Transcript Delirium in the Elderly

UMMS CRIT Module II:
Delirium in the Elderly
Sarah McGee, MD, MPH
Division of Geriatric Medicine, UMMS
DELIRIUM
WHY SHOULD WE CARE
ABOUT THIS?
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
IT IS PREVALENT
• It develops in up to a half of older patients post op especially
after hip fracture and vascular surgery1
• In medical patients the occurrence is 11-42%, but
underestimated because the study had selected for people
without dementia2
• In intensive care units (ICU), the incidence of delirium among
elderly patients ranges from 70% to 87%.3
1Young,J,
Inouye, S; Delirium in older people – Clinical Review BMJ 21 April 2007
MD, Evaluation and management of delirium in hospitalized older patients. Am. Fam. Physician 2008; 78(11), 1265-1270
3Mittal V, Muralee S, Williamson D, McEnerney N, Review: Delirium in the Elderly: A Comprehensive Review AM J ALZHEIMERS DIS OTHER DEMEN
2011 26(2): 97-109.
2Miller
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
IT HAS SERIOUS
SHORT AND LONG TERM
CONSEQUENCES
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
FOR OUR PATIENTS
SHORT TERM
•
•
•
•
2x increase in discharge mortality
Average increase of 8 days in hospital LOS
Increased time in institutional care
Non-detection of delirium in the ED is associated with a 7X hazard for
increased mortality
• Estimated that at least one fifth of the 12.5 million patients over 65 years who
are hospitalized each year in the United States experience complications during
the hospitalization because of delirium
Young, J, Inouye, S; Delirium in older people – Clinical Review BMJ 21 April 2007, 842-846
Mittal V, Muralee S, Williamson D, McEnerney N, Review: Delirium in the Elderly: A Comprehensive Review AM J
ALZHEIMERS DIS OTHER DEMEN 2011 26(2): 97-109.
Fong TG, Tulebaev SR, Inouye SK, Delirium in elderly adults: diagnosis, prevention and treatment, Nat. Rev Neurol 2009; 5(4): 210220
Kiely DK, Marcantonio,E, Inouye, SK, et al, Persistent delirium predicts greater mortality, J. Am Geriatric Soc 2009; 57(1): 55-61
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
FOR OUR PATIENTS
LONG TERM
• Worse physical and cognitive recovery at 6 and 12 months
• Nearly one third of patients remained delirious at 6 months
• Persistent delirium had a cumulative 1-year mortality of 39%, independent
of age, sex, co-morbidity, functional status, and dementia
• Patients with persistent delirium were 2.9 times as likely to die during the
1-year follow-up as participants whose delirium resolved
Young, J, Inouye, S; Delirium in older people – Clinical Review BMJ 21 April 2007, 842-846
Mittal V, Muralee S, Williamson D, McEnerney N, Review: Delirium in the Elderly: A Comprehensive
Review AM J ALZHEIMERS DIS OTHER DEMEN 2011 26(2): 97-109.
Fong TG, Tulebaev SR, Inouye SK, Delirium in elderly adults: diagnosis, prevention and treatment, Nat. Rev
Neurol 2009; 5(4): 210-220
Kiely DK, Marcantonio,E, Inouye, SK, et al, Persistent delirium predicts greater mortality, J. Am Geriatric Soc
2009; 57(1): 55-61
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
FOR ALL OF US
• $6.9 Billion in Medicare Hospital expenditures in 20041
• Average cost/day was >2.5 X cost of patients without delirium2
• $16,303 - $64,421 per patient National burden of delirium on health
care system (calculated in 2007)2
• $38 Billion - $152 Billion/year on delirium (calculated in 2007),
which is a cost greater than that for hip fracture($7 B) or nonfatal
fall ($19 B)2
1Fong
TG, Tulebaev SR, Inouye SK, Delirium in elderly adults: diagnosis, prevention and treatment, Nat. Rev Neurol 2009; 5(4):
210-220
2Leslie DL. Marcantonio ER, Zhang Y, et al, One year Health care costs associated with delirium in the elderly population. Arch
Intern Med. 2008, 168(1): 27-32
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
DELIRIUM
WHAT IS IT ANYWAY?
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
DSM-IV Criteria for Delirium
A. Disturbance of consciousness (i.e., reduced clarity of awareness of
the environment) 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 preexisting,
established or evolving dementia.
