Presentation on theme: "Assessment and Management of Delirium in Older Adults"— Presentation transcript:
1 Assessment and Management of Delirium in Older Adults Dr. Dallas Seitz and Dr. Agata Szlanta
2 ObjectivesUnderstand the differential diagnosis and presentation of delirium in older adults;Review the risk factors and precipitants for delirium; andDiscuss delirium prevention and management strategies.
4 Case 1: Mr. A: 75 y.o. male, resides with wife RFV: wife concerned that husband is depressed
5 HPI:Recently discharged from KGH following 3 week admission for community acquired pneumoniaNever “fully recovered” physically or mentally since his KGH dischargeStarted on antidepressant in hospital for depressive symptoms in hospital, zopiclone to help with sleepSince discharge:Napping for most of the day, having some difficulties with sleep at nightSeems disinterested in environmentWife now having to assist with personal careIncontinence has worsened and gait is unsteadyOral intake poor over last weekSpeech difficult to understand at times
6 Past Medical History: Medications: Mild cognitive impairment CAD with angioplastyDyslipidemiaChronic renal failureHypertensionBenign prostate hypertrophyDepression (recently diagnosed)Medications:Citalopram 20 mg po ODZopiclone 7.5 mg po QHSMetoprolol 25 mg PO BIDRosuvastatin 20 mg PO QHSDutasteride 0.5 mg PO QHSTamsulosin 25 mg PO ODHCTZ 25 mg PO OD
7 Case objectives Differential diagnosis? How to you confirm your diagnosis?Office work-up and management
8 Triple D Delirium Dementia Depression Onset Duration Course AcuteInsidiousVariableDurationDays to weeksMonths to yearsCourseFluctuatingSlowly progressiveDiurnal variationConsciousnessImpaired, fluctuatesClear until late in illnessUnimpairedAttention & MemoryInattentive,Poor memoryPoor memory without inattentionDifficulty concentrating, memory intactAffectDepressed, loss of interest and pleasureCCSMH, Delirium Guidelines, 2006
9 DSM-IV criteria Delirium Disturbance of consciousnessChange in cognition, not accounted for by pre-existing dementiaOnset over a short period of time and fluctuating presentationEvidence from history, physical exam, or lab findings that the disturbance is caused by direct physiological consequences of a general medical condition.
10 Diagnosing Delirium Confusion Assessment Method + + Acute Onset and Fluctuating Course+Inattention+Comments about the sensitivity and specificity of the CAMDisorganized ThinkingAltered Level of ConsciousnessORAdapted from: Inouye, et al. Ann Intern Med 1990;113:
11 Subtypes Hypoactive Hyperactive Mixed More lethargic, difficult to arouse, minimal speech, slowed motor responseDdx: depression or dementiaHyperactiveRestless, agitated, hallucinations, hypervigilance, delusionsDdx: hypomania mania, psychosis, anxiety disorders, akathisiaMixed
12 PathophysiologyFong et al. Nat Rev Neuro April; 5(4):
13 Predisposing Factors/ Vulnerability Precipitating Factors/ Insults High VulnerabilityNoxious InsultAdvanced ageMajor surgeryDementiaICU staySevere illnessMultiple psychoactivemedicationsMulti-sensoryimpairmentSleep deprivationThis is Sharon Inouye’s model of delirium illustrating the interplay of precipitating and predisposing factors in delirium, for example in an elderly person with dementia and perhaps other medical co-morbidities, one dose of sleeping medication or a urinary track infection may be enough to precipitate delirium,On the other hand a young healthy individual would need to be confronted with a major physiological insult such as a mutli organ trauma or major operation to stress them sufficiently to cause deliriumUTIHealthy young personOne dose ofsleeping medicationLow VulnerabilityNon-noxious insultAdapted from: Inouye and Charpentier, JAMA 1996;275:
14 Predisposing Factors Age (>65) Cognitive impairment Male dementia is present in up to 2/3 of cases of delirium in the elderlyMaleHistory of deliriumSensory impairementDehydrationPoor functional status (immobility, falls)Alcohol abusePsychoactive drugsMultiple medical conditions
