Transcript Delirium - Clinical Departments - Medical University of South Carolina

Delirium
Ashley Duckett, MD
Pamela Pride, MD
Medical University of South Carolina
2012
CAM Definition of
Delirium
Acute onset or fluctuating course
AND
Inattention (decreased ability to focus, shift or
sustain attention)
PLUS EITHER
Disorganized thinking (incoherent or illogical
speech (questions – does a stone float on water, etc)
OR
Altered Level of Consiousness (anything other
than alert and calm) – RASS other than 0
Confusion Assessment Method- Inouye, Ann Intern Med 1990
-INATTTENTION is the cardinal feature for diagnosis
-Can use serial 7’s, WORLD, reciting days or months in
reverse, etc; ICU uses letter test (SAVEAHAART)
-SUBTYPES
-Hyperactive – agitated, hyperalert
-Hypoactive – calm and confused, lethargic
-Mixed – features of both
*no difference in etiology or outcomes among the subtypes
*hypoactive pts commonly missed without formal screen
The 3 D’s
Depression - Dementia - Delirium
Delirium
Dementia
Depression
Onset
Abrupt
Slow, insidious
Recent, may be
associated with
loss
Duration
Hours to days
Months to years
Stable, may be
worse in the
morning
Attention
Impaired
Normal, except severe cases
Usually normal
Consciousness
Reduced,
fluctuating
Clear
Clear
Silverstein & Maslow, 2006
Why do we care?


VERY common (esp if older, had ICU
stay) although underdetected
Increased morbidity and mortality
– Higher risk for falls, decubs, pna
– Higher risk of functional decline and
institutional care
– Longer LOS
– Predictor of 12 mo mortality
Risk factors (far from an exhaustive list)





Age >70
Dementia or underlying brain
dysfunction
Alcohol abuse
Hearing or visual impairment
History of delirium
Inouye et al, Multicomponent Intervention of Prevent Delirium
in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76)
Modifiable risk factors







Medications
Polypharmacy (>3 new inpt meds)
Physical restraints and catheters
Sleep deprivation
Immobility
Uncontrolled pain
Medical illness (organ failure, electrolytes,
etc)
Antiparkinson drugs
Insomnia drugs
Corticosteroids
Narcotics
UI drugs
Theophylline
Emptying drugs (motility drugs) Muscle relaxants
Seizures Drugs
Cardiovascular Drugs
H2 blockers
Look to these medications
Antimicrobials
if there is an
NSAIDs
ACUTE CHANGE IN MS
Geropsychiatric drugs
ENT drugs
http://www.geronurseonline.org;
Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly
prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric
Medicine, 14(1): 101-27.
Mini-Cog
Recall 0
Recall 1-2
Impaired
Abnormal Clock
Impaired
Borson S et al. (2000), Int J Geriatr Psychiatry 15(11):1021-1027
Recall 3
Not Impaired
Normal Clock
Not Impaired
Serial administration of a modified RASS for
delirium screening
Chester, JG et al. J Hosp Med 2012 May-June 7 (5) 450-3.
Evaluation







Vital signs, pulse ox, volume status
Focused exam including determining
baseline cognition, urine output, last BM
Blood glucose
Review medications
Consider withdrawal as a cause
Testing – CBC, BMP, UA, CXR, EKG
Additional testing if clinically indicated
Management


Try to identify underlying cause
Prevent complications and provide
supportive care
– Avoid bed rest, catheters, mobilize
patient
– Sleep at night, awake during day
– Monitor nutrition status and output
– Consider aspiration precautions
– Enlist the help of family
Management

Antipsychotics are drug of choice for
treating agitation
– Can consider treating hypoactive delirium to
treat subjective stress (paranoia, hallucinations)

Haldol – cheap, can be given PO, IV, IM
– CAN’T be used in Parkinson’s, Lewy body
dementia, prolonged QT

DON’T USE BENZOs UNLESS YOU’RE
TREATING WITHDRAWAL or NMS!!!
What’s the evidence?

Best drug? Haldol v Atypicals (Risperidone,
Olanzipine, Quetipine)
– Systematic reviews show similar efficacy,
question of fewer side effects
– NEED larger and better studies

2005 FDA warning re risk of death
– Use for shortest duration, with caution
– NEED larger and better studies
Haldol and EKGs?





Concern for prolonged QTc and torsades or
polymorphic VT
Review showed that most conduction
disturbances involve heart disease and high
doses (50mg/24 hrs)
More recent review – heart dz, >65, female,
hypokalemia
Stop if QTc>500
Don’t wait to give Haldol until after EKG
Lawrence, Pharmacotherapy 1997; 17(3);531-537
Screening Inpatients




Delirium task force
Goal should be prevention; cutting
back on physical restraints
Nurses will screen each shift with
RASS
Delirium protocol - order set with
suggested workup and drug dosing
based on patient factors
References

DSM-IV TR, 2000
Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized
Older Patients, NEJM; 1999 (340) 9:669-76)

Borson S et al. (2000), The mini-cog: a cognitive 'vital signs' measure for
dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 15(11):10211027

Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly
prescribed and over-the-counter remedies: causes of confusion. Clinics in
Geriatric Medicine, 14(1): 101-27.

http://www.geronurseonline.org

Lawrence, Conduction Disturbances Associated with Administration of
Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature.
Pharmacotherapy 1997; 17(3);531-537

Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of
Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): 687-93

Delirium. Updates in Hospital Medicine 2012. Harvard Medical School

Antipsychotics for delirium. Cochrane review
