Transcript Delirium in Older Adults

Delirium in Older Adults
Kathleen Pace Murphy, PhD, MS, GNP-BC
Assistant Professor, UTHealth Division of Geriatric and Palliative Medicine
Deputy Director, Consortium on Aging
Kathleen Pace Murphy, PhD, MS, GNP-BC
Assistant Professor, UTHealth Medical School
Division of Geriatrics and Palliative Medicine
Deputy Director, Consortium on Aging
Neither I nor members of my immediate family
have any financial relationship with commercial
entities that may be relevant to this
presentation.
Delirium Incidence
• 10-24 percent of the hospital patient
population
• Incidence increases with patient complexity
• 60 percent occurs in older adult patients
• 60-80 percent incidence in those admitted to
a Medical ICU
• 80-90 percent in older adults with terminal
cancer.
Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Critical Care Clinics.
2008;24:657-722/
Delirium or Acute Confusional State
DEFINITION
• Syndrome
• Acute Brain Failure
• Characterized by:
– Acute
– Disturbance in consciousness
– Reduced ability to focus, sustain or shift attention
– Occur over short period of time
– Fluctuates over the course of a day
Etiology
• Potential causes of delirium include:
o Inadequate pain control
o Drug or toxin
o Metabolic disorders
o Neurovascular insult
o Systemic organ failure
o Complications from a systemic disease
Figure out the trigger
Drug use (hypnotics, anticholinergic) (30%)
Electrolyte abnormalities (40%)
Lack of drugs (withdrawal)
Infection (40%)
Reduced sensory input (24%)
Intracranial problems (stroke)
Urinary retention and fecal impaction
Myocardial or metabolic problems (14- 26%)
Often combination of several of the above.
Francis J, Martin D, Kapoor W: A prospective study of delirium in hospitalized elderly. J Am Med Assoc. 263:1097-1101 1990
Delirium
Increased mortality
Poorer functional status
Limited rehabilitation
Increased hospital-acquired complications
Prolonged hospital stay
Increased risk of institutionalization
Higher health care expenditures.
Differential Diagnosis
• Hypoactive Delirium
• Hyperactive Delirium
• Mixed Delirium (46%)
• **The main feature differentiating delirium
from depression from dementia:
Acute – fluctuating nature of symptoms
Delirium Differential Diagnosis
Depression
Delirium
Dementia
Onset
Weeks to months
Hours to days
Months to years
Mood
Low Apathetic
Fluctuates
Fluctuates
Course
Chronic, Responds
to treatment
Acute, responds to
treatment
Chronic, with
deterioration over time.
Self-awareness Likely to be
concerned about
memory
Maybe aware of
changing cognition
Hide or be unaware of
memory
ADLs
May neglect basic
self-care
Intact or impaired
Intact early, impaired as
disease progresses
IADLs
Intact or impaired
Intact or impaired
Intact early, impaired
before ADLs as disease
progresses
Sarutzki-Tucker & Ferry, 2014
Clinical Presentation
• Clinical manifestations appear over a shorter
period of time (few days)
• Progressive decline in memory, awareness to
surroundings or behavior
• Fluctuate throughout the day
• Inability to maintain normal sequential
thought
PATHOPHYSIOLOGY
• Pathophysiology is unclear
• Widespread derangement of cerebral metabolism or
cerebral insufficiency that leads to decreased synthesis
of cerebral neurotransmitters, especially acetylcholine.
• Brain maladaptive reaction to acute stress (Ham et al,
2014)
• The core group of clinical manifestations:
–
–
–
–
Attention deficits
Sleep-wake cycle disturbance
Motor activity changes
May present as psychosis, mood changes, fluctuating LOCs,
disorientation, memory impairment, and disturbances in
speech and language.
MORTALITY
• Delirium is a medical emergency
• Persons who have delirium have a statistically
significant higher risk of death compared to
age cohorts who do not.