C. The disturbance develops over a short period of time (usually
hours to days) and tends to fluctuate during the course of the day
D. 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.
Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American
Psychiatric Association, 2000. Copyright © 2000, American Psychiatric Association.
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Diagnosis: Call it what it is…
• DELIRIUM: ICD-9 code 780.09
• “Δ MS” or “mental status change”:
– No ICD-9 code
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
CHALLENGES TO DIAGNOSIS
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
MANY FACES TO DELIRIUM
• SUBTYPES
– Hyperactive
– Hypoactive
– Mixed
– Subsyndromal
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
DELIRIUM VS DEMENTIA
• MANY SIMILARITIES
– Confusion
– Memory impairment
– +/- Hallucinations
– +/- Paranoia
– +/- Disordered sleep cycles
• KEY DIFFERENCES: WITH DELIRIUM
– Acute/subacute change in mentation and cognition
– Alterations in attention
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
CONDITIONS CO-EXIST
• MORE OFTEN NOT AN ‘EITHER-OR’, BUT ‘BOTH’
– High incidence of delirium in patients with dementia, and
vice versa
– Cognitive impairment is nearly universally present in the
elderly, if looked for carefully
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
HOW TO LEVERAGE YOUR
CHANCES OF MAKING THE
DIAGNOSIS
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
ANTICIPATE IT
LOOK FOR IT
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
KNOW YOUR PATIENT
• Know your patient’s baseline cognitive function:
– Before the acute illness
– Changes from day-to-day
– Changes over the course of the day
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
TIME WELL SPENT
• Talk with the patient’s family
• Review the previous medical record
• Do an at least daily cognitive assessment
• Listen to the nurses, therapists and other members of
the treatment care team
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
TOOLS TO MAKE YOUR JOB EASIER
• CAM or CAM-ICU
• FOLSTEIN MINI-MENTAL STATUS
• MINI-COG
• DAYS OF THE WEEK BACKWARDS
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Diagnosis: Confusion
Assessment Method (CAM)
AND
1. Acute change in mental
status with a fluctuating
course
3. Disorganized thinking
or
4. Altered level of consciousness
2. Inattention
Sensitivity: 94-100%; Specificity: 90-95%
Inouye SK et al. Ann Intern Med. 1990; 113: 941-948
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
PREDISPOSING RISK FACTORS
Non-treatable delirium risk factors:
• Old age
• Underlying dementia
• Male gender
• Previous history of delirium
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•
•
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Significant medical history
Poor eyesight and hearing
Frailty
Immobility
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
PRECIPITATING FACTORS
• Severe illness
• Dehydration
•
•
•
•
• Medications, esp with
anticholinergic or
psychoactive properties
Poly-pharmacy
Alcohol excess
Renal impairment
Malnutrition
• Sleep deprivation
• Surgery
• Alcohol withdrawal
• Pain
• Stroke, epilepsy, SDH
• Hypoxia
• Infection
• Catheters
• Constipation
• Electrolyte disturbances
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
4 KEY RISK FACTORS
• Visual Impairment
• Severe Illness
• Cognitive Impairment
• BUN/Creat ratio
The greater the # of risk factors the greater the risk.
Inouye SK, Predisposing and precipitating factors for delirium in hospitalized older patients, Dementia, Geriatric Cognitive Disorders, 1999 10(5):393-400
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
Diagnosis: Confusion
Assessment Method (CAM)
AND
1. Acute change in mental
status with a fluctuating
course
3. Disorganized thinking
or
4. Altered level of consciousness
2. Inattention
Sensitivity: 94-100%; Specificity: 90-95%
Inouye SK et al. Ann Intern Med. 1990; 113: 941-948
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
It takes very little to tip a frail
demented person,
but even the hale and hearty
will be felled by a severe illness,
or by the multiplicity of less
significant derangements.
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
INVESTIGATION
LOOK FOR THE HIGH YIELD CAUSES:
– Infections
– Metabolic derangements
– Systemic organ failure
– CNS disorders
– Medication side effects and withdrawal- Drugs may be sole
precipitant in 12-39% of case1
– Trauma
– Toxins and drugs of abuse
– Endocrine disorders
– Nutritional deficiencies
1Young
J, Inouye SK, Delirium in older people, BMJ, 21 : April 2007, 334: 842-846.
