Delirium in the ElderlyDelirium in the Elderly

M. Andrew Greganti, MDM. Andrew Greganti, MD

March 19, 2009March 19, 2009

Outline of DiscussionOutline of Discussion

Case PresentationCase PresentationDistinguishing characteristicsDistinguishing characteristics Prevalence Prevalence Etiology/Pathogenesis/Risk FactorsEtiology/Pathogenesis/Risk FactorsProdromeProdrome Clinical PresentationClinical PresentationDiagnosis/Evaluation Diagnosis/Evaluation Prognostic ImplicationsPrognostic ImplicationsPrevention and TreatmentPrevention and Treatment

Case PresentationCase Presentation

86 yo woman presents with confusion post 86 yo woman presents with confusion post hip fracture surgery. hip fracture surgery.

Medical ProblemsMedical Problems::– HypertensionHypertension– CHF - compensated CHF - compensated – Sick sinus syndrome S/P pacemakerSick sinus syndrome S/P pacemaker– Chronic atrial fibrillationChronic atrial fibrillation– Chronic anxiety about health Chronic anxiety about health

Case PresentationCase Presentation

Long-term resident of life care community Long-term resident of life care community living in an intermediate care facilityliving in an intermediate care facility

Severe anxiety with tendency to obscess Severe anxiety with tendency to obscess over health issues over health issues – Increasing anxiety level recentlyIncreasing anxiety level recently

Less intellectually “sharp” over previous 6 Less intellectually “sharp” over previous 6 monthsmonths

Hospital CourseHospital Course

In the ED could not understand that she In the ED could not understand that she had broken her hiphad broken her hip

No immediate perioperative complications No immediate perioperative complications

Postop day 2Postop day 2: Confused, agitated, waxing : Confused, agitated, waxing and waning of sensoriumand waning of sensorium– Difficulty recognizing familyDifficulty recognizing family– Misinterpreted environmental stimuliMisinterpreted environmental stimuli– ““Sundowning” requiring a sitterSundowning” requiring a sitter

Hospital CourseHospital Course

Hypoxia secondary to aspirationHypoxia secondary to aspiration

Improved post antibioticsImproved post antibiotics

Confusion and difficulty understanding Confusion and difficulty understanding directions - effective PT impossibledirections - effective PT impossible

Poor hearing exacerbated confusion.Poor hearing exacerbated confusion.

Hospital CourseHospital Course

After 10 days, cognition improved but not After 10 days, cognition improved but not back to baselineback to baseline

Discharged to skilled nursing floor of her Discharged to skilled nursing floor of her life care community with persisting:life care community with persisting:– Confusion Confusion – DisorientationDisorientation– Severe anxietySevere anxiety– Poor recent memoryPoor recent memory

Post Hospital CoursePost Hospital Course

Fell 2 months post discharge, fracturing R ankleFell 2 months post discharge, fracturing R ankle– Severe delirium postop marked by episodic yelling outSevere delirium postop marked by episodic yelling out

Never returned to baselineNever returned to baseline:: – Intermittent confusion Intermittent confusion – Somnolence followed by agitation Somnolence followed by agitation – Repetitive vocalizationsRepetitive vocalizations

No response to re-orientation – partial response No response to re-orientation – partial response to clonazepam, then olanzapineto clonazepam, then olanzapine

Characteristics of DeliriumCharacteristics of Delirium

Disturbance of consciousnessDisturbance of consciousnessAbnormal attentionAbnormal attentionAbnormal cognitionAbnormal cognition– OrientationOrientation – MemoryMemory– Thought processingThought processing– Executive functionExecutive function– PerceptionPerception

Acute in onset and fluctuating in courseAcute in onset and fluctuating in coursePrecipitated by acute medical illness, medication, or Precipitated by acute medical illness, medication, or substance intoxicationsubstance intoxicationHyperactive, hypoactive, and mixed formsHyperactive, hypoactive, and mixed forms

Other CharacteristicsOther Characteristics

Misdiagnosis is frequentMisdiagnosis is frequent – unrecognized in – unrecognized in up to 70%up to 70%

May develop over hours to days. May develop over hours to days. – Abrupt onset more common.Abrupt onset more common.– The line between dementia and delirium is The line between dementia and delirium is

often unclear.often unclear.

How common is delirium?How common is delirium?

