Identifying, measuring and managing delirium

Dr Tizzy TealeSenior Clinical Lecturer and Honorary Consultant Geriatrician

University of Leeds and Bradford Teaching Hospitals NHS Trust

How common is delirium?

• Delirium is the commonest complication of hospitalisation in older people

• Large point prevalence study (Italy)

– 108 acute and 12 rehabilitation wards

– Delirium assessments with the 4AT within a pre-determined 24 hour period (“Delirium Day”)

– 1867 patients assessed

Bellelli G, Morandi A, Santo et al BMC Medicine 2016;14:106

• Overall point prevalence of delirium in hospital inpatients over 65 was 22.9%

• This estimate is consistent across prevalence studies

• Over 50% of patients with delirium have a diagnosis of dementia

Ryan DJ, O’Regan et al BMJOpen 2013;3;e001772

Poorer longer term outcomes following delirium

• Poor cognitive outcomes

– Delirium is associated with incident dementia

• OR 8.7 95%CI: 2.1-35

Davis et al Brain 2012; 135:2809-2816

– Acceleration of cognitive decline

• Two-fold increased rate in the first 12 months

Gross et al 2012; Arch Int Med;2012;172(17):1324-1331

• Institutionalisation

– OR 2.41 95%CI: 1.77-3.29 (average follow up 15 months)

• Mortality

– HR 1.95 95%CI: 1.51-2.52 (average follow up 23 months)Witlox et al JAMA 2010;304(4):443-51

People remember being delirious

• Recall of delirium experiences is common after recovery (>50%)

• Those with more severe delirium and with underlying cognitive impairment less likely to recall

– This doesn’t make their distress any less at the time

• Commonly recalled symptoms are of visual hallucinations

• Misinterpretation of real sensory experiences also common

• Source of fear and anxiety

• Delusions common (often threatening)

• Descriptions of incomprehensible situations / time distortion common

• Trying to make sense of situation

• There may be longer lasting neuropsychiatric sequelaeO’Malley et al J of Psychosomatic Res 2008;65:223-228

How often is delirium missed?

• Up to 2/3 of cases of delirium are missed or misdiagnosed by acute medical teams

Collins et al Age Ageing 2010; 39(1):131-135

Delirium is poorly coded in the UK health service

Setting Prevalence from reported studies % (range)

Delirium rate (%) from UK HES data 2006-7 (>65s)

General / geriatric medicine 23.6% (15-42) 0.39

Critical care 48 (29.8-83.3) 0.23

Emergency Department 9.8 (9.6-11.1) 0.14

Orthopaedics 44.8 (29-68.1) 0.05

Clegg A, Westby M, Young J Age Ageing 2011;40(2):283-286

Even if we diagnose it, the ‘bigger picture’ is invisible as we are not coding for delirium at hospital discharge.

Recognising delirium

• Based on DSM 5 criteria

• Diagnosis of delirium requires all DSM 5 criteria to be met

• Criteria operationalised into screening or diagnostic algorithms

• A degree of subjectivity / inconsistently applied criteria

• Delirium is a complex syndrome – features can be difficult to spot

Key features (DSM 5 criteria)

• Disturbance in attention

– Reduced ability to direct, focus, sustain and shift attention

• AND Disturbed level of awareness

– Reduced orientation to the environment

• Acute / subacute onset

– Representing a change from baseline attention and awareness

• A tendency to fluctuation

– Over hours or days

• An additional disturbance in cognition– Memory deficit, disorientation, language, visuospatial, perception

Criterion A

Criterion B

Criterion C

• Not better explained by an existing or evolving neurocognitive disorder

– Not in the context of severely reduced arousal

• e.g. coma

• Physiologically attributable to a medical condition

– History, examination, lab findings

– Substance intoxication or withdrawal

– Exposure to a toxin

– Multiple aetiologies

Criterion D

Criterion E

Key features (DSM 5 criteria)

• Disturbance in attention

– Reduced ability to direct, focus, sustain and shift attention

• AND Disturbed level of awareness

– Reduced orientation to the environment

• Acute / subacute onset

– Representing a change from baseline attention and awareness

• A tendency to fluctuation

– Over hours or days

• An additional disturbance in cognition– Memory deficit, disorientation, language, visuospatial, perception

Criterion A

Criterion B

Criterion C

Inattention

• Difficulty maintaining / shifting focus between tasks

• Easily distracted by sounds, objects, own thoughts

• Perseveration

• May be poor eye contact

• May seem vague

Detecting inattention

• Months of the year backwards (MOTYB)

–Ask to say forwards Jan to Dec.

–Then ask to recite backwards from Dec.

