Transcript B2B Delirium 2010_Barbara Power

ACUTE CONFUSION IN THE
ELDERLY
Dr. Barbara Power
April, 2010
Major Objectives
1. Describe common causes of delirium
2. Recognize risk factors, and means of
prevention of delirium
3. Work up and treatment of delirium when it
does occur, and management of behavioral
problems
Synonyms for Delirium
• Acute confusional state
• Organic brain syndrome
• Toxic/metabolic
encephalopathy
• Out of it
• Uncooperative
Epidemiology in Elderly
Prevalence :
• On Admission
10 - 30%
• ER
10 -18%
Incidence:
• In Hospital
10 - 56%
• Post-operatively
15 - 53%
• Cardiac Surgery
17 - 73%
• ICU
70 - 87%
So What?
Why is Delirium Important?
3 criteria:
Common, Morbidity & Costly!
•on admit? 15-24%
•Death ~20-35%
•LOS doubles
•in hospital?14-31%
•Cognitive drop in
40%
• ++ hospital $
•Ortho? 25-65%
•ICU: 70%!
•Premature
institutionalization
•Caregiver
burden
Recognition of Delirium
• Previous studies 32%-66% of cases
unrecognized by MD’s
• Yale- New Haven study
– 65% unrecognized by Physicians
– 43 % unrecognized by nurses
Case - Delirium
Mrs G. 79 year old lady
• lives alone, manages own
apartment
• slightly forgetful (according to
daughter)
• PMed Hx: HTN; Insomnia
• Meds:
– Hydrochlorothiazide 25 mg OD
– Amitriptyline 50 mg qhs
– Oxazepam 15-30 mg qhs
– Occasional alcohol use
Case - Delirium
Admisssion to Hospital
• Tripped on rug, sustained a hip
fracture
• Brought to hospital. Spends 12
hours in ER waiting for bed
1) What are the risk factors that make Mrs. F vulnerable to
developing delirium?
2) Suggest actions that could be initiated to reduce her risk of
developing delirium
Case - Delirium
Admisssion to Hospital
•
ORIF the following day
•
1st POD
–
–
–
–
climbing over bedrails
shouting all night
sleeping in day
pulling out her IV’s
3. What are the key features of delirium that the MD should
elicit in Mrs. G?
The First Question –What is
this?
Is this Delirium?
Dementia??
Or something else???
Delirium
All Confusion is
Not Dementia
Always Consider
Delirium
Delirium
Definition:
• a disturbance of
consciousness with
inattention that
develops over a
short time &
fluctuates
Delirium (DSM-IV)
A: Disturbance of consciousness (reduced clarity of
awareness of the environment) with reduced ability to focus,
sustain or shift attention
B: Change in cognition (eg. memory deficit, disorientation,
language disturbance) or development of a perceptual
disturbance not due to pre-existing, established or
developing dementia
C: The disturbance develops over a short period of time
(hours to days) and tends to fluctuate during the course of
the day.
D. Evidence of aetiology
Delirium versus Dementia?
DELIRIUM
• Acute
• Inattention
• AbN LOC
• Fluctuations/minutes
• Reversible
• Hallucinations
common
DEMENTIA
• Gradual
• Memory disturbance
• N LOC
• None/days
• Irreversible
• Hallucinations
common only in
advanced disease
It is common for Delirium to be superimposed on Dementia!
Confusion Assessment
Method (CAM)
1. History of acute onset of change in patient’s normal
mental status & fluctuating course?
AND
2. Lack of attention?
AND EITHER
Sensitivity: 94-100%
Specificity: 90-95%
Kappa: 0.81
3. Disorganized thinking?
4. Altered Level of Consciousness?
Inouye SK: Ann Intern Med 1990;113(12):941-8
Arch Intern Med. 1995; 155:301
Testing Attention
• Formal methods:
– MMSE: Serial 7’s, WORLD backwards
– Digit Span: 5 forwards, 4 backwards
– Days of Week, Months of Year backwards
• Affects all other areas of cognition
Delirium: Cognitive
Evaluation
• MMSE:
– inaccurate tool to diagnose delirium as the patient:
• fluctuates
• has poor attention/concentration
– helpful tool to demonstrate improvement in cognitive
status when following patient.