On admission to medical wards, 15 to 20% On admission to medical wards, 15 to 20% of older patients meet criteria for deliriumof older patients meet criteria for delirium..– Incidence during medical hospitalization:Incidence during medical hospitalization: 5 to 5 to

10% - in some studies 30%.10% - in some studies 30%.– Prevalence higher in surgical patients:Prevalence higher in surgical patients:

10 to 15% post general surgery 10 to 15% post general surgery 30% post cardiac surgery30% post cardiac surgery50% post hip fracture50% post hip fracture

Very common in terminally ill patients – Very common in terminally ill patients – 90%90%

Etiology Etiology

Etiology -Etiology - Multifactorial in a patient Multifactorial in a patient predisposed by underlying dementia:predisposed by underlying dementia:– InfectionsInfections– Toxins, including drugsToxins, including drugs– Substance withdrawalSubstance withdrawal– Organ failure: heart, liver, kidney, etc.Organ failure: heart, liver, kidney, etc.– Metabolic derangementsMetabolic derangements– Primary brain disordersPrimary brain disorders

PathogenesisPathogenesis

No specific structural brain lesion identified No specific structural brain lesion identified but subcortical and cortical dysfunctionbut subcortical and cortical dysfunction

Changes in perfusion pressureChanges in perfusion pressure

Depleted acetylcholineDepleted acetylcholine

Dopamine excessDopamine excess

Dopamine, GABA, serotonin, acetylcholine Dopamine, GABA, serotonin, acetylcholine imbalanceimbalance

Cytokine activationCytokine activation

Risk FactorsRisk Factors

Dementia: the strongest risk factorDementia: the strongest risk factor – 25 to 75% – 25 to 75%

Other predisposing brain diseases:Other predisposing brain diseases: stroke, stroke, Parkinson’sParkinson’s

Advanced ageAdvanced age

Severe medical illnessSevere medical illness

Metabolic disturbancesMetabolic disturbances: Hyponatremia, : Hyponatremia, dehydrationdehydration

Drugs:Drugs: anticholinergics,anticholinergics, sedative hypnotics, sedative hypnotics, narcoticsnarcotics

Other Risk FactorsOther Risk Factors

Immobility, low activity levelImmobility, low activity level

Hearing or vision impairmentHearing or vision impairment

Number of hospital room changesNumber of hospital room changes

Environmental high noise levelEnvironmental high noise level

ProdromeProdrome

Patients may describe and/or manifestPatients may describe and/or manifest::– Decreased concentrationDecreased concentration– Irritability, restlessness, anxiety, depressionIrritability, restlessness, anxiety, depression– Hypersensitivity to light and soundHypersensitivity to light and sound– Perceptual disturbancesPerceptual disturbances– Sleep disturbance - daytime somnolence and Sleep disturbance - daytime somnolence and

nocturnal agitationnocturnal agitation

Clinical PresentationClinical Presentation

DisorientationDisorientation to place, time, situation to place, time, situation

Impaired consciousnessImpaired consciousness– Reduced awarenessReduced awareness– Reduced or clouded consciousness with or Reduced or clouded consciousness with or

without overt hallucinationswithout overt hallucinations

Clinical PresentationClinical Presentation

Decreased ability to focus, sustain, or shift Decreased ability to focus, sustain, or shift attention attention – Decreased selective attentionDecreased selective attention– DistractibilityDistractibility

Cognition is made worse by inattention.Cognition is made worse by inattention.Speech: Speech: – Tangential Tangential – Poorly organizedPoorly organized– Slowed, slurred Slowed, slurred – Word finding difficulties: dysnomia, paraphasia, Word finding difficulties: dysnomia, paraphasia,

aphasiaaphasia

Clinical PresentationClinical Presentation

Impaired registration, recent/remote Impaired registration, recent/remote memorymemory with associated confabulation with associated confabulation

Perceptual abnormalities:Perceptual abnormalities: – MicropsiaMicropsia– Macropsia Macropsia – Frank auditory or visual hallucinationsFrank auditory or visual hallucinations, ,

distortion of body imagedistortion of body image– May take action in response to hallucinationsMay take action in response to hallucinations

DiagnosisDiagnosis

History from family and/or caregiversHistory from family and/or caregiversBedside observationsBedside observationsDiagnostic errors are common inDiagnostic errors are common in: : – Hypoactive form Hypoactive form – The setting of rapid fluctuations of cognition. The setting of rapid fluctuations of cognition.

Those with the patient the entire day Those with the patient the entire day (nurses) or less likely to be deceived.(nurses) or less likely to be deceived.Reliable diagnostic instrumentsReliable diagnostic instruments– Confusion Assessment Method (CAM)Confusion Assessment Method (CAM)

Confusion Assessment MethodConfusion Assessment Method

Are these features present?Are these features present?– Acute onset and fluctuating courseAcute onset and fluctuating course– Inattention, distractibilityInattention, distractibility– Disorganized thinking, illogical or unclear Disorganized thinking, illogical or unclear

ideasideas– Alteration in consciousnessAlteration in consciousness

Differential DiagnosisDifferential Diagnosis

DementiaDementia– Alzheimer dementiaAlzheimer dementia– Lewy body dementiaLewy body dementia

Delusional psychosisDelusional psychosis– Psychosis is associated with normal attention, Psychosis is associated with normal attention,

orientation, and sleep/wake cycleorientation, and sleep/wake cycle– Schizophrenia has a more chronic hx with highly Schizophrenia has a more chronic hx with highly

systematized delusions.systematized delusions.

