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Delirium A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 Kendall L. Stewart, MD, MBA, DLFAPA April 19, 2013 1 My aim is to offer.

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Presentation on theme: "Delirium A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 Kendall L. Stewart, MD, MBA, DLFAPA April 19, 2013 1 My aim is to offer."— Presentation transcript:

1 Delirium A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2 Kendall L. Stewart, MD, MBA, DLFAPA April 19, My aim is to offer practical clinical insights that you can use right away in caring for patients. 2 Please let me know whether I have succeeded on your evaluation forms.

2 Why is this important? This is common and it is serious % of hospitalized elderly patients have delirium. 1,2 40% of ICU patients are delirious at some point during their stays. As many as 42% of post-operative orthopedic patients become delirious. As many as 80% of patients become delirious near death. Patients who become delirious during their hospitalizations have mortality rates of 22-76%. Delirium may produce prolonged hospital stays, increased complications, increased costs and long-term disability. After mastering the information in this presentation, you will be able to – Identify the other diagnoses in this category, – Identify the diagnostic criteria for delirium, – Specify three disorders that may produce delirium, – Describe the evaluation of the patient with delirium, – Discuss a differential diagnosis, – Write a typical treatment plan, and – Explain some of the typical treatment challenges. 1 Hospitalists and others are now deploying protocols for preventing delirium in inpatients. 2 See Inouye, Sharon, “A Practical Program for Preventing Delirium in Hospitalized Elderly Patients,” Cleveland Clinic Journal of Medicine, November 2004

3 What other disorders are included in the cognitive disorders category? Delirium – Delirium Due to a General Medical Condition – Substance Intoxication Delirium – Substance Withdrawal Delirium – Delirium Due to Multiple Etiologies – Delirium Not Otherwise Specified (NOS) Dementia Amnestic Disorders Other Cognitive Disorders

4 How do these patients typically present? 1,2 “Doctor, this is a 74-year-old woman.” “She has become increasingly confused, suspicious and agitated this evening.” “Her level of consciousness is fluctuating.”level of consciousness “She is disoriented and it appears to irritate her when I ask the orientation questions.” “She is picking at her gown and the sheet on her bed.” “Sometimes, she mumbles incoherently and I cannot understand her.” “Her family members have never seen her like this and they are very scared.” “She says that her room is full of rats and that they are biting her.” “She has not been able to sleep at all.” “She has a wild look in her eyes and she appears frightened.” “She recognizes her family sometimes and sometimes she doesn’t.” 1 Family members or caregivers usually provide the histories. 2 The diagnosis of delirium is usually easy to make; figuring out what is wrong is another matter altogether.

5 What are the diagnostic criteria for delirium? The patient experiences a disturbance of consciousness with reduced ability to focus, sustain, or shift attention. There is a change in cognition (such as a memory impairment, disorientation, problem with language) or the development of a perceptual disturbance that is not better explained by dementia. The disturbance develops over a relatively short period of time and tends to fluctuate during the course of the day. There is evidence from the history of the cause of the delirium (or there is not). (If the etiology cannot be established or strongly suspected, the proper diagnosis is Delirium Not Otherwise Specified).

6 What are some of the causes of delirium? I nfection (meningitis, encephalitis, systemic infection) W ithdrawal (alcohol, benzodiazepines, barbiturates) A cute Metabolic Disturbances (electrolyte and acid-base abnormalities, renal disease, hepatic disease, postoperative state) T rauma (concussion, heat stroke severe burns) C NS pathology (cerebrovascular accident, seizure, subdural or subarachoid hemorrhage, neoplasms, infections) H ypoxia (anemia, cardiac failure, respiratory failure, hypotension, pulmonary embolus, carbon monoxide poisoning) D eficiencies (vitamin B12, folate, thiamine) E ndocrinopathies (hyper- or hypothyroidism, hyper- or hypocortisolism, hypoglycemia) A cute Vascular (septic shock, hypertensive encephalopathy) T oxins or drugs (amphetamines, anticholinergics, anticonvulsants, clonidine, digitalis, hallucinogens) H eavy Metals (arsenic, lead, manganese, mercury) 1 Every psychiatrist memorizes “I WATCH DEATH” or some similar mnemonic for Board exams.

