Transcript Assessing the Geriatric Psychiatric Patient in the Sub

Assessing the Geriatric Psychiatric
Patient in the Subacute Setting:
Approach to Delirium Assessment
Stephen M. Scheinthal, DO, FACN
Associate Professor, Psychiatry
University of Medicine and Dentistry of New Jersey
School of Osteopathic Medicine (UMDNJ-SOM)
Image created by the University of Medicine & Dentistry of New Jersey School of Osteopathic Medicine
Assessing the Geriatric Psychiatric
Patient in the Subacute Setting:
Approach to Delirium Assessment
This geriatric psychiatry presentation for
general psychiatry residents is offered by the
New Jersey Institute for Successful Aging.
This lecture series is supported by an educational grant from the
Donald W. Reynolds Foundation Aging and Quality of Life program.
Learning Objectives
• To describe the risk factors for acute confusion in
older patients
• To distinguish between appropriate and
inappropriate use of psychoactive medications in a
patient with acute confusion
• To utilize effective management strategies in the
treatment of hypoactive delirium
• To recognize the value of the interdisciplinary team in
caring for patients in the subacute setting
Approach to the Geriatric Consult in
the Subacute Setting
History
Medication Review
Psychiatric Evaluation
Diagnosis and Plan
Follow Up
History Components
Chart Review
 Current status
 Hospital course
Collateral Information
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Nursing
Social Work
Physical Therapy
Family
Medication Review
Case of Mrs. M.
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Consults
Case of Mrs. M
Consult Request
Dr. Smith, Geriatric Psychiatry
Reason for Consult
Patient depressed and tearful
Please evaluate and treat
History
Patient
 Mrs. M is a 78 year old female
Case of Mrs. M
Past Medical History
 Stroke
 Hypertension
Hospital Course
 Diabetes mellitus
 Admitted to subacute facility 2
 Coronary artery
days ago from local hospital for
disease
rehabilitation following right hip
 Degenerative joint
fracture
disease
 Patient fell at home
 Osteoporosis
 Hospital stay of 5 days
 Urinary tract infection
 Patient became very confused
and agitated on Hospital Day 3
Case of Mrs. M
Interdisciplinary Notes
Nursing
 Patient has been very lethargic since admission. She is not
participating in therapy. Sleeps most of the day. Only eats
50% of her meals.
Social Work
 Patient was widowed and living alone. Two children live out
of the area and not very involved in care. She was
independent up until fall. No prior psychiatric history. She is
a college graduate and a former teacher.
Family
 Concerned that patient is over medicated. She was never like
this before. Family reported patient on no psychiatric
medications prior to hospitalization.
PT Notes
Case of Mrs. M
Physical Therapy
 Prior function: Family reported patient was living
independently. Fully functional, no deficits noted.
Current function: Not ambulating, non weight
bearing, not participating in therapy, tearful, but
does not admit to any pain.
Medication Review Components
Current and previous medications
 Conduct medication reconciliation
 Review medications started in hospital and
reasons they were started
High risk medications
 Potential for adverse events
 Drug-drug interactions
 Risk versus benefit
Medications
Case of Mrs. M
Current Medications
New Medications
 Ambien 10mg QHS
 Seroquel 50mg TID
 Glucophage 500mg QD
 Ativan 0.5mg BID
 Metoprolol 50mg BID
 Plavix 75mg QD
 Reglan 10mg QD
 No OTC
Things to Think About
Why is patient on Seroquel?
 Patient was restless and agitated on Hospital
Day 3
 Stat Psychiatry Consult for agitation ordered
 Psychiatry Consult reflects delirium, but no
etiology identified
 Hospital records show Seroquel was started for
delirium
 Records show medication was effective in
reducing agitation
Things to Think About
If acute behavior has resolved, why was the
medication continued?
 Psychiatrist did not return to see patient
before discharge
 Medication was just transposed to transfer
form and continued at subacute unit
Things to Think About
What are the risks of continuing this medication?
 Sedation/Falls/Dizziness/Orthostatic Hypotension
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QT Prolongation
Diabetes Mellitus/Weight Gain
Hyperlipidemia
Extrapyramidal Symptoms (EPS)/Tardive Dyskinesia (TD)
Constipation/Abdominal Pain/Upset Stomach
Abnormal Liver Function Tests
Neuroleptic Malignant Syndrome (NMS)
Antipsychotic Use in Delirium
Antipsychotics are the drug of choice in
delirium
Referred to as the major tranquilizers
Used to address the severe behaviors while
the underlying medical cause is treated
Practice guideline for the treatment of patients with delirium. Am J Psych 156(5 Suppl):1-20, 1999.
