DeliriumDelirium

Ashley Duckett, MDAshley Duckett, MD

Pamela Pride, MDPamela Pride, MD

Medical University of South CarolinaMedical University of South Carolina

20122012

CAM Definition of CAM Definition of DeliriumDeliriumAcute onset or fluctuating courseAcute onset or fluctuating course

ANDANDInattention (decreased ability to focus, shift Inattention (decreased ability to focus, shift

or sustain attention)or sustain attention)PLUS EITHERPLUS EITHER

Disorganized thinking (incoherent or Disorganized thinking (incoherent or illogical speech (illogical speech (questions – does a stone float on questions – does a stone float on water, etc)water, etc)

ORORAltered Level of Consiousness (anything Altered Level of Consiousness (anything

other than alert and calm) – RASS other other than alert and calm) – RASS other than 0than 0

Confusion Assessment Method- Inouye, Ann Intern Med 1990

-INATTTENTION is the cardinal feature for diagnosis-INATTTENTION is the cardinal feature for diagnosis-Can use serial 7’s, WORLD, reciting days or months -Can use serial 7’s, WORLD, reciting days or months in reverse, etc; ICU uses letter test (SAVEAHAART)in reverse, etc; ICU uses letter test (SAVEAHAART)

-SUBTYPES -SUBTYPES -Hyperactive – agitated, hyperalert-Hyperactive – agitated, hyperalert-Hypoactive – calm and confused, lethargic-Hypoactive – calm and confused, lethargic-Mixed – features of both-Mixed – features of both

*no difference in etiology or outcomes among the *no difference in etiology or outcomes among the subtypessubtypes

*hypoactive pts commonly missed without formal screen*hypoactive pts commonly missed without formal screen

The 3 D’sDepression - Dementia - Delirium

Delirium Dementia Depression

Onset Abrupt Slow, insidious Recent, may be associated with loss

Duration Hours to days Months to years Stable, may be worse in the morning

Attention Impaired Normal, except severe cases Usually normal

Consciousness Reduced, fluctuating

Clear Clear

Silverstein & Maslow, 2006

Why do we care?Why do we care?

VERY common (esp if older, had VERY common (esp if older, had ICU stay) although underdetectedICU stay) although underdetected

Increased morbidity and mortalityIncreased morbidity and mortality– Higher risk for falls, decubs, pnaHigher risk for falls, decubs, pna– Higher risk of functional decline and Higher risk of functional decline and

institutional careinstitutional care– Longer LOSLonger LOS– Predictor of 12 mo mortalityPredictor of 12 mo mortality

Risk factors Risk factors (far from an exhaustive (far from an exhaustive

list)list)

Age >70Age >70 Dementia or underlying brain Dementia or underlying brain

dysfunctiondysfunction Alcohol abuseAlcohol abuse Hearing or visual impairmentHearing or visual impairment History of deliriumHistory of delirium

Inouye et al, Multicomponent Intervention of Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76)

Modifiable risk factorsModifiable risk factors

Medications Medications Polypharmacy (>3 new inpt meds)Polypharmacy (>3 new inpt meds) Physical restraints and catheters Physical restraints and catheters Sleep deprivation Sleep deprivation ImmobilityImmobility Uncontrolled painUncontrolled pain Medical illness (organ failure, Medical illness (organ failure,

electrolytes, etc)electrolytes, etc)

Antiparkinson drugs Corticosteroids UI drugs Theophylline Emptying drugs (motility

drugs) Cardiovascular Drugs H2 blockers Antimicrobials NSAIDs Geropsychiatric drugs ENT drugs

Insomnia drugs Narcotics

Muscle relaxants Seizures Drugs

Look to these medications if there is

an ACUTE CHANGE IN MS

http://www.geronurseonline.org; Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): 101-27.

Mini-Cog

Recall 0 Recall 1-2 Recall 3

Abnormal Clock Normal Clock

Impaired

Not ImpairedImpaired

Not Impaired

Borson S et al. (2000), Int J Geriatr Psychiatry 15(11):1021-1027

Serial administration of a modified RASS for Serial administration of a modified RASS for delirium screeningdelirium screening

Chester, JG et al. J Hosp Med 2012 May-June 7 (5) 450-3.