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
RECOMMENDED INVESTIGATION
• Detailed history
– current illness
– medical co-morbidities
– medication list
• Comprehensive general physical exam
• Neurological Examination, comprehensive but with particular
focus on level of consciousness, fluctuating attention, memory
impairment, focal signs, myoclonus, asterixis, nystagmus
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
INVESTIGATION Continued
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•
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Chemistry Panel – Na, K, BUN, Cr, Glu, Ca, Mg, LFTs, NH3
CBC
U/A
ESR, CRP
TSH
Vit B12, Folate, Thiamine
VDRL
Pulse Ox
CXR
Tox Screen
If above is unrevealing and/or focal neurological examHead CT or Brain MRI
LP
EEG
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
TREATMENT
BEST TREATMENT IS PREVENTION
30-40% of delirium is preventable1
1 Mittal
V, Muralee S, Williamson D, McEnerney N, Review: Delirium in the Elderly: A Comprehensive Review AM J ALZHEIMERS DIS OTHER DEMEN
2011 26(2): 97-109
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
PREVENTIVE INTERVENTIONS
TARGET HIGH RISK INDIVIDUALS
• Old age
• Underlying dementia
• Male gender
• Previous history of delirium
•
•
•
•
Significant medical history
Poor eyesight and hearing
Frailty
Immobility
Tabet N, Howard R Non-pharmacological Interventions in the Prevention of Delirium : Educational Intervention; Medscape.com
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
PREVENTION OF DELIRIUM -continued
• Initiate active preventive strategies for all patients and
especially those at high risk:
– Maintain well lit and calm environment
– Minimize the number of staff caring for patient
– Familiarize patient with care team
– Provide proper introductions by staff
– Make patient’s glasses and hearing aids available
– Orient patient
– Review medications carefully and in detail with patient
– Educate care team about delirium, its presentation and
prevention
Tabet N, Howard R Non-pharmacological Interventions in the Prevention of Delirium : Educational Intervention; Medscape.com
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
MISTAKES TO AVOID
• Medications of which to be especially wary:
– Narcotic analgesics such as morphine
– Anticholinergics
– Benzodiazepines
• Sleep deprivation
• Use of restraints
• Nutritional deficiencies
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
MEDICATIONS
HALOPERIDOL
• Mild delirium: Haloperidol 0.25 – 0.5 mg PO
0.125-0.25mg IV/IM
• Moderate/severe delirium:
Initial IV/IM dose of 0.5 mg to 1 mg,
If still agitated in 30 minutes, repeat the dose
Continue in this fashion until satisfactory control is achieved,
which is usually after a total of 2-5 mg has been given.
• Doses of <3 mg have lower side effect potential
• Short term use if possible
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
MEDICATIONS
• Atypical Antipsychotics – risperidone, olanzepine
• Lorazepam – especially for alcohol and drug withdrawal,
patients with significant extrapyramidal disease, but otherwise
avoid
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
CHALLENGES TO TREATING DELIRIUM
• DIFFICULTY OF RECOGNIZING IT:
– Delirium does not exist in isolation – may be partially masked
by co-morbidities
– Many different presentations of the same condition, sometimes
even in the same patient
SO:
– Be on high alert for its presence
– If you wonder IF it might be there, IT IS
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
CHALLENGES TO TREATING DELIRIUM
continued
• MULTIPLE PREDISPOSING AND PRECIPITATING
FACTORS OFTEN CO-EXIST
• SOME PREDISPOSING AND PRECIPITATING FACTORS
NOT EASILY ADDRESSED:
– Frail people with little physical and cognitive reserve
– Chronic diseases
– Acute more permanent insults – hypoxia, strokes, MI’s
– ICU environment, required surgeries, medication needs
• RECOVERY CAN BE DELAYED EVEN AFTER CORRECTION
OF PROVOCATIVE CONDITIONS
• LIMITED ARMAMENTARIUM OF PHARMACOLOGICAL
TREATMENTS WITH REASONABLE RISK:BENEFIT
PROFILES
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
TREAT WHAT YOU CAN
DON’T GET FRUSTRATED!
WHILE IT CAN SOMETIMES TAKE THE PATIENT WEEKS TO
MONTHS TO GET BACK TO BASELINE
DON’T GIVE UP TRYING!
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
SO WE CARE BECAUSE:
• It is prevalent
• It has short and long term sequela
• It burdens the health care system
AND
• It can be prevented and treated
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation
ONE OF THE GREATEST
CHALLENGES TO TREATING
DELIRIUM IS
IGNORANCE
ABOUT IT
UMMS CRIT 2011 Module II: Delirium in the Elderly
Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation