Delirium in the Older Adult Matt Russell,MD, MSc Assistant Professor of Medicine Boston University...
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Transcript of Delirium in the Older Adult Matt Russell,MD, MSc Assistant Professor of Medicine Boston University...
Delirium in the Older Adult
Matt Russell,MD, MSc
Assistant Professor of Medicine
Boston University School of Medicine
Slide show courtesy of Drs. Lisa Caruso and Serena Chao
Objectives
To elicit key features of and define delirium To review epidemiology, risk factors, and
precipitants of delirium To discuss management strategies around
delirium.
Case: 2pm Admission
Agnes D: 88 year old female ALF resident with history of Dementia( MMSE 21/30), HTN, CAD, hearing loss, history of GI bleed (diverticulosis), hyperlipidemia, and COPD presents with a 3 day history of progressive dyspnea, purulent sputum, and wheezing. Per nursing home flow sheet, oxygen saturation was in the low 80s% on room air. She is admitted with COPD exacerbation. At baseline, she is AAOx2. She is minimal assist with some ADLs (dressing and toileting) and ambulates independently.
Case continued
Agnes is admitted to the inpatient medical service. She is placed on 2 liters NC. Her other admission medications are as follows:
• ciprofloxacin, • Solumedrol IV, • Donepezil• Famotidine for GI prophylaxis • Advair 500/50• Spiriva • zolpidem prn• D5 ½ NS at 75 cc/hour
Case cont’d
Because of history of GI bleed, the team puts her on venodyne boots for DVT prophylaxis.
She is placed on telemetry and continuous oxygen saturation monitoring
The patient is settled in and the medical team goes home
Delirium = Syndrome
Definition: An acute disorder of attention and cognition; acute
confusional state
“Delta MS” or “Mental Status Changes” are vague, inappropriate terms and should not be used—CALL IT WHAT IT IS!
Next steps
Go to bedside and see patient Approach in comforting fashion-NOT
GUNS A BLAZIN’!! Obtain history of baseline mental status
from all available sources Perform bedside testing for delirium
screening
Recognition Delirium is unrecognized by physicians in
32-67% of cases in hospitalized patients Reasons for this include
lack of awareness of syndrome as important cognitive assessment not done misdiagnosed or not detected
Inouye SK. The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97:278-88.
Diagnosis: Confusion Assessment Method
(CAM)1. Acute change in
mental status with a fluctuating course
2. Inattention
AND
3. Disorganized thinking
OR4. Altered level of
consciousnessSensitivity > 94%; specificity > 90% ; gold standard used was ratings of psychiatrists
Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion. The Confusion Assessment Method: A new method for detection of delirium. Ann Intern Med 1990; 113:941-8.
Assume it is delirium until proven otherwise:
Delirium may be the only manifestation of a life-
threatening illness in the elderly patient.
Epidemiology
Complicates hospital stays for more than 2.3 million persons 65 years of age and older per year
Prevalence on admission to the hospital is 14-24%
Incidence of new cases arising during hospitalization is 6-56%
Independent predictor of mortality up to 1 year after occurrence; mortality in patients who develop delirium in the hospital is 25-33%
$$$
Etiology
Biology is poorly understood “The development of delirium involves
the interrelationship between a vulnerable patient and noxious insults.”1
1 Inouye SK. Delirium in older persons. NEJM 2006;354:1157-65.
Approaches to Clinical Problem Solving
“simpler explanations are, other things being equal, generally better than more complex ones"
Agnes’Delirium Map
Risks: Age Dementia Medical illnesses Hearing impairment- no hearing aids!!
Precipitants: Change in setting Hidden restraints (IV tubing, venodynes, oxygen) Medications (solumedrol, cipro, ambien,famotidine)
Interventions: Treat underlying process Eliminate restraints Maximize sensory input (hearing aids) Eliminate unnecessary and/or harmful meds: d/c famotidine and use PPI d/c ambien Additional Non-pharm: family presence, orient, remove overt and hidden restraints, soothing
tones, reassurance Pharm: haldol if necessary. Start low
Agnes’ case continued
Agnes’ daughter comes in to help settle her mother down. She asks to speak to the doctor…..
Management and Treatment
Treat medical illness, as possible Always try non-pharmacologic treatment
first don’t change room if possible encourage family visits….EDUCATE FAMILY
MEMBERS!! quiet room with low level lighting make sure patients have their glasses and hearing
aides limit IV’s, catheters, other restraints
Management and Treatment
Pharmacologic management indicated if the patient is endangering him- or
herself or others AVOID BENZODIAZEPINES except for
alcohol withdrawal (delirium tremens) mainstay is the antipsychotic, haloperidol
(Haldol); start with 0.5-1 mg, check vitals in 20 min, repeat dose as needed
olanzapine (Zyprexa) may be a useful alternative
How to distinguish Delirium from Dementia
Features seen in both: Disorientation Memory
impairment Paranoia Hallucinations Emotional lability Sleep-wake cycle
reversal
Key features of delirium: Acute onset Impaired attention Altered level of
consciousness
Slide courtesy of Serena Chao, MD
Management and Treatment
Haldol: advantages readily available PO, IM, IV quick onset of
action high therapeutic
index
Haldol: disadvantages
extrapyramidal SE
contraindicated in pts with Parkinson’s disease or parkinsonism
neuroleptic malignant syndrome
Conclusions
Identify risk factors
Implement prevention strategies
Recognize syndrome when occurs
Determine etiology and treat if possible
When in acute fevers, pneumonia, phrenitis, or headache, the hands are waved before the face, hunting through empty space, as if gathering bits of straw, picking the nap from the coverlet, or tearing chaff from the wall--all such symptoms are bad and deadly.
