Transcript Revisions to Delirium Module A

Karin Neufeld MD MPH
Director of General Hospital Psychiatry
Johns Hopkins University School of Medicine
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Define and describe the features
Describe associated outcomes
Identify risk factors
Review approach to treatment
Review prevention strategies
1.
Define and describe the features
Disturbance in consciousness
 Global cognitive disturbance (esp. attention)
 Of relatively abrupt onset and fluctuating
 Due to underlying physiological disturbances
 Other features often include:
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◦ Sleep-wake cycle reversal
◦ Emotional lability or irritablity
◦ Hallucinations (oneroid), illusions and delusional beliefs
◦ Motor changes: agitation/or lethargy
APA, Diagnostic and Statistical Manual – IV edition
 Acute
Δ
mental status change
MS
 Subacute befuddlement
 Encephalopathy
 ICU Delirium
 Sundowning
Hyperactive
Mixed
Symptoms
Agitation and
Hyperarousal,
Hallucinations and
delusions common
Pulling at lines and
catheters
Periods of both
hyperactive and
hypoactive types of
symptoms
Prevalence
1%
64%
Diagnosis
Hard to miss
Often attributed to
primary psychiatric
disorder eg., mania
Hypoactive
Hypoarousal,
Lethargy,
Confusion,
Sedation
35%
Easy to miss
Often attributed to
primary psychiatric
disorder:
depressive disorder
Ely, EW, et al. JAMA 2001; 286, 2703-2710; McNicoll L, JAGS 2003;51:591-98;
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History
◦ Acute change from a previous baseline (collateral information)
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Mental State Exam
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Motor changes (lethargy or agitation)
Changes in level of arousal (fluctuating level of consciousness)
Disorientation
Difficulty sustaining attention (days of the week backwards, serial 7’s or
“world” backwards)
◦ Difficulty learning new information (decreased short term recall)
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Laboratory Investigations
◦ EEG - “generalized dysfunction”
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Further history, physical exam and investigation
◦ To identify etiology of the delirium
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Clinical diagnosis requiring exam of the mental state
Psychiatrist are often involved in detection however…
Delirium belongs to every specialty in medicine
Many patients missed
◦ Physicians miss 75% percent of delirious patients in ED
◦ Most of these remained undetected on inpatient units after
admission
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Need to improve detection
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Define and describe the features
Describe associated outcomes
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ICU Ventilated Population
◦ 60-85%
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General Medical Inpatient Units
◦ 10-40%
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Medical Oncology Units
◦ 20-70%
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Orthopedic Surgery: Hip fracture repair
◦ > 40%
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Emergency Room by 65+ year olds
◦ 10-20%
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Higher mortality for 1 year after occurrence
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Hazard ratio = 2-3 (Mortality Delirium + vs Delirium -)
◦ Adjusting for age, illness severity, comorbid
conditions, dementia, use of sedatives or analgesic
meds
◦ Demonstrated in critical care settings, and routine
inpatient settings
Salluh JI et al Crit Care 2010, 14:R210.
•Nonspecific warning sign
•Like fever or hypotension
•Something is wrong and requires further investigation
•39% of in-patients with delirium die within one year
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•Don’t ignore this red flag
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Functional decline
New nursing home placement
Persistent cognitive decline:
◦ 18-22% of hospitalized elders had complete resolution of
delirium 6-12 mo after discharge
◦ Many had preexisting cognitive impairment
◦ Significant proportion develop dementia in 2 years of f/u
Levkoff SE et al. Arch Intern Med. 1992; 152:334-40;
McCusker J et al. J Gen Intern Med. 2003; 18:696-704)
For Patients:
 Often have terrifying experiences during delirium
 More prone to developing anxiety disorders (PTSD, phobias)
For Family Members and Loved Ones:
 Very frightening
 Need reassurance and teaching in order to understand
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Define and describe the features
Describe associated outcomes
Identify risk factors
A multifactorial syndrome that arises from:
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Predisposing factors underlying vulnerability
AND
Precipitating factors noxious insults
Delirium arises when noxious insults act in combination
with a patient’s predisposing factors.
Incidence of Delirium (per day)
Baseline
Predisposing Risk
15
10
5
High
Low
Intermediate
High
Low
0
High
Low
Precipitating Factor Group
Inouye & Charpentier; JAMA. 1996 20;275:852-7
“Pushing sixty isn’t the problem--it’s pulling fifty-nine.”