Medication Hierarchy
• Level 1 - Neuroleptic
Level One - Neuroleptics
• Level
- – Analgesics; Sedatives-Hypnotics; Dopamine agonists
Level 2
Two
• LevelLevel
3 Three – Antihistamine; anti-inflammatory;
anticholinergic; antidepressants; cardiac glycosides
Level Four – H2 Antagonist, Dihydropyridine;
Tricyclic antidepressants; anti-Parkinson;
antimicrobials
ANTICHOLINGERGIC
MEDICATIONS
Play a major role in
delirium development
Cumulative anticholinergic
burden
**ACA= anticholinergic
activity
Score 3- High ACA
Score 2 – Moderate
ACA
Score 1 – Mild ACA
Amitriptyline
Amantadine
Alprazolam
Atropine
Belladonna
Atenolol
Clozapine
Carbamazepine
Bupropion
Darifenacin
Cyclobenzaprine
Captopril
Desipramine
Cyproheptadine
Chlorthalidone
Diphenhydramine
Loxapine
Cimetidine
Doxepin
Meperidine
Clorazepte
Hydroxyzine
Methotrimeprazine
Codeine
Imipramine
Molindone
Colchicine
Nortriptyline
Oxcarbazepine
Diazepam
Olanzapine
Pimozide
Digoxin
Oxybutynin
Fentanyl
Paroxetine
Furosemide
Quetiapine
Haloperidol
Tolterodine
Metoprolol
Imipramine
Prednisone
Screening Tools
• Richmond Agitation Sedation Scale (RASS)
• Confusion Assessment Method (CAM)
• Confusion Assessment Method for ICU (CAMICU)
• Neelon and Champagne Confusion Scale
(NEECHAM)
E. Wesley Ely, MD MPH and Vanderbilt University, 2002.
Confusional Assessment Method (CAM)
Delirium if you have 1 + 2 +[either 3 or 4].
Diagnostic Features
Definitions and Characteristics
1. Acute Onset
Fluctuating Course
• Is there evidence of an acute change in mental status from
baseline?
• Did the abnormal behavior fluctuate during the day, does it
come and go, or increase and decrease in severity?
2. Inattention
• Did the patient have difficulty focusing attention (easily
distracted) or have difficulty keeping track or what was being
said?
3. Disorganized
Thinking
• Was the patient’s thinking disorganized or incoherent, e.g.
rambling, irrelevant conversation, unclear or illogical flow of
ideas, or unpredictable switching from subject to subject?
4. Altered LOC
• LOC – alert (normal), vigilant (hyper alert), lethargic (drowsy but
easily arousable), stupor (difficulty to arouse) or coma
(unarousable)
Inouye SK, vanDyck CH, Alessi CA, et al. Clarifying confusion: The Confusion Assessment Method. A new method for
detection of delirium. Ann Intern Med 1990:113:941-8.
Delirium Management Listical
• Knowledge and addressing the underlying
cause
• Be mindful of the environment
• Do not over stimulate
• Good patient care
• Medications (hopefully last resort)
Assessment
Vital Signs: BP, P, HR, T, Pulse Ox, Pain
Physical Examination
Urinalysis
Cr, Na, K, Ca, Glucose
CBC with differential
Review old and new anticholinergic medications
Review old and new sedating medications
Review the need for Foley catheters, IV lines, and
other tethers
Apply glasses, insert hearing aides
Intervention Step 1
• Identify and Treat reversible contributors
– Medications
– Infection
– Fluid balance disorders
– Impaired CNS oxygenation
– Severe pain
– Sensory deprivation
– Elimination Problems
Intervention Step 2
• Maintain behavioral control
– Behavioral interventions
– Pharmacologic Interventions
• Necessary for behavior that is dangerous to patient or
others and does not respond to other management
strategies
Intervention 3
• Anticipate and prevent or manage
complications
– Urinary incontinence
– Immobility and falls
– Pressure ulcers
– Sleep disturbance
– Feeding disorders
Intervention 4
• Restore function in delirious patients
– Hospital environment
– Cognitive reconditioning
– Ability to perform ADL
– Family education/support/ participation
– Discharge
Prevention
• Limit use of medications known to cause
delirium
• Ensure good nutrition and hydration
• Correct sensory deprivation
• Encourage normal sleep patterns
• Promote cognitive stimulation
Prognosis
• Delirium is usually reversible.
• Take several weeks for mental function to
return to normal levels
• The longer the delirium goes untreated –
there is worsening global cognition and
executive function worsening.
• Pathophysiological evidence – inflammation –
neuronal apoptosis – brain atrophy
References
• Catic AG. Identification and management of in-hospital
drug-induced delirium in older patients. Drugs Aging.
2011:28(9):737-748.
• Clegg A, Young JB. Which medications to avoid in
people at risk of delirium: a systematic review. Age
and Ageing. 2011. 40:23-29.
• Gatewood M. Managing delirium among elderly
patients in the ED. Physician’s Weekly, 2013.
• Maldonado JR. Delirium in the acute care setting:
characteristics, diagnosis and treatment. Critical Care
Clinics. 2008;24:657-722.
• Reade MC, Finfer S. Sedation and delirium in the
intensive care unit. New England Journal of Medicine
2014;370(5):444-454.
• Sarutzki-Tucker A, Ferry R. Beware of delirium. The
Journal for Nurse Practitioners 2014:10(8); 575-581.