Transcript The Elderly Patient with Delirium

The Elderly Patient with Delirium
Thomas Price, MD
Emory University School of Medicine
Division of Geriatric Medicine and Gerontology
Overview
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Definition
Presentation
Pathophysiology
Risk Factors
Prevention
Management
Consequences
What’s Going On?
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BT is an 85 year old man who has been
admitted to the hospital for repair of a hip
fracture he sustained while playing golf
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He has a history of hypertension and
hypercholesterolemia, both of which are treated
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On review of systems, he admits to some
“memory problems” and difficulty sleeping at
night
What’s Going On?
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The day after admission he undergoes total hip
replacement
Blood loss is estimated at 300cc
Two units of blood transfused during the
surgery
Seems to recover well the next day after
surgery, is talking with his family about “getting
back on the course”
What’s Going On?
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Four days post-op his wife voices concern that
he is “not himself”
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He seems to ignore her at times during
conversations and is not eating much
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She says he is often confused, saying that he
asks her if she’s “taken the dog out” when they
haven’t had a dog in years
What’s Going On?
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That night he pulls his IV line out and is
witnessed trying to remove his Foley catheter
by the nurse
Definition
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DSM-IV
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Disturbance of consciousness with reduced ability to focus,
sustain, or shift attention.
A change in cognition or the development of a perceptual
disturbance that is not better accounted for by a preexisting,
established, or evolving dementia.
The disturbance develops over a short period of time and tends
to fluctuate during the course of the day.
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, DSM-IV
Definition
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Confusion Assessment Method (CAM)
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Inouye et al, 1990
56 subjects (65-96 yrs old), 26 with delirium and 30
without, measured with CAM
Results
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94-100% sensitive
90-95% specific
PPV 91-94%, NPV 90-100%
Interobserver reliability of CAM is high (=0.81-1.0)
Inouye, SK et al. Annals of Internal Medicine
1990;113:941-948
Definition
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Confusion Assessment Method (CAM)
 All of:
• Acute onset
• Fluctuating course
• Inattention
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And one of the following:
• Disorganized thinking
• Altered level of consciousness
Inouye, SK et al. Annals of Internal Medicine
1990;113:941-948
Definition - ICU Patients
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Modified CAM - The CAM-ICU
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Ely et al. modified CAM
• Visual recognition to test attention and short-term
memory
• Scale based on degree of consciousness
• Head nodding and hand movements as
responses
• Sensitivity and specificity comparable to the basic
CAM
Ely EW et al. Crit Care Med 2001;29(7)
Presentation
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Types of Delirium
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Hyperactive Delirium
• Agitation, vigilance, hallucinations
• Easiest to recognize (loud, disruptive patients)
Hypoactive Delirium
• Lethargy, reduced psychomotor functioning
• More likely to go unrecognized (“good patients”)
Mixed Delirium
• Features of both hypo- and hyperactive delirium
Normal Consciousness Delirium
• Meet CAM criteria due to disorganized thinking
Flacker, JM and Marcantonio ER Drugs & Aging 1998;13(2):119-30
Presentation
Normal
13%
Hypoactive
13%
Mixed
57%
Hyperactive
17%
Original graphic by Thomas Price, adapted from data by Lipzin B, Levkoff SE (Br J Psychiatry 1992;161:843-5)
Presentation
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So we can say that delirium…
Is a common complication of illness in the
elderly
 Is an acute change in mental status
 Always fluctuates
 Always features abnormal attention
 Is often a “missed diagnosis”
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Consequences
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Morbidity and mortality
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Francis and Kapoor, 1992
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229 pts >70 years (223 survived hospitalization)
followed up for 2 years
• RR of Death
1.82 (1.04-3.19)
• RR of Institutionalization
1.82 (1.31-2.53)
• RR if pt with cancer
2.61 (1.32-5.18)
• RR if pt with ADL dependence 2.00 (1.03-3.89)
Francis J and Kapoor WN, JAGS 1992:40(6);601-606
Pathophysiology
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Cholinergic System
Central cholinergic inhibition
 Elevated serum anticholinergic activity
 Endogenous anticholinergic substances
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• Dynorphin A
• Myelin Basic Protein
• Protamine
Flacker, JM et al. Am Journal Geriatric Psych 1998;6(1):31-41
Flacker, JM and Lipsitz LA Journal of Gerontology 1999;54A(1):M12-16 and 54A(6):B239-246
Pathophysiology
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Cholinergic System
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Direct drug binding of receptors
• Atropine, scopolamine
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Muscarinic binding of drug metabolites
• Furosemide, cimetidine, digoxin
Flacker, JM and Lipsitz LA Journal of Gerontology 1999;54A(6):B239-246
Pathophysiology
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Serotonin
Affects cognition, mood and wakefulness
 Serotonin depletion
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• Phenyalanine  tryptophan  serotonin
• Limited trials show branched-chain amino acid infusions
reduce phenylalanine and increase cognition
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Can cause delirium in both over-stimulation
and deficiency
• SSRIs for delirium?