Antipsychotic Use in Delirium
 Recommended Haldol dosing in Delirium
 0.5-1mg po Q1 hour until desired effect is reached
 Avoid IV Haldol due to risk of Torsade des pointes unless the
patient is on a cardiac monitor
 Antipsychotics should be tapered and discontinued over 2-3
days after symptoms resolved.
 Risks
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Falls, orthostatic hypotension, sedation
Neuroleptic Malignant Syndrome (NMS)
Extra Pyramidal Symptoms (EPS)/ Tardive Dyskinesia (TD)
Increased risk of cerebral adverse events
Markowitz JD, Narasimhan M. Delirium and antipsychotics: A systematic review of epidemiology and somatic treatment options.
Psychiatry 5(10):29-36, 2008.
Practice guideline for the treatment of patients with delirium. Am J Psych 156(5 Suppl):1-20, 1999.
Antipsychotic Use in Delirium
Atypical Antipsychotics have also been shown
to be effective
 May have lower incidence of anticholinergic side
effects
 Recommended dosing of Risperdal in Delirium
 Dosing 0.25-0.5mg po or dissolvable tab Q 8-12 hours
 Do not exceed 2mg in 24 hours
Practice guideline for the treatment of patients with delirium. Am J Psych 156(5 Suppl):1-20, 1999.
Things to Think About
Why is the patient on Ativan?
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Chart reflects Ativan 0.5mg Q 8 hours is for crying
Hospital notes reflect patient was crying
Ativan was started on Hospital Day 2 for crying
Follow up notes reflect patient much calmer, no crying
Ativan is a renally cleared benzodiazepine
Patient may have been calmer due to tranquilizing
effect
 Ativan is not a treatment for depression
Benzodiazepines
 Minor tranquilizer
 Indicated for anxiety, muscle relaxants, status
epilepticus, nausea/vomiting, preoperative sedation
 Contributes to an increase risk of:
 Falls
 Confusion
 Depression/Suicidal ideation
 Delirium
 Very habit forming
Indications for Medication Use for
Acute Confusion
 Psychotropic medications reserved for patients in distress due
to severe agitation or psychotic symptoms
 Avoid psychotropic medications for the specific purpose of
controlling wandering
 Aim for monotherapy, lowest effective dose, and tapering as
soon as possible
 Antipsychotics are the treatment of choice
 Use of Benzodiazepines should be avoided
 Reserved for delirium caused by withdrawal from
alcohol/sedative hypnotics
Recupero PR, Rainey SE. Managing risk when considering the use of atypical antipsychotics for elderly patients with dementia-related
psychosis. Journal of Psychiatric Practice 13(3):143-152, 2007.
Case of Mrs. M
Exam
Mental Status Exam
Appearance
78 yo female who appears much older than stated age. Fair
dress and grooming. Patient is in bed, min-cooperative, poor
eye contact.
Speech
Speech sparse, underproductive, no pressure.
Affect/Mood
Mood “horrible” with a sad/tearful affect.
Thoughts
No suicidal or homicidal ideation, no auditory or visual
hallucinations, no looseness of associations, no flight of ideas, no
ideas of reference, no paranoia.
Sensorium/
Cognition
AAOX 2 (self and place, not date). Memory: short term memorylimited, long term memory-good, insight and judgment-fair.
Things to Think About
What is happening with the patient?
 Dementia
 Delirium
 Depression
Assessment
Case of Mrs. M
Does the patient have depression?
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Tearful
Not eating
Says she is depressed
Not participating in therapy
No prior history of depression
DSM-IV-TR Diagnostic Criteria
for Depression
A. Five (or more) of the following symptoms have been present
during the same 2-week period and represent a change from
previous functioning; at least one of the symptoms is either (1)
depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or
hallucinations.
1)
2)
3)
depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad or empty) or observation made by others
(e.g., appears tearful). Note: In children and adolescents, can be irritable
mood.
markedly diminished interest or pleasure in all, or almost all, activities most
of the day, nearly every day (as indicated by either subjective account or
observation made by others)
significant weight loss when not dieting or weight gain (e.g., a change of
more than 5% of body weight in a month), or decrease or increase in
appetite nearly every day. Note: In children, consider failure to make
expected weight gains.