– If able to reach July without error, attention likely intact

• MOTYB in >69yo without dementia

– 84% sensitivity

– 90% specificity for deliriumO’Regan JNNP 2014;85:1122-1131

Detection of delirium superimposed on dementia (DSD) is particularly challenging

• Impaired attention is a key feature of delirium

• May help distinguish delirium from dementia

• But patients with dementia struggle to complete tests of attention

Rutter et al EDA Conference Abstract 2016; #13

• MOTYB in those with dementia

– Poor specificity for delirium

– Patients with dementia may struggle to complete

O’Regan JNNP 2014;85:1122-1131

• Patterns of errors may help to discriminate between delirium and dementia (more work needed)

– omissions / repetitions / self-correction Rutter et al EDA Conference Abstract 2016; #13

Duncan et al EDA Conference Abstract 2016 # 35

• Use of informant instruments can help to identify pre-existing dementia (e.g. the IQCODE-SF)

Jackson et al Age Ageing 2016;45(4):505-11

Consciousness, arousal and attention

• Altered consciousness (DSM-IV) changed to disturbance in attention and awareness in DSM-5

• Consciousness is a hierarchical construct

– Level of consciousness = arousal

– Content of consciousness = attention

• Consciousness therefore includes implicit assessment of arousal

– Removed in DSM-5

• It is important not to miss delirious patients in whom attention cannot be assessed due to alterations in arousal (e.g. too sleepy)

• Those with sudden onset of altered arousal (over, or underactive) not attributable to existing or evolving condition (e.g. stroke) should be considered to meet DSM-5 criterion A for delirium

• EDA and ADS BMC Medicine 2014; 12:141

• Hypoactive delirium– Most common subtype (39%)

– Withdrawn, quiet, sleepy, poorly rousable

– Little interest in environment, poor oral intake

– Slurred speech

– Often missed – need to consider the diagnosis

– Associated with particularly poor outcomes

• Hyperactive delirium – Less common (21%)

– Agitated, wandersome, hyper-alert

– Behavioural disturbances

Mixed delirium fluctuates between these subtypes (27%)13% have no motor symptoms

Delirium subtypes

Key features (DSM 5 criteria)

• Disturbance in attention

– Reduced ability to direct, focus, sustain and shift attention

• AND Disturbed level of awareness

– Reduced orientation to the environment

• Acute / subacute onset

– Representing a change from baseline attention and awareness

• A tendency to fluctuation

– Over hours or days

• An additional disturbance in cognition– Memory deficit, disorientation, language, visuospatial, perception

Criterion A

Criterion B

Criterion C

Acute onset and fluctuating course

• Aim to identify a change from baseline

• SQiD (single question in delirium)– “Do you think [patient] has been more confused lately”?– 80% sensitivity for delirium– 71% specificity

• Have there been fluctuations over the course of days or hours?

Sands et al. Palliat Med 2010; 24: 561-565

Key features (DSM 5 criteria)

• Disturbance in attention

– Reduced ability to direct, focus, sustain and shift attention

• AND Disturbed level of awareness

– Reduced orientation to the environment

• Acute / subacute onset

– Representing a change from baseline attention and awareness

• A tendency to fluctuation

– Over hours or days

• An additional disturbance in cognition– Memory deficit, disorientation, language, visuospatial, perception

Criterion A

Criterion B

Criterion C

Additional cognitive disturbance

• Disorganised thinking, incoherent speech, perceptual problems, disorientation

• Problems making sense of what is going on

• Misinterpreting the environment

• Asking abstract questions can help identify

• May be hallucinations or persecutory ideas

– Do you feel frightened by anything or anyone?

– Are you concerned about anything going on here?Health Improvement Scotland Delirium toolkit 2014

• Mumbling, slurred or rambling speech which may be difficult to understand

4AT (the4at.com)

• 4AT can be used in those untestable with other methods

– e.g. stupor

• Does not rely on skilled assessment of attention

• Previous validation study (Italy)

– Sensitivity 89.7%

– Specificity 84.1%Bellelli Age Ageing 2014;43(4):496-502

• Utility in non-English speaking patients

– Sensitivity 91%

– Specificity 71%De et al Int J Geriatr Psych 2016; epub ahead of print

Alertness (normal / abnormal)

AMT4 (Age, DOB, Place, Current Year)

Attention (MOTYB)

Acute change or fluctuating course (yes / no)

Who gets delirium ?

