Transcript Delirium

Managing Delirium in the
Emergency Department
Introduction
• Not a talk about the agitated patient
• They’re easy and there is lots of literature
- sedate, intubate and let ICU sort it out
Talk about delirium
- emphasis on the emergency department
- very little literature
- big management problem
Introduction
• Managing a patient with delirium is difficult
and labour intensive
• A bigger problem is actually recognising
that the patient has a delirium
• The 2 groups where we need to have a
high index of suspicion are the elderly and
the (first presentation) psych patient
Delirium
• Neuropsychiatric Syndrome
- multiple causes
- produce a similar constellation of
symptoms
Delirium Definitions
• A sudden and significant decline in mental
functioning not better accounted for by a
preexisting or evolving dementia
• Disturbance of consciousness with
reduced ability to focus, sustain, and shift
attention
DSM-IV Diagnosis
• DSM-IV
– A. Disturbance of consciousness with reduced
ability to focus, sustain, or shift attention.
– B. A change in cognition or the development of
a perceptual disturbance that is not better
accounted for by a pre-existing, established, or
evolving dementia.
– C. The disturbance develops over a short period
of time and tends to fluctuate during the course
of the day
– D. There is evidence from the history, PE, or labs
that the disturbance is caused by the direct
physiologic consequences of a general medical
condition
Introduction
• Simplest definition of delirium is “acute
brain failure” with a combination of
- behavioural symptoms
- psychological symptoms
- cognitive symptoms
- neurological symptoms
Introduction
• Common presenting problem
> 40% of patients over 65
• Frequently develops during an admission
• Frequently misdiagnosed as psych or
dementia
- overlap of symptoms
- dementia predisposes to delirium
Introduction
• Frequently missed all together
• We forget that there are a range of
presentations
- agitated delirium
- quiet delirium
- mixed
Why Does Delirium Matter?
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Increased morbidity and mortality
Increased length of stay
Increases rate of cognitive decline
Increased distress to patient and family
- may believe delusions and hallucinations
really happened even after delirium
resolved
Behavioural Symptoms
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Aggressive or agitated
Quiet and withdrawn
Screaming / calling out
Wandering
Disinhibited
Altered sleep-wake cycle
Behavioural Symptoms
• Constant questioning
• Hide things / hoarding objects
• Frontal lobe release
- picking at the air / bed clothes
- pulling on IVC or IDC
Psychological Symptoms
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Anxiety
Paranoid
Delusions (usually persecutory)
Hallucinations (usually visual)
- auditory hallucinations: think psych
- visual delusions: think delirium
Cognitive Symptoms
• Can’t focus / inattention
- beware of the “vague historian”
• Can’t shift focus
• Can’t solve problems
• Trouble with abstract thought
• Impaired recent and remote memory
Neurological Symptoms
• Dysphasia
• Dysarthria
• Tremor
Psychiatry and Delirium
• Many of the symptoms of delirium also can
occur in a psychiatric illness
- easy to see why there is confusion
• Liason psych are often called to review
patients whose delirium has been missed
by the treating team
“Psychiatric Symptoms”
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Altered mood
Altered behaviour
Altered thought or cognition
Altered perception
If patients are triaged with these problems,
we jump to the conclusion that is a psych
illness
“Psychiatric Symptoms”
• May be caused by or aggravated by a
medical illness (organic illness)
• Incidence is unclear
- 10 to 75% range quoted in A&E literature
Medical illness is a significant cause of
“psychiatric symptoms”
“Psychiatric Symptoms”
• Unfortunately, medical illnesses often go
unrecognized due to inadequate and poorly
documented medical assessment in A&E
Tintinelli (1994)
- assessment of: mental state 40 – 80%
LOC 80 – 95%
orientation 70 – 90%
full motor exam 50 - 60%
cranial nerves 20 – 55%
“Psychiatric Symptoms”
• Reeves (2000): still the same problem
• 64 patients with medical illness admitted
inappropriately to a psychiatric unit
- full history 66%
- vital signs 90%
- full physical exam 65%
- full mental state exam 0%
“Psychiatric Symptoms”
• Problems with medical assessment are
not due to a lack of imaging or esoteric
blood tests.