16 DELIRIUM – multifactorial! D rugs E yes, ears L ow oxygen states (MI, PE, stroke) I nfection R etention I ctal U nderhydration/undernutrition M etabolic S ubudural
17 Consequences of Delirium One year mortality of 35-40%.Associated with worse prognosis-↑ risk of dementia, institutionalization and deathUnderdiagnosedPrevalence in community:1-2% in older adults, 14% in > 85 yoUp to 1/3 of cases are preventable
18 Persistent Delirium Systematic review by Cole1 Substantial number of patients with in-hospital delirium not fully recoveredWorse outcomes: LTC placement, cognition, function and mortalityTime to recovery is variableDischarge1 month3 mo6 moPersistent Delirium45%33%26%21%1Cole, M. Systematic Review. Age and Ageing 2009: 38:
22 Case 2 Mrs. O.P. 83 year old women lives alone in own home room Found by paramedics on floor in home after family called police due to no telephone callTripped on rug in home fell (?approximately 24 hours)Pain and bruising over L hipVitals: Pulse = 110, BP = 150/95, RR = 16
23 Past Medical History Medical Conditions Medications HTN Moderate aortic stenosisObesityDiabetes mellitus IIOsteoarthritisHearing ImpairmentUrinary incontinenceHCTZInsulinOxybutyninIbuprofenTylenol
25 Hospital Course 4 day delay to surgery, NPO in emergency room Lying on stretcher in hallwayFoley catheter due to limited mobilityReceives general anesthetic for surgeryUndergoes left hip pin and plateDischarged to orthopedic floor
26 QuestionsWhat risk factors does Mrs. E.B. have for postoperative delirium?
27 Postoperative Delirium Outcomes associated with postoperative delirium:Functional decline: OR = 2.0↑ hospital length of stayMortality: OR = 2.4Surgical ProcedureIncidenceOrthopedic30 – 50%Cardiac20 – 50%General surgery18%Urologic5 – 10%
28 Predisposing Factors for Delirium Demographic characteristicsAdvanced age (> 65)Male sexCognitive StatusDementiaDepressionPast History of DeliriumFunctional StatusImmobilityFunctional dependenceLow level of activityHistory of fallsSensory ImpairmentVisual impairmentHearing impairmentNutritional StatusDehydrationMalnutritionMedicationsPolypharmacyPsychoactive medicationsAlcohol abuseMedical HistoryStrokeNeurological diseaseMetabolic diseasesHepatic or renal failureSeverity of illnessFracture or trauma
29 Risk Factors for Postoperative Delirium Relative RiskAge ≥ 703.4Male Gender2.0MMSE < 244.0Severity of illness4.3Visual impairment3.0Dehydration (BUN/creatinine ratio ≥ 18)2.9Alcohol abuse2.4Functional impairment2.1Abnormal Na2+, K+, or glucose2.8WBC > 122.3
30 QuestionsWhat interventions could be utilized to prevent postoperative delirium?
31 Hospital Elder Life Program Prevention of delirium through addressing common delirium risk factors:CognitionSleep deprivationImmobilityVisual impairmentHearing ImpairmentDehydrationDelirium outcomes:Incidence: 9.9 vs 15% (OR = 0.6, p=0.02)Duration and recurrence of delirium also reduced
32 NICE Delirium Prevention Ensure providers are familiar with patient, avoid unnecessary transfers within and between wards.Multicomponent intervention should be used for all individuals including risk assessment within 24 hours.Intervention should be delivered by multidisciplinary teamAddress cognitive impairment by orientation measures, clear signage, clock, calendar, and reassurance.Ensure adequate oral intake and prevent constipation.Assess for and treat hypoxia.Look for and treat infections, avoid catheterization.
33 NICE Delirium Prevention Address and minimize immobility through encouragement of walking and/or active range of motion exercises.Assess and address pain, look for non-verbal signs of pain in individuals with communication difficulties.Carry out a medication review.Address poor nutrition and ensure that dentures fit.Address sensory impairment by resolving reversible causes of impairment and ensure use of aids.Promote good sleep patterns and hygiene through scheduling of work routines and minimizing noise.