DSM-IV-TR Diagnostic Criteria
for Depression
A. Cont’d
4)
5)
6)
7)
8)
9)
insomnia or hypersomnia nearly every day.
psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of restlessness or being slowed down).
fatigue or loss of energy nearly every day.
feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being
sick).
diminished ability to think or concentrate, or indecisiveness, nearly every
day (either by subjective account or as observed by others).
recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide.
DSM-IV-TR Diagnostic Criteria
for Depression
B.
C.
The symptoms do not meet criteria for a Mixed Episode.
The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a
substance (e.g., a drug of abuse, a medication) or a general
medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by Bereavement, i.e.,
after the loss of a loved one, the symptoms persist for longer than
2 months or are characterized by marked functional impairment,
morbid preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor retardation.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
Washington, DC: American Psychiatric Association, 2000.
Assessment
Case of Mrs. M
Does the patient have dementia?
 Decline in function
 Short term memory limited
 Long term memory good
DSM-IV TR Criteria for Dementia of the
Alzheimer’s Type
A. The development of multiple cognitive deficit manifested by both:
1) Memory impairment (impaired ability to learn new
information or to recall previously learned information).
2) One (or more) of the following cognitive disturbances:
(a)
(b)
(c)
(d)
B.
aphasia (language disturbance)
apraxia (impaired ability to carry out motor activities despite intact
motor function)
agnosia (failure to recognize or identify objects despite intact
sensory function)
disturbance in executive function (i.e. planning, organizing,
sequencing, abstracting)
The cognitive deficits in Criteria A1 and A2 each cause significant
impairment in social or occupational functioning and represent a
significant decline from a previous level of functioning.
DSM-IV TR Criteria for Dementia of the
Alzheimer’s Type
C.
The course is characterized by gradual onset and continuing
cognitive decline.
D. The cognitive deficits in Criteria A1 and A2 are not due to any of
the following:
1)
2)
3)
other central nervous system conditions that cause progressive deficits
in memory and cognition (e.g. cerebrovascular disease, Parkinson’s
disease, Huntington’s disease, subdural hematoma, normal-pressure,
hydrocephalus, brain tumor)
systemic conditions that are known to cause dementia (e.g.
hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency,
hypercalcemia, neurosyphilis, HIV infection)
substance-induced condition
DSM-IV TR Criteria for Dementia of the
Alzheimer’s Type
E.
F.
The deficits do not occur exclusively during the course of
delirium.
The disturbance is not better accounted for by another Axis I
disorder (e.g., Major Depressive Disorder, Schizophrenia)
DSM-IV TR Criteria for Dementia of the Alzheimer’s Type
References
1. Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can
Fam Physician 47(1):101-107, 2001.
2. Practice guideline for the treatment of patients with delirium. Am J
Psych 156(5 Suppl):1-20, 1999.
3. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
Washington, DC: American Psychiatric Association, 2000.
Assessment
Case of Mrs. M
Does the patient have ongoing delirium?
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Lethargic
Fluctuating mental status
Acute onset
Disorientation
Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can Fam Physician 47(1):101-107, 2001.
DSM-IV-TR Diagnostic Criteria
for Delirium
A. Disturbance of consciousness (i.e., reduced clarity of awareness of
the environment) with reduced ability to focus, sustain, or shift
attention.
B. A change in cognition (e.g., memory deficit, disorientation,
language disturbance).
C. Development of a perceptual disturbance that is not better
accounted for by a pre-existing, established, or evolving dementia.
D. Disturbance develops over a short period of time (usually hours to
days) and tends to fluctuate during the course of the day.
E. There is evidence from the history, physical examination, or
laboratory findings that the disturbance is caused by the direct
physiological consequences of a general medical condition.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR).
Washington, DC: American Psychiatric Association, 2000.
Psychomotor Variants of Delirium
• Hyperactive (30%)
 Agitation, combativeness, restlessness, hallucinations
 Easiest to recognize (loud, disruptive patients)
• Hypoactive (24%)
 Lethargy, reduced psychomotor functioning
 More likely to go unrecognized (“good patients”)
• Mixed (46%)
 Features of both hypo and hyperactive delirium
 Agitated and combative with alternating episodes of
somnolence and hypoactivity
Meagher DG, O’Hanlon D, O’Mahony E, et al. Relationship between symptoms and motoric subtype of delirium. J Neuropsychiatry Clin
Neurosci 12(1):51-56, 2000.
