Delirium Teaching Rounds “ Itching for a Fight!”

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Delirium Teaching Rounds “Itching for a Fight!”

November 4, 2011

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Objectives

• Identify risk factors and key presenting features of delirium

• Appreciate the role of different professions in recognition and management

• Identify medications that contribute to the development of delirium

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A BIG Problem

• Hospitalized patients over 65: – 10-40% Prevalence– 25-60% Incidence

• ICU: 70-87%• ER: 10-30%• Post-operative: 15-53%• Post-acute care: 60%• End-of-life: 83%

Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009.

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Costs of Delirium• In-hospital complications1,3

– UTI, falls, incontinence, LOS– Death

• Persistent delirium– Discharge and 6 mos.2 1/3• Long term mortality (22.7mo)4 HR=1.95• Institutionalization (14.6 mo)4 OR=2.41

– Long term loss of function• Incident dementia (4.1 yrs)4

OR=12.52• Excess of $2500 per hospitalization

1-O’Keeffe 1997; 2-McCusker 2003; 3-Siddiqi 2006; 4-Witlox 2010

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Clinical Features of Delirium

• Acute or subacute onset• Fluctuating intensity of symptoms • Inattention • Disorganized thinking• Altered level of consciousness

– Hypoactive v. Hyperactive• Sleep disturbance• Emotional and behavioral problems

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Common Risk Factors for DeliriumPredisposing• Advanced age• Preexisting dementia• History of stroke• Parkinson disease• Multiple comorbid conditions• Impaired vision• Impaired hearing• Functional impairment• Male sex• History of alcohol abuse

Precipitating• New acute medical problem• Exacerbation of chronic medical problem• Surgery/anesthesia• New psychoactive medication• Acute stroke• Pain• Environmental change• Urine retention/fecal impaction• Electrolyte disturbances• Dehydration• Sepsis

Marcantonio, 2011.

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Itching for a Fight!

• Mr. S is an 81 year old retired Baptist minister admitted for an exploratory laparotomy…..

• Gather in a group with students representing all professions

• Read the case and discuss the questions• Designate a spokesperson• Have fun!

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Common Risk Factors for DeliriumPredisposing• Advanced age• Preexisting dementia• History of stroke• Parkinson disease• Multiple comorbid conditions• Impaired vision• Impaired hearing• Functional impairment• Male sex• History of alcohol abuse

Precipitating• New acute medical problem• Exacerbation of chronic medical problem• Surgery/anesthesia• New psychoactive medication• Acute stroke• Pain• Environmental change• Urine retention/fecal impaction• Electrolyte disturbances• Dehydration• Sepsis

Marcantonio, 2011.

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Anticholinergic Exposure in Geriatric Patients

Smaller reserve of neurotransmitters + Increased blood brain barrier

permeability

= ↑ Sensitivity to adverse effects of anticholinergic medications

Fundamentals of Geriatric Pharmacotherapy 2010

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Adverse Effects of Anticholinergics Central

• Confusion• Memory Impairment• Cognitive Dysfunction• Drowsiness• DizzinessContributing to:• Delirium• Unsteady gait• Increased falls risk

Peripheral• Urinary retention• Constipation• Dry mouth• Dry eyes• Worsening of glaucoma• Impaired sweating• Tachycardia

Pharmacotherapy 2005; 25 (11):1592–1601

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Anticholinergic Risk Score (ARS)

• Ranks medications for anticholinergic potential on a 3-point scale:• 0= no or low risk• 3 = high anticholinergic potential

• To calculate the patient’s ARS score: identify anticholinergic medications and add the total points for each medication.

• Anticholinergic effects are cumulative!

Arch Intern Med 2008; 168: 508-513

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Game time:

Anticholinergic Medications!

The Game

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Anticholinergic risk scale3 points

Amitriptyline HydroxyzineAtropine products Imipramine

Benztropine MeclizineCarisoprodol Oxybutynin

Chlorpheniramine PerphenazineChlorpromazine Promethazine

Cyproheptadine Thioridazine

Dicyclomine TizanidineDiphenhydramine Trifluoperazine

Fluphenazine Hyoscyamine

Arch Intern Med 2008; 168: 508-513

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Anticholinergic Risk Scale

2 pointsAmantadine Loperamide

Baclofen LoratadineCetirizine Nortriptyline

Cimetidine OlanzapineClozapine Prochlorperazine

Cyclobenzaprine Pseudoephedrine

Desipramine Tolterodine

Arch Intern Med 2008; 168: 508-513

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1 pointCarbidopa-levodopa Pramipexole

Entacapone QuetiapineHaloperidol Ranitidine

Methocarbamol Risperidone Metoclopramide Selegiline

Mirtazapine Trazodone

Paroxetine Ziprasidone

Anticholinergic Risk Scale

Arch Intern Med 2008; 168: 508-513

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Anticholinergic Activity

0/+ (No or minimal)Celecoxib Fentanyl

Hydrocodone PropoxypheneDuloxetine AmoxicillinCephalexin Levofloxacin

Digoxin FurosemideDonepezil Phenytoin

Topiramate Diphenoxylate

JAGS 2008; 56 (7): 1333-1341

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Non-PharmacologicManagement of Pruritus

• Wearing sheer clothing• Avoiding hot baths, alcohol, spicy foods• Maintain proper humidity of rooms• Avoid contact with wool or animal fur• Prevent dry skin (moisturize and apply emollients)• Apply cold wet dressings• Keep fingernails short

“Happiness is having a scratch for every itch.”–Ogden Nash

Reich, 2011; Patel, 2010.

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PharmacologicManagement of Pruritus

Medication/ClassMedication/Class DrawbacksDrawbacksTopical Agents

Menthol Short-acting, may be irritating to skin

Anesthetics (lidocaine) May cause allergic contact dermatitis

Antihistamines Limited efficacy and contact allergies

Capsaicin Burning sensation when initiating

Corticosteroids May only be effective if inflammation involved

Systemic Agents

Antihistamines Sedation, delirium, etc.

Opioid Receptor Antagonists (naloxone) Reverse opioid effects (pain management)

Antidepressants May only be useful in psychiatric conditions

Reich, 2011; Patel, 2010.

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Summary

• Maintain a high level of suspicion– Watch out for precipitating medications

• Discuss with other members of the team– Involve pharmacists

• Consider non-pharmacologic strategies for treating common problems (e.g. pruritis)

• Inform/educate patients and families

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A better way….

PsychosocialPsychosocial

PharmacologicPharmacologic

PhysiologicPhysiologic

EnvironmentalEnvironmental

Medicine

Nursing

PT/OT

Pharmacy

Social work

Nutrition

PA’s

Patients and

Caregivers

Administrators

NP’s

Delirium Teaching Rounds “ Itching for a Fight!”

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