Psychomotor Variants of
Delirium :
• Hyperactive ("wild man!"); 25%
• Hypoactive ("out of it!“, “pleasantly
confused”); 50% - Individuals often not recognized
as they may not cause a disturbance so they don’t get
ATTENTION
• Mixed delirium (features of both), with
reversal of normal day-night cycle
(“sundowning”)
Case – Delirium: CAM
• Acute /Fluctuating Course
• Altered level of
Consciousness
• Inattention
• Disorganized Thinking
9 am
1 pm
Top 4 Independent Risk
Factors for Delirium
Vision impairment:
RR=3.5 (1.2-10.7)
Any severe illness:
RR=3.5 (1.5-8.2)
Cognitive impairment:
RR=2.8 (1.2-6.7)
High Urea/Creatinine:
RR= 2.0 (0.9-4.6)
Inouye S. Ann Intern Med 1993: 119-474
What causes delirium:
Inouye Delirium Model
Fit 65 y.o. who plays senior’s hockey
Strong or repeated
precipitant needed
Frail 89 y.o. with baseline
dementia
Minimal precipitant
needed
Added Independent Precipitating
Factors in Hospital For Delirium
(i.e.. bad things WE do to elderly
patients):
• Restraints (RR 4.4)
• NPO status (RR 4.0)
• 3+ new med/24 hr
(RR 2.9)
• Foley catheter (RR 2.4)
• Any iatrogenic event
(RR 1.9)
Inouye SK, Charpentier PA, Precipitating Factors for Delirium in
Hospitalized Elderly Persons. JAMA. 1996;275:852-857
Causes of Delirium?
• brain’s way of demonstrating “acute organ
dysfunction”
• Anything that hurts the brain or impairs its
proper functioning can provoke a delirium!
I
WATCH DEATH
Mnemonic
• I Infection: Most
common are pneumonias
& UTI in elderly, but
sepsis, cellulitis, SBE and
meningitis can also occur
I
WATCH
• I Infection
• W Withdrawal:
benzodiazapines, ETOH,
DEATH
I
WATCH
• I Infection
• W Withdrawal
• A Acute metabolic:
electrolytes, renal failure,
acid-base disorders,
abnormal glycemic
control, Calcium
DEATH
I
WATCH
• I Infection
• W Withdrawal
• A Acute metabolic
• T Trauma: head injury
(SDH, SAH), pain,
vertebral or hip fracture,
urinary retention, fecal
impaction
DEATH
I
WATCH
• I Infection
•
•
•
•
•
W Withdrawal
A Acute metabolic
T Trauma
C CNS pathology
H Hypoxia from COPD
exacerbation, CHF
DEATH
Medication review:
• Look at all prescriptions
• include PRNs, regular, ETOH
and OTC meds
• Ask if anything has been
added, changed or stopped
• Watch for sleeping meds ie
Gravol; Nytol,
Miscellaneous Causes of Delirium
• Pain
• Fecal Impaction
• Urinary Retention
In other words, anything that
makes an older person very
very sick…
…can cause a delirium in a
vulnerable older person!
Delirium Workup
• On History:
– time course of
mental status
changes?
– association with
other events (i.e..
meds, illness)?
– Pre-existing
impairments of
cognition or sensory
modalities?
How to find out more? One of the
most useful and underused medical
tools:
Physical Exam
– Vitals: normal range of BP, HR Spo2, Temp?
– Good physical exam: particular emphasis on
Cardiac, pulmonary and neurologic systems
– Hydration status ? (dry axilla=dehyd!; + LR ~3)
– Also rule out
• fecal impaction (DRE)
• urinary retention (bladder U/S, in-and-out catheter)
• Infected decubatis ulcer
Delirium workup: Lab testing
• Basic labs most
helpful!