Delirium versus Dementia
Symptom
Delirium
Dementia
Onset
Acute
Insidious
Duration
Days to weeks
Months to years
Course
Fluctuating
Slowly progressive
Attention
Poor
Usually unaffected
Consciousness
Impaired
Clear until late in course of
illness
Confusion Assessment Method (CAM)
Criteria
1. History of acute onset of change in patient’s
normal mental status & fluctuating course
AND
2. Lack of attention
Sensitivity: 94-100%
Specificity: 90-95%
AND EITHER
3. Disorganized thinking
4. Altered level of consciousness
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(12):941–948.
Pompei P, Foreman M, Cassel CK, et al. Detecting delirium among hospitalized older patients. Arch Intern Med 1995;155(3):301-307.
Acute Onset and Fluctuating Course
 Usually obtained from family member or
somebody who spends a lot of time with the
patient
 “Is there evidence of acute change in mental
status from the patient’s baseline?”
 “Did the behavior fluctuate during the day;
that is, did it tend to come and go or
increase/decrease in severity during the
day?”
Inattention
 “Did the patient have difficulty in focusing
attention?”
 “Was the patient easily distractible?”
 “Is the patient having difficulty in keeping
track of what was being said?”
 Serial 7s or spell the word “world” backwards
Disorganized Thinking
 “Was the patient’s thinking disorganized or
incoherent?”
 “Rambling or irrelevant conversations?”
 “Unclear or illogical flow of ideas?”
 “Unpredictable switching from subject to
subject?”
Assessment
Axis I
Axis II
Axis III
Axis IV
Axis V
Case of Mrs. M
Delirium, to consider Dementia NOS, to
consider Depression NOS, to consider
Adjustment Disorder with Depressed
Mood
Defer
S/P Fx hip, HTN, DM, CAD, DJD,
Osteoporosis, UTI
Social, financial, chronic medical illness
50
Search for Underlying Cause
D Drugs
E Electrolytes
L Lack of drugs (poor pain control, sedative or alcohol
withdrawal)
I Infection
Reduced sensory input (restraints, visual or hearing
R
impairment)
I Intracranial (seizure, subdural hematoma, stroke)
U Urinary retention/fecal impaction
M Myocardial (congestive heart failure, MI)
Who is at risk for
developing delirium?
 Pre-existing cognitive
disorder
 Depression
 Visual impairment
 Age greater than 70
 Environmental change
 Alcohol history
 Psychoactive
medication history
 Surgical procedure
Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can Fam Physician 47(1):101-107, 2001.
How do you manage delirium?
 Establish underlying causes & treat
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D/C or  drugs
Fluids, lytes, nutrition, O2
Supportive care + reorientation
Minimize environmental isolation
Glasses/hearing aids
Attention to patient concerns & fears
Remove immobilizing lines and devices
Avoid restraints
Adequately assess and treat pain
Conn D, Lieff S. Diagnosing and managing delirium in the elderly. Can Fam Physician 47(1):101-107, 2001.
Plan
Case of Mrs. M
1. D/C Seroquel. Patient does not have any signs or
symptoms of agitation or psychosis. Can be
increasing sedation, can exacerbate Diabetes. Can
cause QTC prolongation.
2. D/C Ativan. Benzodiazepines do not treat
depression (tearfulness). Benzodiazepines can
increase confusion, lethargy, falls, cause agitation
and may increase depression.
Prognosis and Follow Up
 It will take 7 to 14 days to allow the medication to
wash out.
 Patient did not have prior psychiatric history
 This is a good prognostic indicator
 Greater likelihood that patient will return to baseline
 Avoid temptation to treat side effects with more
medication, this is called the prescribing cascade.
 Cannot determine if patient had dementia or
depression until delirium has resolved.
Pearls
 Multiple sources of information are key to
adequate assessment. Do not exclude the roles
of nursing, social work, physical therapists.
 Don’t assume because a patient is on a
medication that it should be continued.
 Antipsychotics are the drug of choice for
delirium but can be safely removed once the
acute episode has ended.
Pearls
 Medications are frequently prescribed for
reasons that they are not indicated.
 Dementia is the major risk factor for Delirium.
 Dementia and Depression commonly co-exist
and it can be difficult to distinguish between
the two.