Flacker, JM and Lipsitz LA Journal of Gerontology 1999;54A(6):B239-246
Pathophysiology
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Other biochemical suspects
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Dopamine (activation)
GABA (increased activity)
Glutamate (increased activity)
Cortisol (excessive endogenous production)
IL-1, IL-2, Prostaglandin D2 (increased in sepsis
cascade)
Flacker, JM and Lipsitz LA Journal of Gerontology 1999;54A(6):B239-246
Risk Factors
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Can be split into two categories
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Predisposing factors
• “Pre-hospitalization”
• Can alert the physician to risk but are often unmodifiable in
the acute setting
• Prevention can focus on these on a “chronic” timetable
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Precipitating factors
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“Post-hospitalization”
Often iatrogenic
Often modifiable
Often preventable
Predisposing Factors
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Past Medical History
Falls
 Stroke
 Delirium
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Chronic Illness
Cognitive disorders/dementia
 Poor vision or hearing
 Malnutrition
 Renal failure or chronic dehydration
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Predisposing Factors
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Psychosocial
Age
 Male sex
 Alcoholism or other drug use
 Depression
 Functional impairment
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Prevention - The Short List
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At risk patients - key features
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Predisposing
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Visual impairment
Illness severity
Cognitive impairment
BUN:Cr ratio >18
Precipitating
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Malnutrition
Use of physical restraints
More than 3 medications added
Use of a bladder catheter
Iatrogenic (adverse) event
Inouye SK and Charpentier PA JAMA 1996;275(11):852-7
Update on Our Patient
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In the morning, the attending is told the events
of the previous day by his resident. “We had to
restrain him and I gave him 2 mg Haldol to get
him to stop yelling.”
Medications are reviewed:
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Aspirin 325mg po daily
Atenolol 25mg po daily
Simvastatin 20mg po qHS
Propoxyphene/APAP (Darvocet) 1 q4h prn pain
Diphenhydramine 25mg po qHS prn sleep
Update on Our Patient
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Physical Exam
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130/62, HR 64, RR 16, SpO2 98% RA, T 95.4 F
Patient is unrousable but responds to pain
Lungs clear, heart regular, abdomen normal
Surgical site intact, no inflammation/drainage
Foley catheter in place
Patient in wrist restraints, bruising along arms
Heavily wrapped 20 ga. IV in left arm AC hooked to
75cc/hr NS
Prevention
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Inpatient Consultation
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Inouye 1999
• 852 patients, 70 or older, admitted to general medicine unit
at Yale New Haven Hospital (1995-98)
• Intervention: Elder Life Program
• Interdisciplinary team including geriatrician
• Targeted six delirium risk factors
Usual Care
Intervention (HELP)
Incidence of Delirium
15.0%
9.9%
Delirium, Patient Days
161
105 (P=0.02)
Delirium, Episodes
90
62 (P=0.03)
Inouye SK et al. NEJM 1999;340(9):669-76 Data used with permission from the author.
Prevention
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How did they do this?
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Cognitive Impairment
• Orientation protocols
• Therapeutic activities
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Sleep Deprivation
• Nonpharmacologic sleep protocol
• Sleep-enhancement protocol
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Immobility
• Early mobilization protocol
• Minimal use of tethers/restraints
Inouye SK et al. NEJM 1999;340(9):669-76
Prevention
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How did they do this?
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Visual Impairment
• Vision protocol
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Hearing Impairment
• Hearing protocol
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Dehydration
• Early recognition protocol
• Encourage PO fluids
Inouye SK et al. NEJM 1999;340(9):669-76
Prevention
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Inpatient Consultation
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Marcantonio and Flacker, 2001
• 125 patients > 65 years admitted for surgical repair of hip
fracture
• Consultation focused on 10 specific recommendations
• Consultation reduced incidence of delirium during acute
hospitalization after hip fracture
Outcome
With consult
Usual care
P-value
Delirium incidence, cumulative
20 (32%)
32 (50%)
0.04
Severe delirium incidence
7 (12%)
18 (29%)
0.02
Marcantonio ER, Flacker JM, Wright RJ, Resnick NM JAGS 2001;49(5):516-522 Data used with permission from the author.