Depression and ManiaDepression and Mania– Misdiagnosed as depression in as many as 40% of Misdiagnosed as depression in as many as 40% of

cases cases

EvaluationEvaluation

Search for causative medicationSearch for causative medication is is especially important – up to 40% of cases.especially important – up to 40% of cases.– Psychotropics, narcotics, anticholinergicsPsychotropics, narcotics, anticholinergics– Digoxin, prednisone, furosemide, cimetidine Digoxin, prednisone, furosemide, cimetidine

have anticholinergic properties.have anticholinergic properties.

EvaluationEvaluation

CBC, electrolytes, BUN, Cr, glucose, LFTsCBC, electrolytes, BUN, Cr, glucose, LFTsO2 SaturationO2 SaturationUrinalysisUrinalysisTSH, B12TSH, B12Toxin screenToxin screenCXRCXRCNS imaging CNS imaging LP in febrile patient with meningeal signsLP in febrile patient with meningeal signsCause not identified in 15 to 25%Cause not identified in 15 to 25%

PrognosisPrognosis

Delirium is independently associated with:Delirium is independently associated with:– Increased functional disability Increased functional disability – Increased LOS Increased LOS – Admission to long-term careAdmission to long-term care

Hospital mortality of 22 to 76% - one year mortality of 35 Hospital mortality of 22 to 76% - one year mortality of 35 to 40%to 40% – Highest in the hypoactive subtypeHighest in the hypoactive subtype

May persist for months or indefinitely – more likely in May persist for months or indefinitely – more likely in dementiadementiaTwo factors related to better outcomes:Two factors related to better outcomes:– Admission from homeAdmission from home– Better premorbid functioning Better premorbid functioning

Preventive MeasuresPreventive Measures

Supportive overall approach with constant Supportive overall approach with constant reorientationreorientationEffective management of anxietyEffective management of anxietyEffective management of painEffective management of painEarly mobilizationEarly mobilizationFocus on assuring optimal vision and Focus on assuring optimal vision and hearing.hearing.Haloperidol and donepezil prophylaxis not Haloperidol and donepezil prophylaxis not effectiveeffective

TreatmentTreatment

Recognize and treat the prodromal stageRecognize and treat the prodromal stage

Focus on re-orientation – bedside sitterFocus on re-orientation – bedside sitter

Reduce or discontinue psychotropic, Reduce or discontinue psychotropic, anticholinergic, sedative, and narcotic anticholinergic, sedative, and narcotic meds.meds.

Optimize nutrition. Optimize nutrition.

Physical therapy to increase mobilityPhysical therapy to increase mobility

TreatmentTreatment

Nonpharmacologic measuresNonpharmacologic measures::– Increase interpersonal contact and Increase interpersonal contact and

environmental support. environmental support. ? use of around the clock sitters? use of around the clock sitters

– Provide clocks, calendars, soft lighting.Provide clocks, calendars, soft lighting.– Place family pictures in clear view.Place family pictures in clear view.– Reduce noise levels.Reduce noise levels.– Maximize visual and auditory acuity.Maximize visual and auditory acuity.– Minimize room changes in the hospital.Minimize room changes in the hospital.

TreatmentTreatment

Use medications only as a last resort:Use medications only as a last resort:– AntipsychoticsAntipsychotics:: haloperidol haloperidol – Atypical antipsychoticsAtypical antipsychotics: risperidone, : risperidone,

aripiprazole, ziprasidone, quetiapine, aripiprazole, ziprasidone, quetiapine, olanzapineolanzapine

– Benzodiazepines - lorazepamBenzodiazepines - lorazepam

TreatmentTreatment

Future therapiesFuture therapies::– Cholinergic drugs:Cholinergic drugs: donepezil, rivastigmine, donepezil, rivastigmine,

physostigminephysostigmine– Selective dopamine antagonistsSelective dopamine antagonists– Benzodiazepine receptor (GABA) antagonistsBenzodiazepine receptor (GABA) antagonists– Antiplatelet and anti-inflammatory agentsAntiplatelet and anti-inflammatory agents

Summary of Key PointsSummary of Key Points

Delirium is an Delirium is an acute or subacute change in acute or subacute change in mental statusmental status marked by a waxing and waning marked by a waxing and waning course.course.The The etiology is multifactorialetiology is multifactorial superimposed on superimposed on dementia and precipitated by acute medical dementia and precipitated by acute medical illness.illness.Risk factorsRisk factors include age, drug Rx, and metabolic include age, drug Rx, and metabolic derangements.derangements.It is associated with increased LOS, It is associated with increased LOS, institutionalization, and institutionalization, and increased mortalityincreased mortality..

Summary of Key PointsSummary of Key Points

EvaluationEvaluation should focus on ruling out should focus on ruling out infection, medication toxicity, neurological infection, medication toxicity, neurological events, metabolic abnormalities, and new events, metabolic abnormalities, and new cardiorespiratory problems.cardiorespiratory problems.

Prevention is the best therapyPrevention is the best therapy – focus on – focus on interpersonal and environmental support.interpersonal and environmental support.

Use medications as a last resort.Use medications as a last resort.