• Strong predictors:

– Frailty

– Dementia

– Visual impairment

– Dehydration

– Severe illness

• Modifiable vs non-modifiable risk factors

Delirium prevention strategies:

• Up to one third of delirium is preventable through multicomponent delirium prevention interventions

Siddiqi et al Cochrane Review 2016 DOI: 10.1002/14651858.CD005563.pub3

• Personalised care delivered in a ward environment geared for delirium prevention

• What don’t we know? – Which are the most important / effective components of a

multicomponent intervention and how should these best be delivered ?

Metabolic

Oxygenation

Glucose

Perfusion

Electrolytes

Infections

Environmental

Ambient noise

Signage

Re-orientation

Early mobilisation

Avoid ward moves

Attention to sleep pattern

Individual

Avoid catheters if possible

Bowel Care

Hydration

Nutrition

Treat pain

(avoid opiates if possible )

Is early discharge possible /

appropriate / safe?

Sensory

Ensure hearing aids work and

have batteries in

Specs!

(are they clean?)

Medication

Avoid deliriogenic

drugs

Simplify meds as much as

possible

Modify these factors where you can

Non-pharmacological treatment of delirium

• It is important to be aware of, and modify potential triggers in non-delirious patients, as well as targeting contributing factors in those who are delirious

• Delirium episodes shorter and less severe if occur in the context of a multicomponent delirium prevention intervention

Marcantonio JAMA 2001;49(5):516-22O’Hanlon et al JNNP 2014;85(2):207-213

• No convincing evidence that multicomponent interventions are beneficial for the treatment of established delirium

Drugs and delirium

• Drugs implicated in development of delirium

• Drugs for delirium prevention

• Drugs for delirium treatment

• Drugs for management of delirium symptoms

Drugs implicated in delirium

• In general avoid– Drugs with anticholinergic properties

• Antihistamines

• TCAD

• Treatments for OAB

– Benzodiazepines

– Opioids (but treat pain)

• Medication review is a key aspect of delirium prevention / management

• Pay attention to the number, and type of medication

Drugs to prevent delirium (outside ICU)

• Drugs investigated for prophylaxis– Antipsychotics

– Melatonin / melatonin agonists

– Acetylcholinesterase inhibitors

– Citicoline

– Gabapentinoids

• No evidence to support the use of any of these drugs for prevention of delirium

Siddiqi et al Cochrane Review 2016 DOI: 10.1002/14651858.CD005563.pub3

Pharmacological treatment of delirium

• Evidence remains limited

• No convincing benefit for pharmacological therapies for treatment or prevention of delirium in non-ICU settings

• There is a need for further trials to identify agents that are safe for older people, and that have efficacy in the treatment / prevention of delirium

Management of delirium symptoms

• Identify and manage the underlying cause

• Symptoms should be managed through verbal and non-verbal de-escalation techniques

• If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short-term (usually for 1 week or less) haloperidol or olanzapine

• Start at the lowest clinically appropriate dose and titrate cautiously according to symptoms

• Use antipsychotic drugs with caution or not at all for people with conditions such as Parkinson's disease or dementia with Lewy bodies

• No drugs have a UK license for treatment or prevention of delirium https://www.nice.org.uk/guidance/cg103/chapter/1-Guidance#treating-delirium

Delirium recovery

• Persistence of delirium beyond hospital discharge is common

– Discharge 44.7% (half of these will have recovered by 3/12)

– 1 month 32.8%

– 3 months 25.6%

– 6 months 21%Cole et al Age Ageing 2009; 38:19-26

• Outcomes for people with persistent delirium are worse than for those who recover

• Those with dementia are more likely to develop persistent delirium

• 38% of people presenting with delirium have undiagnosed cognitive impairment

Jackson et al Age Ageing 2016;45(4):493-499

Follow up

• People who have had delirium are more likely to develop incident dementia

• Follow up after an episode of delirium is useful:

– For education / give the opportunity for patients to make sense of their experience if they want to

– To identify features of persistent delirium

– To identify / signpost those with incident dementia

Bradford Teaching Hospitals NHS Foundation Trust delirium patient information leaflethttp://johnscampaign.org.uk/docs/external/bradford-teaching-hospitals-delirium-prevention.pdf

• Please contact BTHFT for copyright permissions if you wish to use / adapt

Medical.Illustration@bthft.nhs.uk

Resources

NICE Delirium: Diagnosis, Prevention and Management of delirium guidelines (CG103) July 2010http://www.nice.org.uk/guidance/cg103

The 4AThttp://www.the4at.com/

The Scottish Delirium Association “Delirium Management Comprehensive Pathway” Dec 2013http://www.scottishdeliriumassociation.com

Healthcare Improvement Scotlandhttp://www.healthcareimprovementscotland.org• E-modules• Information for patients and carers• TIME delirium care bundle