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Baseline cognitive
impairment
◦ 2.5 X risk if Demented
◦ 25-31% of delirious patients
have underlying dementia
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Medical comorbidities:
◦ Any medical illness
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Visual impairment
Hearing impairment
Functional impairment
History of ETOH abuse
Increased age
The more predisposing risk factors present…
 The more likely delirium will develop
 Target high risk patients
 More to follow with prevention discussion
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Medications
New medical illnesses
Infections
ETOH/drug withdrawal
Fluid/electrolyte
abnormalities
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Urinary retention
Fecal impaction
Immobility
Environmental influences
Physical restraints
Indwelling catheters
Uncontrolled pain
Medications
Drug Withdrawal
Neurotransmitter
Imbalance
(Especially cholinergic deficiency and
dopaminergic excess)
Hypoxia
Hypoperfusion
Direct
Ischemic
Damage
Cytokine
Imbalance
Systemic
Inflammation
DELIRIUM
Cortisol Excess
Acute Stress Response
Glucocorticoids
Cushing’s Syndrome
Neufeld, K, et al McGraw Hill, in press.
 Medications
with psychoactive effects:
◦ 3.9X increased risk of delirium
◦ 2 or more psychoactive meds: 4.5X
 Sedative
hypnotics: 3.0 to 11.7X
 Narcotics: 2.5 to 2.7X
 Anticholinergic meds: 4.5 to 11.7-fold
 Delirium  as overall # medications 
Lu & Tune, Am J Geriatr Psychiatry. 2003;11:458-61
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Define and describe the features
Describe associated outcomes
Identify risk factors
Review approach to treatment
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Get history and examine first
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Neurologic and mental status examination
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Vital signs, oxygen saturation
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Medication review, including OTC drugs, alcohol, prn meds
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General medical work-up
◦ Focus on time course of cognitive changes
◦ Association with other symptoms or events
Treat the Underlying Causes and Correct Insults
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Requires interdisciplinary effort
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MDs
Nurses and Aides
Physical Therapy and Occupational Therapy
Pharmacists
Family and loved ones
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Multifactorial approach best because of multiple causes
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Failure to diagnose and manage delirium is bad
◦ Life-threatening complications,
◦ Loss of function,
◦ Costly
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Facilitate constant presence of family members
Interpersonal contact and reorientation
Provide visual and hearing aids if needed
Remove indwelling devices (eg., Foley catheters) ASAP
Wrap IV lines in gauze (so patient can’t see them)
Mobilize patient as soon as possible
Encourage OT and cognitive exercises
Keep patient awake during the daytime
Provide uninterrupted sleep at night
AVOID RESTRAINTS: Measure of Last Resort
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If absolutely necessary, use antipsychotics to calm
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Use LOW DOSE antipsychotic agents (not FDA approved)
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Antipsychotics have side effects (start low/go slow)
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◦ Haloperidol
◦ Quetiapine
◦ Olanzepine
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Anticholinergic
Orthostatic hypotension
Extrapyramidal side effects and acute dystonias
Can prolong the QT interval
Avoid sedative hypnotics (benzodiazepines)
◦ Unless precipitating cause is alcohol/benzodiazepine withdrawal
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Define and describe the features
Describe associated outcomes
Identify risk factors
Review approach to treatment
Review prevention strategies
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1/3 of delirium is preventable in the inpatient setting
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With 1-4 of the following predisposing characteristics:
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Visual impairment (worse than 20/70 corrected)
Severe illness
Cognitive impairment (MMSE<24/30)
Dehydration
Give them the following targeted interventions
RISK FACTOR
Cognitive impairment
INTERVENTION
Sleep deprivation
Nonpharmacologic protocol, noise reduction,
schedule adjustments
Immobility
Ambulation or active ROM exercises; minimize
equipment, physiotherapy
Visual impairment
Glasses or magnifying lens, adaptive
equipment
Hearing impairment
Portable amplifying devices, remove earwax
Dehydration
Early recognition and volume repletion
Orientation protocol, cognitively stimulating
activities 3x/day, occupational therapy
Inouye SK et al. NEJM. 1999;340:669-76
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Delirium is common and easy to miss
Associated with mortality and suffering
Predisposing and precipitating risk factors
Signals need for tx of underlying medical
causes
Targeted strategies can prevent delirium