• The problem is a failure to do a thorough
history, examination and mental state
examination
ie we aren’t doing the basics
Psych Vrs Delirium
• First presentation of a psych illness is rare
over 45 years of age
• Auditory hallucinations are more common
• Even floridly psychotic patients tend to
remain orientated to time and place
• Memory is usually intact
• Does not fluctuate over the course of a
day
Delirium Vrs Dementia
• Memory deficits, language disturbances
and disorganized thinking are common to
both diagnoses
• Need to know the patients baseline, what
has changed and how quickly it has
changed
• Need a good history from multiple sources
Delirium versus Dementia
• Delirium
Rapid onset
Primary defect in attention
Fluctuates during the
course of a day
Visual hallucinations
common
Often cannot attend to
MMSE or clock draw
• Dementia
Insidious onset
Primary defect in short
term memory
Attention often normal
Does not fluctuate during
day
Visual hallucinations less
common
Can attend to MMSE or
clock draw, but cannot
perform well
Pathophysiology of Delirium
• Systemic pathology leading to a local
inflammatory response in the brain with
subsequent changes in neurotransmission
- we don’t care
• It involves predisposing factors and
precipitating factors
- we do care
Pathophysiology of Delirium
Can use predisposing factors to predict who
is at risk of developing delirium
Can use precipitating factors to guide our
management strategies
Pathophysiology of Delirium
Predisposing factors
- Children and elderly (<10 & > 65)
- history of brain disease (dementia, CVA)
- history of delirium
- impaired vision or hearing
- medications (benzo’s; anti-cholinergics)
- alcohol dependance
- psych history
Pathophysiology of Delirium
• Precipitating factors
- lots
• The main ones are
- underlying medical condition
- substance intoxication
- substance withdrawal
- combination of any or all of these
Pathophysiology of Delirium
Other Precipitating Factors
- new medications
- invasive procedures (IVC; IDC; NG)
- fluid and electrolyte abnormalities
- metabolic disturbances
- change of environment (ED is bad!)
- nutritional deficiencies
Pathophysiology of Delirium
• The more precipitants, the greater the
chance of developing a delirium
• The more predisposing factors, the fewer
precipitating factors are needed to trigger
delirium
- In the frail elderly, constipation alone
can trigger delirium
Making the Diagnosis
• Delirium is common
• Delirium is important
• Delirium seems really complicated
• How can I make the diagnosis?
Medical Assessment
• Stable / Unstable
• Danger to Self or Others
• Detailed History
- medical & psychiatric
- from multiple sources
- baseline ADL, cognition, behaviour etc
eg family, ambo’s, bystanders, NH
GP, old notes, CMH team
Clues for an Organic Cause
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Age less than 12 or greater than 40
Sudden onset (hours to days)
Fluctuating course
Disorientation
Decreased consciousness
Visual hallucinations
No psychiatric history
Emotional lability
Abnormal vitals / physical examination findings
History of substance abuse or toxin exposure
Clues for a Functional Cause
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Age 13 to 40 years
Gradual onset (weeks to months)
Continuous course
Awake and alert
Auditory hallucinations
Psychiatric history
Flat affect
Normal physical examination findings (including
vital signs)
Medical Assessment
• Full physical Examination
- head to toe
eg head / neck / CVS / lungs / abdo
neuro / periphery / skin
- includes vital signs
eg BP, HR, RR, Temp, BSL, RAIR sats
Medical Assessment
• Bedside tests
- mental state exam
- mini mental exam
- EEG
- CAM
Making the Diagnosis
Mini Mental
- Useful at separating “normal” from
“abnormal”
- Not specific for distinguishing
delirium from dementia
- May be useful as change from
baseline
- Suggestive if score varies during or
between days
Making the Diagnosis
• Mini mental does include tests of attention
- serial 7’s
- spell “world” backwards
Other simple tests
- counting backwards from 20
- days of week backwards
- month of year backwards
EEG
• Can be diagnostic
- generalised slowing of brain activity
• Significant false positive and negative rate
• Is done on the wards
- but is it useful?
• Not done in A&E
Confusion Assessment Method
Is there evidence of:
1) Acute onset and fluctuating course
2) Inattention
3) Disorganized thinking
4) Altered LOC (increased or decreased)
1 and 2 and either 3 or 4
Sens = 95% spec = 90%
Confusion Assessment Method
1) Acute onset & fluctuating course
- is there an acute change from the
patient’s baseline?
What are they normally like, what has
changed and when did it change
Confusion Assessment Method
2) Inattention
- did the patient have difficulty keeping track
of what was being said?