34 Delirium Rooms 4-bed room within Acute Care of Elderly (ACE) unit Rationale: provide constant nursing supervision without use of “sitters”, restraints, and minimize use of medicationsStaffed by one RPN with shared RN coverageAll patients are visible to RPN, room close to RN stationTADA: tolerate, anticipate, and don’t agitateNo increase in rates of falls, reduction in use of psychotropics to manage delirium symptoms
35 Pharmacological Interventions Antipsychotics:Postoperative ICU patients receiving bolus (0.5 mg IV) + infusion (0.1mg/hour) haloperidol had a lower rate of postoperative delirium (15.3% vs 23.2%)Low-dose haloperidol (0.5 mg PO TID) reduced severity and duration of delirium but not incidence in hip surgerySingle dose of 1 mg risperidone reduced delirium in cardiac surgery patientsCholinesterase inhibitors:3 small RCTs have failed to show any benefitGabapentin:1 small RCT demonstrating benefit (? opioid sparing)
37 Case 3 Mrs. A.D., 89 y.o. female, resident in LTC facility for 2 years Nurses ask you to assess as she hasn’t been herself over past two daysFlucuates between being drowsy and restless, yelling out, picking at air, falling out of bed, increasingly difficult to provide careIn Broda chair most of the day now, bed rails up at night to prevent fallsPRN lorazepam ordered by on-call physician
38 Hydromorphone 0.5 mg po BID prn MedicationsDonepezil 10 mg 0dMemantine 10 mg BIDClopidogrel 75 mg po odBisoprolol 5 mg PO ODPantoprazole 40 mg po odTylenol 1 g TIDHydromorphone 0.5 mg po BID prnLorazepam 1 mg PO BID prn (given twice in last 24 hours)Past Medical HistoryAlzheimer’s diseaseLast MDS-RAI: Cognitive Performance Scale score: 6Global Deterioration Scale: stage 7 (non-verbal, bed-bound, incontinent of bowel and bladder)StrokeCoronary artery diseaseCOPDGERDOsteoarthritis in both hips (L THR)
39 What is your differential diagnosis? Initial investigations?
40 Delirium Superimposed on Dementia Prevalence: % of hospitalized and community patientsAccelerates cognitive and functional declineUnderdiagnosed as some behaviours can also occur in dementiaDifficult to diagnosis in advanced dementia
41 Delirium in Long-Term Care PrevalenceMMSE ≥ 10: 3.4%MMSE < 10: 33.3%Incidence:MMSE ≥ 10: 1.6/100 person weeksMMSE < 10: 7/100 person weeksRisk FactorHazard RatioDementia2.6Dementia SeverityMinimalMildModerateSevere1.05.110.19.5Depression2.1
42 Behavioral Changes and Medical Illness SymptomPredictive ValueLiklihood RatioLethargy*0.517.3Weakness*0.507.0Decreased appetite*0.466.0Agitation*0.374.2Disorientation0.313.2Dizziness0.272.5Falls*0.232.1Delusions0.211.9Depressed mood0.171.4Weight lossAggression0.131.0*p < 0.05Boockvar, JAGS, 2003
43 Acute Medical Illness in LTC UTIPneumoniaGICardiacDehydrationOtherBoockvar, 200328%18%20%17%8.8%8%Hung, 201027%10%--16%5%40%Alessi, 199833%
44 Management of Delirium Treat correctable causesWithdraw all medications contributing to delirium when possibleStart antibiotics promptlyEnsure cardiovascular stability, oxygenation, and electrolyte balanceEnsure hydration and monitor fluid intake and output
45 Management of Delirium Assess and monitor nutrition and skin integrityIndentify and correct sensory deficitsAssess and manage pain using safest interventionsSupport normal sleep patterns and avoid use of sedatives
47 ConclusionsDelirium is common among older adults and can have a number of presentationsManagement of delirium needs to include a comprehensive review of risk factors and potential precipitantsPrevention and non-pharmacological interventions are cornerstones of delirium care
48 RESOURCESCanadian Coalition for Seniors’ Mental Health. The Assessment and Treatment of Delirium.CCSMH Pocket Card: Delirium Assessment and Treatment for Older AdultsAmerican Geriatrics Society. Geriatrics at Your Fingertips.Inouye SK. Delirium in Older Persons. N Eng J Med 2006;354:Journal of the American Geriatrics Society. 2011; Nov Supplement: Advancing Delirium Science: Systems, Mechanisms, and Management