevere sepsis secondary to UTICase 4 Whats going on?You are the medicine inpatient consultant for the surgical teamsYou receive a consult from orthopedics for MS a 70 year old female admitted for ankle fracture, POD #2 s/p ORIF is now disoriented, climbing out of bed and pulling off her splint.

What is the cause of her delirium?Her medications are:Metoprolol 25mg PO BIDLisinopril 10mg PO QdayLasix 10mg PO dailyOxybutynin 5mg PO dailyAtivan 0.5mg IVP Q2 prn agitationBenadryl 25mg PO QHS prn insomina

You see this on physical exam22Delirium in this patient>65 years oldPost-opPolypharmacyAnticholinergic drugsBenadrylScopolamine patchOxybutyninSedative hypnoticsAtivan

Causes of delirium - organizingCategoriesAcronymCauses of delirium25Causes of delirium26Causes of deliriumCauses of deliriumD DrugsE Eyes, earsL Low oxygen states (hypoxia, MI, stroke)I InfectionR Retention of urine or stoolI IctalU Underhydration, undernutrition (hypoglycemia, thiamine deficiency)M MetabolicUncovering the responsible illnessThere are dozens of causes of delirium!

How do you approach a patient with delirium?Recognize/identify itFind the etiologyTreat the central causeManage patient symptoms

Case 5You are the medicine night float. It is 3:00 AM. You are covering 60 patients tonight. You get a page from the med/surg RN. She says, Doctor, Mr. Johnson is getting agitated again. Hes trying to pull out his foley. Can we get a prn ativan?

What do you do?Uncovering the responsible illnessHistory: Evaluate for: recent febrile illness, organ failure, detailed medication list, alcohol or drug abuseCase 5You review your signout80 year old male, diabetic, nursing home resident here for decompensated heart failure and AKI, diuresing. HD day #4. He has been NPO because of an ileus, not on any fluids because of volume overload. His last labs were drawn 48 hours ago.Meds: Lasix 40mg IV BID, Coreg 6.25mg PO BID, Lisinopril 20mg PO daily, Lantus 10 units QHS, Heparin 5000units SQ BID

What are you thinking?Now what?Uncovering the responsible illnessHistory: Evaluate for: recent febrile illness, organ failure, detailed medication list, alcohol or drug abusePhysical Exam: Vitals, volume status, infection, hyperventilationJaundice, breath (smell of alcohol, ketones), tongue biting, retinal hemorrhages, asterixis, myoclonus, nystagmusCase 538C, HR 99, BP 105/70, RR 22, O2 90% RAHe is tachypneic, agitated, pulling at his foleyJVD to jawCrackles at bases2+ edemaHe has only diuresed 2 L since admission despite aggressive lasix

What are you thinking?Now what?Case 5What is on your differential diagnosis?HypoxiaHypoglycemiaInfection / sepsisUremiaHyponatremiaArrhythmiasHeart failure

Uncovering the responsible illnessAccucheckABGCXRCBCCMPUA, urine cultureBlood culturesEKG / cardiac enzymesUtoxAmmoniaDrug levels (lithium, digoxin)Lumbar punctureHead CT

Case 5

pH7.37pCO2 33pO2 55 on 4L NC

Blood glucose 122Uncovering the responsible illnessTHE KEY POINTS:You must find out WHY the change occurredYou then can address the primary issue and manage symptoms

NUMBER ONEIs the change in mental status acutely life threatening?Life threatening causes

UpToDateLife threatening causesHypoxia & HypoglycemiaBedside testingReverse with treatmentSepsisMay present with fever or hypothermiaLook for SIRS criteriaHypertensive EncephalopathyDiagnosis of exclusionReduce blood pressure appropriatelyLife threatening causesWernickes EncephalopathyUncommonAlcoholic or malnutritioned patientsTx: empirically with Thiamine (high dose, more than what is inside a banana bag)Drug overdose (opiates, benzos, etc.)Remember ABCPoison control or medical toxicology for help