Prevention
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How did they do this?
Geriatric consultation focused to make
recommendations on 10 specific areas
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Adequate CNS oxygen
delivery
Fluid/electrolyte balance
Treatment of severe pain
Elimination of unnecessary
medications
Regulation of bowel/bladder
function
Adequate nutritional intake
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Early mobilization and
rehabilitation
Prevention, early detection,
and treatment of major postoperative complications
Appropriate environmental
stimuli
Treatment of agitated delirium
Marcantonio ER, Flacker JM, Wright RJ, Resnick NM JAGS 2001;49(5):516-522
Prevention
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Potentially inappropriate
medications included:
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Sedatives (sleeping meds, benzos)
Antihistamines (diphenhydramine)
Neuroleptics (phenytoin, phenobarb)
Antiarrhythmics (digoxin)
Narcotics (meperidine, propoxyphene)
Tricyclic antidepressants
Anticholinergics (atropine, scopolamine)
Prevention
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Nursing Programs
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Milisen and Foreman, 2001
• Small study; 120 pts (mean age 80) admitted for
hip fracture
• Intervention included cognitive screen, pain
protocol, and staff education
• Results:
• No significant effect on delirium incidence
• Reduced duration of delirium (1 v. 4 days, P=0.03)
• Reduced severity of delirium (P=0.015, scored by CAM)
Milisen et al. JAGS 2001;49(5):523-32
Management
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History and physical exam
Last bowel movement
 Pulse Ox
 Blood glucose
 Post-void residual
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Lab workup
LP not suggested as routine workup
 CT or not CT?
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Management
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Delirium is almost always multifactorial in
origin
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Work up should approach several
possible diagnoses at a time
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Correcting a single derangement will
rarely resolve the delirium
Correct Underlying Pathology
 Iatrogenic
Causes
 Environmental
• Tethers
• Lighting
• Noises
• Lack of reorientation
• Sensory impairment
Correct Underlying Pathology
 Iatrogenic
Causes
Medications
 Untreated (or under-treated) pain
 Constipation/impaction
 Urinary retention
 Nutrition (modify diet if needed)
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Correct Underlying Pathology
 Infections
 Urinary tract infections
 Respiratory tract infections
 Cardiopulmonary events
 Acute coronary event
 Congestive failure
 Reduced output (atrial fibrillation, SVT)
 Hypoxia (PE, CHF, pneumonia)
Correct Underlying Pathology
 Metabolic Abnormalities
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Dehydration
• Hypernatremia, ARF
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Hypo/hyperkalemia
 Anemia
Pharmacologic Management
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Antipsychotic agents are preferred over benzodiazepines
 Haloperidol
• 0.25-0.5 mg IV or IM, q1-2 hrs prn
• Long-term use is associated with EPS/dyskinesia
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Risperidone
• 0.25 - 0.5 mg PO or oral dissolvable, q8-12 hrs prn
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Olanzapine
• 2.5 - 5 mg IM q1h prn, 2.5 - 5 mg PO QD
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Quetiapine
• 12.5 - 25 mg PO q8-12 hrs prn, 12.5 - 25 mg PO BID
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Ziprasidone
• 10 - 20 mg PO/IM q12 hrs prn
Pharmacologic Management
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It takes smaller doses of sedatives to “knock”
an elderly patient out
Notify family of the need for use
Use of antipsychotics in long term care
facilities carry additional complications
Update on Our Patient
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Diphenhydramine-induced urinary retention
diagnosed and treated - foley removed
Urinary tract infection diagnosed and treated
Propoxyphene replaced with
hydrocodone/APAP
IVF stopped and IV removed
Update on Our Patient
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Patient woke up the next day
In three days was cooperating with inpatient PT
again
Some residual confusion handled well with redirection and reinforcement
Successfully transferred to subacute rehab
facility 9 days post-op with improved cognitive
function
Caveats
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Delirium can persist from days to months after
treatment of the underlying cause but is often
reversible
Discharge destination may need to be
reconsidered upon diagnosis of delirium
Dementia and delirium often co-exist
Many patients experience some degree of
permanent cognitive function loss after a
delirium episode
Take Home Points
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The cause of delirium is multi-factorial
Delirium may be preventable or its severity
lessened by targeted interventions
Treatments for delirium are interdisciplinary and
involve multiple approaches
Psychotropic drug therapy (at appropriate
dosage) is a last resort
The End