Delirium in the Older Adult

Delirium in the Older Adult

Matt Russell,MD, MScAssistant Professor of Medicine

Boston University School of MedicineSlide 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.

What is your first thought?

What could possibly go wrong?

A case for contingency planning…

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

Beep Beep!Dear Dr.Nightfloat….

“Hi, are you covering for Agnes D?....”

Delirium: She is OFF THE WALL!!

Delirium Definition?

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!

Your next step is….

MEDICAL EMERGENCY!

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. InattentionAND

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.

Please complete Agnes’ Delirium Map

Agnes’ Delirium Map

Risks:

Precipitants:

Your interventions:

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…..

What the hell are you people doing to my

mother??!!!

A brief skills practice….

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]

Acknowledgements

Dr. Lisa Caruso Dr. Serena Chao

Thank You

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