EvaluationEvaluation

Vital signs, pulse ox, volume statusVital signs, pulse ox, volume status Focused exam including determining Focused exam including determining

baseline cognition, urine output, last BMbaseline cognition, urine output, last BM Blood glucoseBlood glucose Review medicationsReview medications Consider withdrawal as a causeConsider withdrawal as a cause Testing – CBC, BMP, UA, CXR, EKGTesting – CBC, BMP, UA, CXR, EKG Additional testing if clinically indicatedAdditional testing if clinically indicated

ManagementManagement

Try to identify underlying causeTry to identify underlying cause Prevent complications and provide Prevent complications and provide

supportive caresupportive care– Avoid bed rest, catheters, mobilize Avoid bed rest, catheters, mobilize

patientpatient– Sleep at night, awake during daySleep at night, awake during day– Monitor nutrition status and outputMonitor nutrition status and output– Consider aspiration precautionsConsider aspiration precautions– Enlist the help of familyEnlist the help of family

ManagementManagement

Antipsychotics are drug of choice for Antipsychotics are drug of choice for treating agitationtreating agitation– Can consider treating hypoactive delirium to Can consider treating hypoactive delirium to

treat subjective stress (paranoia, treat subjective stress (paranoia, hallucinations)hallucinations)

Haldol – cheap, can be given PO, IV, IMHaldol – cheap, can be given PO, IV, IM– CAN’T be used in Parkinson’s, Lewy body CAN’T be used in Parkinson’s, Lewy body

dementia, prolonged QTdementia, prolonged QT DON’T USE BENZOs UNLESS YOU’RE DON’T USE BENZOs UNLESS YOU’RE

TREATING WITHDRAWAL or NMS!!!TREATING WITHDRAWAL or NMS!!!

What’s the evidence?What’s the evidence?

Best drug? Haldol v Atypicals Best drug? Haldol v Atypicals ((Risperidone, Olanzipine, Quetipine)Risperidone, Olanzipine, Quetipine)

– Systematic reviews show similar efficacy, Systematic reviews show similar efficacy, question of fewer side effects question of fewer side effects

– NEED larger and better studies NEED larger and better studies

2005 FDA warning re risk of death 2005 FDA warning re risk of death – Use for shortest duration, with cautionUse for shortest duration, with caution– NEED larger and better studiesNEED larger and better studies

Haldol and EKGs?Haldol and EKGs?

Concern for prolonged QTc and Concern for prolonged QTc and torsades or polymorphic VTtorsades or polymorphic VT

Review showed that most conduction Review showed that most conduction disturbances involve heart disease and disturbances involve heart disease and high doses (50mg/24 hrs) high doses (50mg/24 hrs)

More recent review – heart dz, >65, More recent review – heart dz, >65, female, hypokalemiafemale, hypokalemia

Stop if QTc>500Stop if QTc>500 Don’t wait to give Haldol until after Don’t wait to give Haldol until after

EKGEKGLawrence, Pharmacotherapy 1997; 17(3);531-537

Screening InpatientsScreening Inpatients

Delirium task forceDelirium task force Goal should be prevention; cutting Goal should be prevention; cutting

back on physical restraints back on physical restraints Nurses will screen each shift with Nurses will screen each shift with

RASSRASS Delirium protocol - order set with Delirium protocol - order set with

suggested workup and drug dosing suggested workup and drug dosing based on patient factorsbased on patient factors

ReferencesReferences DSM-IV TR, 2000DSM-IV TR, 2000

Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76)Older Patients, NEJM; 1999 (340) 9:669-76)

Borson S et al. (2000), Borson S et al. (2000), The mini-cog: a cognitive 'vital signs' measure for The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry Int J Geriatr Psychiatry 15(11):1021-102715(11):1021-1027

Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): 101-27.Geriatric Medicine, 14(1): 101-27.

http://www.geronurseonline.orghttp://www.geronurseonline.org Lawrence, Conduction Disturbances Associated with Administration of Lawrence, Conduction Disturbances Associated with Administration of

Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Pharmacotherapy 1997; 17(3);531-537Pharmacotherapy 1997; 17(3);531-537

Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): 687-93Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): 687-93

Delirium. Updates in Hospital Medicine 2012. Harvard Medical SchoolDelirium. Updates in Hospital Medicine 2012. Harvard Medical School Antipsychotics for delirium. Cochrane reviewAntipsychotics for delirium. Cochrane review