Transcript Delirium in the Older Adult Patient: Not Just Altered Mental Status

Delirium in the Older Adult Patient:
Not Just Altered Mental Status
Lisa R. Mack, MD, FACEP
Assistant Professor Emergency Medicine
Emory University, Atlanta, GA
June 14, 2003
Georgia College of Emergency Physicians
St. Simons Island, Georgia
Goal
 For
you to recognize delirium as a
specific disease entity and to begin
ruling it in or out in your patients with
AMS
Objectives
1.
2.
3.
4.
Identify the 4 risk factors for delirium
Identify the 4 features of the CAM
diagnostic algorithm and the criteria
for diagnosing delirium
Identify the top 3 causes of delirium
State the pharmacological treatment
for delirium
Delirium?
 Case
1: Patient dozes off when you’re
trying to talk to him…
 Case 2: Mr. P. keeps picking at his bed
clothes as you try to talk to him…
 Case 3: The nurse asks you to
prescribe something to stop Mrs. B from
being agitated, but when you go in to
see her she “looks fine”…
Definition
 Older
adult= age > 65
 Delirium= A disturbance of
consciousness and an acute change in
cognition or perception
3
types:
Hyperactive (22-30%)
 Hypoactive (24-26%)
 Mixed (42-46%)

Why Important?
 In
2000, a consensus panel identified
delirium as 1of 3 target conditions for
quality improvement in older patients*
 Missed diagnosis in up to 67% of pts.
Up to 55% of ED patients*
 Prevalence in ED is 9.6 % *
 Bundled as “AMS” by ED physicians

*Sloss, EM, et al. J Am Geriatric Soc. 2000
*Hustey, FM et al. Academic EM 2000
*Elie, M. Et al. CMAJ 2000
Why Important? cont.
 Under-recognized
 Case
as a disease entity
1, 2, 3
 Increased
morbidity/mortality*
 Increased costs
 Majority of causes are reversible
 Potentially preventable
*Kakuma, R et al. J Am Ger Soc. April 2003
Prevention
 1993
Inouye identified 4 independent
and cumulative risk factors:
 Vision
impairment
 Severe illness (APACHE II score <16)
 Cognitive impairment
 Dehydration
Prevention cont.

1999, Inouye et al NEJM:
“A multicomponent intervention to prevent delirium in
hospitalized older patients.”
-Delirium developed in 9.9% of
interventional group vs 15% control
-Improvement in cognition and reduction in
use of sleep medication were significant
-Delirium prevented, but no impact on severity
or recurrence once it developed
What we know:
* Intervention before onset reduces
delirium*
* A validated assessment tool exists (CAM);
95-100% sens.; 89-100% spec. +
So why are we frequently missing the diagnosis?
*Inouye, SK et al. NEJM 1999; AGS Mtg May 2003 few studies ongoing
+Ely, EW et al.Crit Care Med 2001; Monette, J et al General Hosp Psych 2001
Barriers to diagnosis
 Individual
patient presentation
 The presentation of severe illness in
older people
 Differential diagnosis
 Vascular
dementia may present w/acute
cognitive decline
 Hypoactive delirium may be mistaken for
depression
The Diagnosis


Delirium is a clinical diagnosis
The criteria: Confusion Assessment
Method (CAM)
1.
2.
3.
4.
Inattention
Acute onset and fluctuating symptoms
Altered level of consciousness
Disorganized thinking
Must have 1 and 2 and either 3 or 4
Inattention
 Inability
to shift attention (Perseverance)
 Inability to focus
 Simple test:
 Recite
the days of the week backward
 Digit span test (repeat 5 numbers forward
without errors)
Acute onset/fluctuating
 Sxs
usually present for <2 weeks
 May fluctuate over the course of
minutes to hours (Ask caregiver)
Altered Level of Consciousness
Hyperactive vs hypoactive
 Alert
(normal)
 Vigilant
 Lethargic (drowsy, but easily aroused)
 Stupor
 Coma
Disorganized Thinking
 Rambling
 Illogical
conversation
Management
1.
2.
3.
Recognize and treat the underlying
cause
Modify the environment
Control the symptoms
Etiologies
Top 3 causes:
1. Infection
2. Metabolic disturbances
3. Medications
-anticholinergics
-opiates
Etiologies cont.
 AMI
 CVA
 Drug
withdrawal
The work-up therefore reflects the above: CBC,
Chem, U/A, CXR, ECG, +CT scan, +Drug screen
Environment
 Keeping
patient oriented to time/place
 Adequate
lighting, routine sleep times
 Involving friends/family
Symptom control
 First-line
treatment= Haloperidol
 Least
anticholinergic activity
 Rapid onset
 Dose: 0.25- 0.5 mg, max 5mg/24hr
 BDZs=
first-line tx in ETOH w/drawal
 Lorazepam
0.25-1 mg, titrate
Symptom control cont.
 Haloperidol
plus lorazepam
 Synergistic
effect
 Allows for lower doses of haloperidol and
therefore reduced extrapyramidal effects
Note: BDZs can actually cause a paradoxical
reaction of agitation
Summary
 Delirium
is misdiagnosed in up to 55% of
ED patients
 The 4 risk factors of delirium are:
 The 4 features of the CAM are:
 The top 3 causes of delirium are:
 The drugs used to control symptoms are:
Take Home Points
 Delirium
 ED
is not a just “AMS”
physicians need to recognize
delirium as a distinct disease entity
 ED physicians need to recognize risk
factors for delirium to assist in
prevention
Questions???