– CBC, lytes, BUN/Cr,
glucose
– TSH, B-12, LFTs
Calcium, & albumin
• Infection workup
(Urinalysis, CXR) +/blood cultures
• Other investigations
based on Hx- EKG/CT
Scan/Drug levels
Case - Delirium
Admisssion to Hospital
•
ORIF the following day
•
1st POD
–
–
–
–
climbing over bedrails
shouting all night
sleeping in day
pulling out her IV’s
5. What are the main immediate treatments you would
initiate?
Helping to improve Delirium
Once it starts, needs to ride its course;
but you can make a difference!
Delirium Reduction:
• You can get
improvement of
delirium with such
simple measures as:
–
–
–
–
–
–
Glasses
Using hearing aids
Fluids/nutrition
reducing noise
Early mobility
Familiar faces
S Inouye A multicomponent intervention to prevent delirium in
hospitalized older patients.
N Engl J Med. 1999 Mar 4;340(9):669-76.
Can We Prevent of Delirium
• Multi component intervention strategy
targeted to 6 delirium risk factors
Ref: Inouye SK, NEJM. 1999;340:669-676
Yale Delirium Prevention Trial
Risk Factors
Cognitive Impairment
Intervention
Reality orientation / therapeutic
activities program
Vision/Hearing impairment Vision / hearing aids / adaptive
equipment
Immobilization
Early mobilization / Reduce
immobilizing equipment
Psychoactive medication Non pharmacologic approaches to
sleep / anxiety / Restricted use of
sleeping medication
Dehydration
Early recognition / Volume
expansion
Sleep deprivation
Noise reduction strategies/sleep
enhancement program
Ref: Inouye SK, NEJM. 1999;340:669-676
Yale Delirium Prevention Trial
Significance
• Practical intervention towards evidence
based risk factors
• Significant reduction in risk of delirium
( 9.9% in intervention group vs 15% in usual
care)
• Significant reduction in total delirium days
Pharmacological Rx: Goals
• Reverse psychotic
signs and symptoms
• stop dangerous or
potentially
dangerous behavior
• To calm the patient
sufficiently to
conduct the
necessary evaluation
and treatment
Drug Treatment of Agitation
• Only 4 RCTs (largest N=73):
– Neuroleptics preferable to benzodiazepines
in most cases (except: PD, DLBD, ETOH)
– Low dose high potency neuroleptics (e.g.,
starting at haloperidol 0.25-1 mg)
– Newer “atypical” agents: no better than
haloperidol
• Avoid Combination Drugs – SINGLE Drug is
better
Lacasse et. al., Ann Pharm, 2006
IF SEVERE AGITATION consider Rx w/ high
potency antipsychotic:
•
Haloperidol: po/IM/(IV short acting):
– start with 0.5 - 1 mg initial dose
– Repeat dose of 0.25-0.5 mg Q30 minutes if patient remains
unmanageable without adverse events until sedation achieved and
continue monitoring
– repeat cycle until acceptable response or adverse events occur
– max suggested Haldol dose in frail elderly 3-4mg/24 hr
• Maintenance: 50% loading dose in divided doses over
next 24 hrs
• Taper the dose as soon as possible
• Avoid in individuals with Parkinson’s Disease
Benzodiazepines
1.
Avoid use in combination with
antipsychotics - SINGLE drug is better.
2.
May cause distribution/increased agitation.
3.
Best reserved for Delirium 2o to alcohol /
Benzodiazepine withdrawal.
4.
Relatively contraindicated in Delirium from
Hepatic Encephalopathy.
Summary - Recognition of
Delirium
• Delirium is Common
• Yale- New Haven study
– 65% of cases unrecognized by Physicians
• Don’t be part of that group!
Now! …That should clear up a
few things around here!