Week 1 Module B: Instructions Please view video 2 and review charts prior to starting this module. ...

Week 1 Module B: Instructions

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Week 1 Module A: Instructions

For each question, please choose one answer that best addresses the question and then hit “click here.”

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Week 1 Module B: Question 1

Mrs. Rivera has now been in the hospital for one full day; she was sent to BMC straight from clinic. What is the ICD-9 diagnosis of her cognitive status in video clip 2?

A. Δ MS click here B. Dementia with sundowning click here C. Delirium click here D. Acute mental status change click here

Delirium Takes Various Forms

It’s obvious that Mrs. Rivera has hyperactive delirium now:– 25% of all delirium cases are hyperactive

However, there is also a hypoactive form:– Less recognized or appropriately treated

Mixed: with hypo- and hyperactive features Additional features include emotional and

psychotic symptoms


Your initial evaluation of the etiologies of Mrs. Rivera’s delirium should include all of the following EXCEPT:

A. Complete history, including what prn meds were given overnight click here

B. Vital signs and oxygen saturation click here C. Complete physical exam, including

neurological exam click here D. CT scan of head click here

Always see the delirious hospital patient!

When the nurse pages you about an agitated, hyperactive delirious patient, resist the urge to order medications or restraints over the phone.

GO EXAMINE THE PATIENT BEFORE TAKING ACTION

Evaluation begins with history & physical

Focus on time course of cognitive changes esp. their association with other symptoms or events

Medication review, including OTC drugs, alcohol, prn meds

Vital signs, oxygen saturation General medical evaluation Neurologic and mental status examination


Mrs. Rivera has a temp of 101.2 despite one day of antibiotic treatment, no nuchal rigidity, rales in the left base, and a non-focal neuro exam. She has not received any prn medications recently.

Given her history and exam findings, the following tests are appropriate to order as part of the initial evaluation EXCEPT:

(go to next slide)

Week 1 Module B: Question 3 continued

A. CBC click here B. BMP click here C. UA and urine C&S click here D. TSH click here E. EKG click here

Evaluation: Laboratory Testing

Base on history and physical Think of possible precipitating factors and let this

guide your choice of testing Include electrolytes, renal function tests, CBC,

and UA for every patient (these are high yield) Cerebral imaging rarely helpful, except for head

trauma or new focal neuro findings EEG and CSF rarely helpful, except for

associated seizure activity or signs of meningitis

Management: General Principles

Requires interdisciplinary effort by MDs, nurses, family, others (such as PT)

Multifactorial approach is most successful because multiple factors contribute to delirium in most cases

Failure to diagnose and manage delirium: life-threatening complications, loss of function, costly

Keys to Effective Management

TREAT THE UNDERLYING DISEASE Address contributing factors

– Including medications: see if you can reduce or eliminate suspected contributors


Because Mrs. Rivera is agitated, initial management should include all of the following EXCEPT:

A. Wrist restraints and Posey vest click here B. Asking family members to stay with her click

here C. Removal of the Foley catheter click here D. Placing her in a cardiac chair at the nurses

station click here

Always try nonpharmacologic measures first

Nonpharmacologic Management

Presence of family members Interpersonal contact and reorientation Provide visual and hearing aids if needed Remove indwelling devices (such as Foley

catheters) ASAP Wrap IV lines in kerlix (so patient can’t see them) Mobilize patient as soon as possible Keep patient awake during the daytime Provide uninterrupted sleep at night


Despite the presence of family members, removal of the Foley catheter, and giving Mrs. Rivera her glasses, she remains agitated and refuses to take her meds. The most appropriate next management step is:

A. lorazepam 2 mg IV click here B. haloperidol 1 mg IV click here C. haloperidol 5 mg IV click here

Pharmacologic Management

Reserved for patients at risk for harm of self or others– Including refusal to take potentially life-saving

treatment Use LOW DOSE antipsychotic agents Remember: haloperidol and other antipsychotics

have side effects– Anticholinergic– Orthostatic hypotension– Extrapyramidal side effects and acute dystonias– Can prolong the QT interval

Management: Hyperactive, Agitated Delirium

Avoid pharmacologic or physical restraints If absolutely necessary, use haloperidol

(IV, IM, or PO)– For mild delirium: 0.25-0.5 mg PO or 0.125-

0.25 mg IV/IM– For severe delirium: 0.5-1 mg IV/IM repeated

every 30 min until patient is calm (total dose = loading dose)

Key Points about Antipsychotic Use

Patients who have never been exposed to haloperidol or antipsychotics in the past will usually only need less than 5 mg as a total loading dose

If patient is willing to take PO, try low doses of atypical antipsychotics such as olanzepine and risperidone– lower risk of extrapyramidal side effects than

haloperidol

What about Ativan (lorazepam)?

Second line agentReserve for:

– Sedative and ETOH withdrawal– Parkinson’s Disease– Neuroleptic Malignant Syndrome

AVOID RESTRAINTS AT ALL COSTS:

Measure of LAST(!!!) resort

Can delirium be prevented?

YES! Prevention is possible.