Life threatening causesAcute neurologic disordersMeningitis and subarachnoid hemorrhageConfusion, headache, or feverAcute or delayed CNS traumaSubdural hematomaSeizuresPostictal stateSome seizures may present without convulsions and persistent confusion (status epilepticus)Diagnostic approachDELIRIUMAdequate Oxygen and Blood GlucoseFever or other signs of infections?Correct as neededDetermine causeYESNO43Diagnostic approachFever or other signs of infection?Do history and physical exam suggest likely cause of altered behavior?Search for sourcePursue likely causeDiagnosis UncertainYESYESNONODiagnostic approachDiagnosis UncertainBasic Testing:CBC, Electrolytes, UA, ECG, CXRAdvanced testing or consulting as need:ABG, EEG, head CT, tox screen, drug levels, consultsCase 5Doctor, Mr. Johnson is awaiting his ICU bed. He is still pulling at his foley. What do you want to order?Preventing ComplicationsProtect Airway prevent aspirationIf applicable, maintain volume with IVF if unable to take POMaintain nutritionPrevent pressure sores with frequent mobilizationMinimize unnecessary IVs, NG tubes, foley catheters, etc.Management of deliriumRemember, you have to identify the causeNon-pharmacologic therapies are the bestBedside sitterFamily involvementNormalize patients sleep/wake cycle uninterrupted sleep at nightMusic relaxationHearing/visual aidsLight during the day, dark at night (pull the blinds open!)Management of deliriumAvoid the following as much as possible:Physical restraintsPharmacological agents given increased risk for:FallsDeath

If nonpharmacologic methods failHaldol: 0.5 1 mg POProlongs QTExtrapyramidal symptoms (>3mg/day)IV has short duration AVOID IV USE

Seroquel: 12.5mg 25mg POProlongs QTExtrapyramidal symptoms

Dont use benzos unless it is for alcohol or benzo withdrawalAtypical and typical antipsychotics are not approved for dementia related psychosis due to increased risk of death (black box warning)

Clues in AssociationAltered mental status + DiabetesThink of oral hypoglycemics, get an accucheckAltered mental status + FeverThink meningitis/encephalitis/UTI/PNAAltered mental status + HypotensionThink sepsis or inferior MIAltered mental status + DyspneaThink hypoxia, pneumonia or MI/CHFAltered mental status + Hemiparesis or DysarthriaThink strokeAltered mental status + Failure to thriveThink metabolic derangements

A 75-year-old woman with a history of COPD is evaluated in the intensive care unit for delirium. She had a median sternotomy and repair of an aortic dissection and was extubated uneventfully on POD #4. Two days later she developed fluctuations in her mental status and inattention. While still in the intensive care unit, she became agitated, pulling at her lines, attempting to climb out of bed, and asking to leave the hospital. Her arterial blood gas values are normal. The patient has no history of alcohol abuse. The use of frequent orientation cues, calm reassurance, and presence of family members has done little to reduce the patient's agitated behavior.Q: Which of the following is the most appropriate therapy for this patient's delirium? A. DiphenhydramineB. HaloperidolC. LorazepamD. Propofol

A 75-year-old woman with a history of chronic obstructive pulmonary disease is evaluated in the intensive care unit for delirium. She had a median sternotomy and repair of an aortic dissection and was extubated uneventfully on postoperative day 4. Two days later she developed fluctuations in her mental status and inattention. While still in the intensive care unit, she became agitated, pulling at her lines, attempting to climb out of bed, and asking to leave the hospital. Her arterial blood gas values are normal. The patient has no history of alcohol abuse. The use of frequent orientation cues, calm reassurance, and presence of family members has done little to reduce the patient's agitated behavior.Q: Which of the following is the most appropriate therapy for this patient's delirium? A. DiphenhydramineB. HaloperidolC. LorazepamD. Propofol

ReferencesAlagiakrishnan, K. C.A. Wiens. An approach to drug induced delirium in the elderly. Postgrad Med J 80: 388-393. 2004.Fong, T.G. Delirium in elderly adults: diagnosis, prevention and treatment. Nat. Rev. Neurol. 5, 210-220. 2009.Huff, J.S. UpToDate: Evaluation of abnormal behavior in the emergency department. 2013.McCusker, J., M. Cole, N. Dendukuri, L. Han, E. Belzile. The course of delirium in older medial inpatients. J Gen Intern Med 18: 696-704. 2003.McCusker, J. M. Cole, M. Abrahamowicz, F. Primeau, E. Belzile. Delirium predicts 12-month mortality. Arch Intern Med 162:457-463. 2002.Medical Knowledge Self-Assessment Program (MKSAP 15).Schnieder, L.S., K.S. Dagerman, P. Insel. Risk of death with atypical antipsychotic drug treatment for dementia; meta-analysis of randomized placebo-controlled trials. JAMA 19: 1934-1943. 2005.Young, J and S.K. Inouye. Delirium in older people. BMJ. 334: 842-846. 2007.