Hippocrates, [460-375 BC]
Some drug classes that are associated with delirium
Medications with psychoactive effects: 3.9-fold increased risk 2 or more meds: 4.5-fold
Sedative-hypnotics: 3.0 to 11.7-fold Narcotics: 2.5 to 2.7-fold Anticholinergic drugs: 4.5 to 11.7-fold
antihistamines (Benadryl, Atarax) antispasmodics (Lomotil) tricyclic antidepressants antiparkinsonian agents (Cogentin, Artane) antiarrhythmics (Quinidine, Norpace)
Etiology: Medications Cardiac (digoxin, lidocaine) Antihypertensives (beta-blockers, Aldomet) Miscellaneous
H2-blockers steroids metoclopramide lithium anticonvulsants NSAIDS
Evaluation Recognize syndrome History
establish patient’s cognitive and functional baseline
thorough medication review: drug toxicity may account for up to 30% of all cases of delirium
Evaluation Physical Exam
vital signs including O2 saturation search for signs of infection neurological exam include cognitive evaluation (ex. MMSE) other tests for attention
• forward digit span (able to repeat 5 digits forward)• months of the year or days of week backwards
Evaluation Individualized work-up Metabolic: CBC, electrolytes, BUN/Cr, glucose,
Ca2+, phosphate, LFT’s, magnesium. Consider also TSH, drug levels, tox screen, ammonia.
Infection: urine cx, CXR, blood cultures, consider LP
If no obvious cause, ABG, ECG, brain imaging, EEG
Prevention: It can be done!
Objective: To evaluate the effectiveness of a multicomponent strategy for the prevention of delirium
Design: Controlled clinical trial. Randomization not possible but pts meeting criteria admitted to intervention unit were prospectively matched by age, sex and base-line risk of delirium (meaning for number of risk factors).
Subjects: 852 patients >70 yrs old admitted to general medicine service at a teaching hospital
426 usual care, 426 intervention
Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.
Prevention: Modify Risk Factors
Intervention was standardized protocols to manage six risk factors for delirium
Risk factors targeted were: cognitive impairment, sleep deprivation, immobility, vision impairment, hearing impairment, dehydration
Intervention unit staffed by a trained team (geriatric nurse specialist, two specially trained Elder Life specialists, a certified therapeutic-recreation specialist, a physical therapy consultant, a geriatrician and trained volunteers.)
Outcomes: Delirium by Confusion Assessment Method, severity, recurrence
Prevention: Modify Risk Factors
OUTCOME
INTERVENTION(Experimental Event Rate)
USUAL CARE(Control Event Rate)
MATCHED Number Needed to Treat (NNT)(unmatched)
1ST episode of delirium (number of pts)
42 (9.9%) 64 (15%) OR,0.60 (95% CI 0.39-0.92);P=0.02
19.4 (10.4-134.2)
Total days of delirium
105 days 161 days P=0.02
Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.
Prevention: Modify Risk Factors
Intervention did not change the severity of the delirium episode.
Rates of recurrence of delirium did not differ in the two groups.
Adherence rates high; lowest in non-pharm sleep protocol at 71%.
Cost of intervention per case of delirium prevented was $6,341.
Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.
Risk FactorsRisk Factor Studies/Pts in
analysis (n/n)Combined Odds Ratio
(95% Confidence Interval)
P Value: Test of Homogeneity
Dementia 12/289 5.2 (4.2, 6.3) .01
Medical illness 4/3 3.8 (2.2, 6.6) .47
Medications (narcotics)
2/128 1.5 (0.9, 2.3) .096
Male gender 6/103 1.9 (1.4, 2.6) .32
Depression 5/78 1.9 (1.3, 2.6) .01
Alcohol 3/27 3.3 (1.9, 5.5) .90
Abnormal sodium
2/23 2.2 (1.3, 4.0) .03
Hearing impairment
3/122 1.9 (1.4, 2.6) .17
Visual impairment
3/112 1.7 (1.2, 2.3) .05
Diminished ADL 2/33 2.5 (1.4, 4.2) .60
Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. J Gen Intern Med. 1998;13:204-12.
Risk FactorsRisk Factor Studies/Pts in
analysis (n/n)Combined Odds Ratio
(95% Confidence Interval)
P Value: Test of Homogeneity
Dementia 12/289 5.2 (4.2, 6.3) .01
Medical illness 4/3 3.8 (2.2, 6.6) .47
Medications (narcotics)
2/128 1.5 (0.9, 2.3) .096
Male gender 6/103 1.9 (1.4, 2.6) .32
Depression 5/78 1.9 (1.3, 2.6) .01
Alcohol 3/27 3.3 (1.9, 5.5) .90
Abnormal sodium
2/23 2.2 (1.3, 4.0) .03
Hearing impairment
3/122 1.9 (1.4, 2.6) .17
Visual impairment
3/112 1.7 (1.2, 2.3) .05
Diminished ADL 2/33 2.5 (1.4, 4.2) .60
Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. J Gen Intern Med. 1998;13:204-12.
Etiology
1940’s: Cortical function on EEG characterized by abnormal slow-wave activity.
Exception: alcohol and sedative withdrawal showing predominately low-voltage, fast-wave activity
Subcortical structures important, also. Patients with subcortical strokes and basal
ganglia abnormalities are more susceptible to delirium.
EtiologyRole of Acetylcholine (Ach)
Neurotransmitter involved in multiple aspects of cognitive functioning including memory
Anticholinergic medications are frequent causes of delirium
Patients with Alzheimer’s disease are particularly susceptible
Serum anticholinergic activity (SACA) is increased in older pts with delirium and in postoperative delirium
Some evidence that certain patients with delirium improve with administration of acetylcholinesterase inhibitors, such as physostigmine and donepezil