Find patients who do not have delirium with 1-4 of the following predisposing characteristics :– Visual impairment (worse than 20/70 corrected)– Severe illness– Cognitive impairment (MMSE<24/30)– High BUN/Cr ratio (>18) – (Inouye SK et al. Ann Intern Med. 1993; 119:474-481)

Give them the following targeted interventions:

Prevention=Good Hospital Care for the Elderly Patient (Inouye SK et al. NEJM. 1999;340:669-76)

RISK FACTOR INTERVENTION

Cognitive impairment Orientation protocol, cognitively stimulating activities 3x/day

Sleep deprivation Nonpharmacologic protocol, noise reduction, schedule adjustments

Immobility Ambulation or active ROM exercises; minimize equipment

Visual impairment Glasses or magnifying lens, adaptive equipment

Hearing impairment Portable amplifying devices, earwax disimpaction

Dehydration Early recognition and volume repletion

A Multicomponent Intervention to Prevent Delirium (Inouye SK et al. NEJM. 1999;340:669-76)

Outcome (n=852)

Interv. group

Usual care group

Statistical analysis

1st delirium episode

9.9% 15% OR=0.60 (95% CI 0.39 to 0.92)

Total days delirium

105 161 P=0.02

# delirium episodes

62 90 P=0.03

Take Home Points: Delirium in the Elderly

A multifactorial syndrome arising from a patient’s predisposing vulnerability and precipitating insults

Delirium can be diagnosed with high sensitivity and specificity using the CAM

Prevention should be our goal If delirium occurs, treat the underlying causes Try nonpharmacologic approaches first Use low dose antipsychotics in severe cases Avoid physical restraints

References and Resources

Inouye SK. Delirium in hospitalized older patients. Clinics in Geriatric Medicine.14(4):745-64, 1998.

American Psychiatric Association: Practice Guideline for the Treatment of Patients with Delirium, May 1999.

Inouye SK et al. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Based on Admission Characteristics. Ann Intern Med. 119:474-481, 1993.

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

Delirium. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Teaching Slides. Volume 1, Fifth Edition. Blackwell Publishing, copyright American Geriatrics Society, 2003.

click here to end

Delirium is the diagnosis with an ICD-9 code

Because Mrs. Rivera’s MMSE is 22/30, it is possible that she may have dementia and that her agitation could be due to the “sundowning” phenomenon.

However, “sundowning” does not have an ICD-9 code.

Again, assume delirium until proven otherwise, as it may be the only manifestation of acute life-threatening illness in elders.

click here for the correct answer

Delirium is the diagnosis with an ICD-9 code.

Oftentimes, you will see Δ MS or acute mental status change written in chart notes.

However, these entities do not have ICD-9 codes.

Delirium has its own ICD-9 codes:– Delirium = 780.09– Acute delirium = 293.0

click here for the next slide

Correct answer.

Yes, this is delirium. ICD-9 code = 780.09 click here for the next slide

Initial evaluation should always include…

A complete history: including what medications were given prn during the last 24 hours.

A comprehensive physical exam: including vital signs, skin examination to look for pressure sores, and neurological and mental status examinations (i.e. CAM)


Correct answer.

A head CT scan should be ordered only after you have obtained a history and done a physical exam of the delirious patient.

If the history is suggestive of a fall with possible head trauma, then a CT scan is warranted.

If the physical exam reveals focal neuro deficits, then a CT scan is appropriate.


This test is appropriate to order.

For all delirious elderly patients, order a basic metabolic profile (sodium disorders, hypo- or hyperglycemia, hypercalcemia, and prerenal azotemia).

Given the likely presence of infection, checking a CBC is warranted.

Given Mrs. Rivera’s persistent fever and Foley catheter, check a UA and urine culture.

An EKG is appropriate given her risk factors for cardiac ischemia (HTN, age > 65).


Correct answer.

Of the choices for testing, checking a TSH level is the least likely to yield an etiology given the time course of her symptoms.

Usually, cognitive changes of hypo- and hyperthyroidism worsen gradually over time.


Nonpharmacologic measures should always be initiated first.

Since Mrs. Rivera is yelling out for her daughter, asking family members to stay with her might calm her down.

Does Mrs. Rivera really need the Foley catheter? Probably not, and it’s likely to be one source of her agitated delirium.

Sometimes placing agitated patients in cardiac chairs by the nursing station (without any physical restraints) can calm them down.


Correct answer.

Pharmacologic and physical restraints are last-resort measures.

They should never be used before nonpharmacologic interventions are attempted.


Avoid benzodiazepines

Mrs. Rivera is agitated now, not anxious. Therefore, lorazepam is not the ideal medication

choice. Furthermore, 2 mg of lorazepam is too high an

initial starting dose. Remember: benzodiazepines increase falls risk in

elderly patients (another reason to avoid this class of meds).


Start low, go slow.

Haloperidol 5 mg is too large a dose to use in an elderly patient who is not accustomed to taking antipsychotic medications.

You are likely to make Mrs. Rivera quite lethargic with this dose.


Correct answer.

Haloperidol 1 mg IV is a reasonable medication and dose to give at this time.

Because Mrs. Rivera has never taken antipsychotic medications in the past, a small dose of haloperidol will likely be sufficient to calm her down.


End of Week 1 Module B

Week 1 Module B: Instructions Please view video 2 and review charts prior to starting this module. ...

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