Transcript Slide Presentation: Part II - Curriculum for the Hospitalized Aging

CHAMP
Delirium Part 2:
Evaluation & Management
Andrea Bial, M.D.
University of Chicago
Goals
1. Develop a plan for teaching a
Systematic Approach to the
Evaluation of hospitalized older
patient with delirium.
2. Develop a plan for teaching an
appropriate Treatment Plan for the
hospitalized older patient with
delirium
Overnight Events:
Morning Rounds at the Bedside
• 75yo W admit 2d ago w/ COPD,
bronchitis
• Intern reports: o/n she pulled out her IV,
thought she was at home
• X-cover ordered Prosom 1mg & po abx
Overnight, cont’d
• Currently, pt w/o c/o. Doesn’t recall
events of previous night.
• PE: sleepy, arouseable
37.6 148/62 88 20 93%2L
Lungs w/ faint wheeze bilat
Rest w/o change
Labs WBC 13.2, diff P; H/H stable
Na 133, BUN 26, Cr 1.2
Overnight, cont’d
• A/P #1) COPD—cont nebs, steroids, po
abx
#2) HTN—stable on meds
#3) Confusion—add risperdal 1mg
QHS prn
#4) Disp—await PT/OT
Systematic Approach to the
Evaluation of Delirium
• No one “gold standard” approach
• Multiple Mnemonics (e.g., Delirium) &
algorithms
• Need individualized, systematic approach
to avoid missing potential causes
• Few studies exist specifically looking at
causes
Evaluation of Delirium: Causes
• Francis (1990)
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Large teaching hospital
General medicine patients (n=229)
Delirium developed in 22% (n=50)
Determined cause(s) as: definite, probable, or
possible
• 18 (36%) w/ one definite cause
(Drug toxicity, then infection=fluid/lyte
imbalance)
• 10 (20%) w/ one probable cause
• 22 (44%) w/ >1 cause; 62 possible etiologies (2.8/pt)
DELIRIUM
Evaluation
History
(dementia?) and
Physical Exam
(head to toe)
Management
NON-AGITATED
PATIENT:
Non-Pharmacologic
treatment
FOCAL EXAM:
Do appropriate next
step (e.g.,fevercx)
THEN, review meds&
Order other tests
Treat Findings &
Manage symptoms
NON-FOCAL EXAM:
Review meds
Order addn’l tests
Treat Findings &
Manage symptoms
AGITATED
PATIENT:
Non-Pharmacologic
& Pharmacologic tx
Evaluation:
Dementia Teaching Points
1.
2.
3.
4.
Hx of dementia?
Hx of sundowning?
Agitated dementia ≠ delirium
Importance of considering dx:
DEMENTIA
DELIRIUM
Evaluation: Physical Exam
• Head to toe:
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Vitals (temp, HR, RR, BP, pulse ox, pain)
Head (CVA, bleed, meningitis, sz, blind, deaf)
Lung (pneumonia, PE, CHF)
Chest (ischemia, CHF, arrhythmia)
Abd (ischemia, impaction, bleed)
GU
(UTI, retention)
Extrem (pain, volume status, CVA)
Skin (pressure ulcer, volume status)
Evaluation: Head CT?
• No evidence to support routine
ordering
• Order if:
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new focal finding(s) on exam
head trauma
suspicion of encephalitis
no other identifiable causes found
Evaluation: Medication Review
• Too little (alcohol or other drug w/d)
– Francis (1990) 1/50pts (2%)
– Lawlor (2000) 4/71pts (6%)
• Too much
– narcotics, neuroleptics, anticholinergics,
antiemetics
Francis 1990, Schor 1992, Lawlor 2000
Evaluation: Medication List
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Antibiotics (aminogly, PCN, ceph, sulfa)
Benadryl
Benzodiazepines (triazolam, alprazolam, diazepam)
Digoxin
GI (Reglan, Bentyl)
Lithium
Narcotics
Neuroleptics
Steroids
NSAIDs (Indocin)
H2 Blockers (Cimetidine,…)
Parkinsons drugs (Levodopa, Benztropine, Amantadine)
Tricyclics
Evaluation: Medication List
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Antibiotics (aminogly, PCN, ceph, sulfa)
Benadryl
Benzodiazepines (triazolam, alprazolam, diazepam)
Digoxin
GI (Reglan, Bentyl)
Lithium
Narcotics
Neuroleptics
Steroids
NSAIDs (Indocin)
H2 Blockers (Cimetidine,…)
Parkinsons drugs (Levodopa, Benztropine, Amantadine)
Tricyclics
Evaluation: Medications, cont’d
Anticholinergic properties frequently
overlooked:
Elavil (amitriptyline)
Cogentin (benztropine)
Bentyl (dicyclomine)
Ditropan (oxybutynin)
Detrol (tolterodine)
Benadryl (diphenhydramine)
Zyprexa (olanzapine)
Levsin (hyoscyamine)
Flexeril (cyclobenzaprine)
Atarax/Vistaril(hydroxyzine)
Welbutrin/Zyban (bupropion)
Antivert (meclizine)
Ipratropium (atrovent)
Phenergan (promethazine)
Atropine
Quinidine
Evaluation: Additional tests
• Labs
– CBC, lytes, liver, renal
– Consider TSH, B12, cortisol, ammonia, abg
• Drug levels (digoxin, etc)
• Urine tox, UA
• CXR
• EKG
• EEG
Evaluation: EEG
• Since 1950’s, recommendations for EEGs
• Usually: generalized slowing
• Sensitivity 75%
Management: Non-Pharmacologic
• Cognition: orientation board (carry pen!) & open drapes
during day
• Sleep: minimize deprivation (no 2am labs, no o/n
BS/vitals if able, give meds when awake)
• Mobility: OOBchair asap, PT/OT, no foley/restraints