- can’t focus
- can’t shift focus
- Serial 7’s
- World backwards etc
Confusion Assessment Method
3) Disorganized thinking
- rambling conversation
- unclear or illogical flow of ideas
- Interpret a proverb
- “Will a stone float on water?”
CAM Diagnostic Algorithm
4) Altered level of consciousness
- alert (normal),
- vigilant (hyperalert),
- lethargic (drowsy, easily aroused),
- stupor (difficulty to arouse)
Any answer other than “alert” is abnormal
Management
• The key is to identify and treat the
underlying causes
Also need to:
- minimise patient anxiety
- prevent harm to the patient
Management: Investigations
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Not to make the diagnosis
To help guide our treatment
Often use a “shotgun” approach
EUC, FBC, LFT, MSU, blood cultures,
cardiac biomarkers, CT brain, ABG, ECG,
CXR, PR, etc etc etc
Management: Treatment
• Can treat against their will using the
mental health act
• Non-pharmacological Strategies
• Pharmacological Strategies
Soapbox Moment
• We used to have a CNC for dementia and
delirium but admin in their wisdom has
terminated the position
• Each speciality has a CNC who should be
involved early in the management of
admitted patients with a delirium
Non-pharmacological Treatment
• “A calm, quiet atmosphere, frequent
prompts concerning orientation, clear
precise communications and a night light
are helpful in the management of delirium”
Some dude who has never stepped foot
inside an Emergency Department
Non-pharmacological Treatment
• Numerous strategies that aren’t practical
in ED (or wards either?)
1)Providing support and orientation
2)Providing an unabiguous environment
3)Maintaining Competence
Non-pharmacological Treatment
In English
- Frequent reminders about time and place
- Constant reassurance
- Staff to wear name tags and indentify
themselves often
- Minimise stimuli (noise, lights, procedures)
- Place familiar objects in room
- Minimise the number of staff involved in
care
Non-pharmacological Treatment
• Patients with delirium are unpredictable.
• Unpredictability = bad things happen
- fall; pull out vascaths; abscond; ride
around naked in elevators
• They need a special.
• If none available, place the bed where
they can be seen at all times
Pharmacological Treatment
• Not Indications
- calling out
- wandering
- convenience of staff
No drug will stop a patient from wandering.
Drugs will help a wandering patient fall
Consider sedating the nurse
Pharmacological Treatment
Indications for drug therapy
- relieve patient anxiety
- behaviour putting patient or others at risk
- agitation distressing to patient
Not aiming to sedate the patient
Trying to calm them down
Pharmacological Treatment
• No good evidence based studies
• Large range of treatment guidelines
• Are now Australian Best Practice
Guideines
Pharmacological Treatment
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Aim to use one drug
Keep doses to a minimum
Avoid escalating doses
Seek expert advice early
Review medications daily
Benzodiazepines
• Don’t use as a first line agent
- long half life & easy to over sedate
- respiratory depression
- may worsen delirium
- no anti-psychotic actions
- role in alcohol withdrawal & terminal
delirium
Haloperidol
• Haloperidol
- first line in the Australian Guidelines
- widely used (outside of Westmead ED)
- oral, IM or IV
- no agreement in dosing strategy
- “start low, go slow”
Haloperidol Dosing
• 0.5 to 1 mg initially
• repeat in 30 mins to 2 hours if needed
• Maximum 2 to 4 mg / 24 hours
Haloperidol
• Haloperidol in ICU
- 1 , 2 or 5 mg IV
- double dose every 30 minutes till settled
- then give total 24 hr dose as qid on
subsequent days
Second Line Agents
• If after haloperidol, there are prominent
psychotic features
- risperidone
- olanzepine
• If after haloperidol, agitation is prominent
- lorazepam
Resperidone
• 0.25 to 0.5 mg PO, Q4 hourly, PRN,
maximum 2 mg / day
• Maximum 4 mg / 24 hours
• Side effects include hypotension and
sedation
Olanzapine
• Tablets, wafer, IM
• 2.5mg If needed repeat in 4 hours
• Maximum 10 mg / 24 hours
Lorazepam
• 0.5 – 1 mg initially
• If needed repeat in 4 hours
• Maximum 3 mg / 24 hours
Conclusions
• Maintain a high index of suspicion for
delirium in elderly patients and possible
psych patients
• Remember the red flags for organic &
functional illness
• Thorough exam & clear documentation
Conclusions
• Remember the CAM
• Try to avoid drug therapy
• Calling out and wandering are not
indications for drug treatment