7 What about the physical examination of the delirious patient? Slide 1 of 6

8 What about the physical examination of the delirious patient? Slide 2 of 6

9 What about the physical examination of the delirious patient? Slide 3 of 6

10 What about the physical examination of the delirious patient? Slide 4 of 6

11 What about the physical examination of the delirious patient? Slide 5 of 6

12 What about the physical examination of the delirious patient? Slide 6 of 6

13 What should be included in the laboratory workup for delirium? Standard studies – Blood chemistries (including electrolytes, renal and hepatic indexes, and glucose) – Complete blood count with white cell differential – Thyroid function tests – Serologic tests for syphilis – Human immunodeficiency virus (HIV) antibody test – Urinalysis – Electrocardiogram – Chest radiograph – Blood and urine drug screens When indicated – Blood, urine, and cerebrospinal fluid (CSF) cultures – B12, folic acid levels – Computed tomography or magnetic resonance imaging brain scan – Lumbar puncture and CSF examination

14 What are some of the differential diagnoses? Dementia Delirium – Due to a general medical condition – Due to substance intoxication – Due to substance withdrawal – Due to multiple etiologies – Not otherwise specified Substance Intoxication Substance Withdrawal Brief Psychotic Disorder Schizophrenia Mood Disorder with Psychotic Features Acute Stress Disorder Anxiety Disorder Malingering Factitious Disorder Cognitive Disorder Not Otherwise Specified

15 What are the differences between delirium and dementia?

16 What might be included in a typical treatment plan? General Principles – Treat the underlying cause. – This often means stopping some of the patient’s medications. – Avoid adding medication if possible. – Sedate if necessary. – Observe the patient briefly to confirm the presence of delirium, then obtain a history from family members or caregivers. – Reassure family members. 1,2 – Provide physical, sensory and environmental support. – Arrange for a relative or friend sit with them. – Provide soft lighting and orientation cues. Pharmacotherapy – Haloperidol (Haldol) 2-10 mg IM repeated hourly is still pretty much the gold standard. Haloperidol (Haldol) – Avoid the phenothiazines because of their anticholinergic toxicity. – Physostigmine salicylate (Antilirium) IM or IV can be repeated every minutes for anticholinergic toxicity. Physostigmine salicylate (Antilirium) – Avoid over-sedation. – Use short half-life benzodiazepines such as lorazepam (Ativan) 1-2 mg if necessary for sleep. Avoid the long half-life benzodiazepines.lorazepam (Ativan) – The benzodiazepines are particularly helpful in alcohol withdrawal syndromes. 1 The last time I came to the hospital in the middle of the night was to treat a delirious patient. 2 When I left, I felt I had really made a difference.

17 What are some of the typical treatment challenges? These patients usually cannot contribute meaningfully to the history. Questioning them just causes more agitation. Families are usually very upset, scared and sometimes panicked, distracted and suspicious. It is rarely clear what exactly is causing the problem. These patients cause real management problems for nurses and other caregivers. The problem is usually worse at night, i.e., “sun downing” (This problem is not specific to delirium.)“sun downing” A delirium is a relative emergency. Restless, fearfulness and mild paranoia are frequent harbingers of worse things to come. paranoia Patients’ memories are spotty afterwards and embarrassment is common. 1,2 Irritability encourages hatefulness and hurt feelings often result. 1 What appears to be an obvious delusion sometimes turns out to be reality. 2 I patient in the ICU once told me he had worked on his electric fence the prior evening.

18 The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. Introduce yourself using AIDET 1.AIDET Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of my problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

19 How can you access the OU-HCOM psychiatry flash card online? Go to Quizlet.Quizlet Create a free account. When you receive a confirmatory , click on the link to activate your new account. With your activated account open in another browser window, click on this link to join the class.link You can download the free Quizlet app to your iPhone or import these learning sets to the more robust Flashcards Deluxe app. Enjoy. I hope you find these cards helpful. Please post your feedback or suggestions on the Quizlet site.

20 Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, Concise Textbook of Clinical Psychiatry, Third Edition Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,”

21 Where can you find evidence-based information about mental disorders? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,” Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.here

22 Are there other questions?  Safety  Quality  Service  Relationships  Performance 


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