• Vision: glasses
• HOH: get aids; adapt environment; stethoscope trick
• Dehydration: po fluids; observe at mealtime; avoid “Boost
at nightstand”
• Observation: Involve family (rotate members) or get sitter;
move pt to room close to RN station
Management: Non-Pharmacologic
Restraint Use
• Avoid whenever possible; use only if
needed for patient or staff safety
• Increase risk of falls, injury, agitation &
worsened delirium
• Use only in emergency, for as short a
duration as possible with frequent reevaluations, and d/c asap
• Absolutely no “sheeting”
Management: Pharmacologic
• Few RCT of treating delirium in hosp pt
• Extrapolation from other populations studied
(AIDS, NHs, outpatient AD, …)
• Mainstay of tx: antipsychotics
– NOT FDA-approved for use in delirium
– Need to choose type and dose carefully
– Black box warning of increased mortality w/ use of
antipsychotics in older pts (infectious and cardiac
causes of death)
• See Table in handout
Management: Pharmacologic
Antipsychotics
Typical: Haloperidol
Advantages:
Disadvantages:
Dose:
min sedating
less ↓BP
↑ sz risk
more EPS side effects
↑ QT
↑ risk of Torsades
0.25-0.5mg po, IM, IV *
*risk of QTc prolongation w/ IV
APA 1999
Management: Pharmacologic
Antipsychotics, cont’d
Atypicals:
Advantages:
Disadvantages:
less EPS
+/- sedation
↓ BP
weight gain
↑ BS
↑mx (infection, CVS)
Management: Pharmacologic
Antipsychotics, cont’d
Starting Daily Doses:
Risperidone:
0.25-0.5mg PO
Olanzapine: 2.5-5mg IM,PO
Aripiprazole: 2-5mg PO
Quetiapine: 12.5mg-25 PO bid*
*some concern for QTc prolongation; better in PD pts
Management: Pharmacologic
Benzodiazepines
Should not be used as first-line agents; may
prolong or worsen delirium
Used best if pt is delirious due to w/d of
EtOH or benzo’s
– Consider use in PD, NMS
– Consider use as second-line, esp if sedation is
desired
Lorazepam 0.5-1mg PO, IM, IV q4-6hrs
(no adjustment needed for liver or renal dz)
Management: Pharmacologic
Bottom Line
• Try to avoid meds, but if needed:
– Use haloperidol (or olanzapine) in acute
settings; start low and titrate carefully
according to symptoms.
– Use risperidone, if needed for longer-term use
(unless PD: quetiapine or lorazepam)
– Use lorazepam for w/d
Back to case!
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75yo W admit 2d ago w/ COPD, bronchitis
Intern reports: o/n she pulled out her IV, thought she was a home
X-cover ordered Prosom 1mg & po abx
Currently, pt w/o c/o. Doesn’t recall events of previous night.
PE: sleepy, arouseable
37.6 148/62 88 20 93%2L
Lungs w/ faint wheeze bilat
Rest w/o change
Labs WBC 13.2, diff P; H/H stable
Na 133, BUN 26, Cr 1.2
• A/P #1) COPD—cont nebs, steroids, po abx
#2) HTN—stable on meds
#3) Confusion—add risperdal 1mg QHS prn
#3) Disp—await PT/OT
Teaching Points
1. Ask: What do you think caused last night’s
events?
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Was a h/o dementia missed?
(dementia/delirium relationship; role of MMSE;
further family hx)
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Was her PE different at the time x-cover was
called?
(systematic evaluation/head-to-toe)
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Did we start or alter dose of any medications?
(nebs, steroids, abx)
Teaching Points, cont’d
2. Ask: Is she delirious now?
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Discuss use of CAM
(comfort of tool; dx of delirium in chart)
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Discuss outcomes of delirium
(increases: LOS, healthcare costs, mx, d/c to LTCF)
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Discuss use of Prosom (and other benzo’s) in
delirium
Teaching Points, cont’d
3. Ask: Is there anything we should do today
to follow-up on her confusion?
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Discuss further studies that may or may not be
needed
(CXR? UA? Repeat Na?)
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Discuss the non-pharmacologic measures that
should be put into place
(orient board, fluids, mobility, drapes, HS nebs & labs)
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Discuss use of risperidone (and other
antipsychotics) in delirium
Recommended Reading
• Inouye SK. Delirium in older persons. NEJM
2006;354:1157-65
• Schneider LS et al. Effectiveness of atypical antipsychotic
drugs in patients with Alzheimer’s disease. NEJM
2006;355:1525-38.
• Sink KM et al. Pharmacological treatment of
neuropsychiatric symptoms of dementia. JAMA
2005;293:596-608.
• Breitbart W et al. Agitation and delirium at end of life.
JAMA 2008;300(24)2898-2910.
• Martins S. Delirium in elderly people: a review. Front
Neuro 2012;3(101)1-12.