1. UMMS CRIT Module II: Delirium in the Elderly Sarah McGee, MD, MPH Department of Medicine Division of Geriatric Medicine University of Massachusetts Medical School

2. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation 1/3 of patients presenting to ER 1/3 of inpatients aged 70+ on general med units Incidence ranges 5.1% to 52.2% after noncardiac surgery –15-53% of older patients post op –Highest rates after hip fracture and aortic surgeries –70-87% of patients in the ICU Dasgupta M et al. J Am Geriatr Soc 2006;54:1578-89 Incidence Among Elderly Patients is HIGH

3. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation One-year mortality: 35-40% Independent predictor of higher mortality up to 1 year after occurrence Hazard Ratio between 2 and 3 –Elderly medical inpatients: Adjusted for dementia, comorbidity, clinical severity, APACHE II score, admitting service (med vs. geri), demographic variables (McCusker J et al. Arch Intern Med. 2002; 162:457-463) –Mechanically ventilated MICU & CCU patients: Adjusted for coma, age, Charlson Comorbidity Index, APACHEII score, SOFA, admitting diagnosis of sepsis or ARDS, sedative and narcotic use Ely EW et al. JAMA. 2004; 291:1753-62 Delirium: Increased Mortality

4. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Functional decline New nursing home placement Persistent cognitive decline: –18-22% of hospitalized elders with complete resolution 6-12 months after discharge –CAVEAT: Many subjects with preexisting cognitive impairment Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704 Delirium: Increased Risk of…

5. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Complicates the hospital stays for >7.3 older pts Diagnosis increases the hospital costs by $2,500 per patient 6.9 billion (2004) of Medicare hospital expenditures Delirium: Costs

6. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation DELIRIUM: ICD-9 code 780.09 “Δ MS” or “mental status change”: –No ICD-9 code Diagnosis: Call it what it is…

7. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Why is diagnosis not made? Fluctuating course Overlap with dementia Lack of formal cognitive assessment Under appreciation of consequences Failure to consider it important

8. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Diagnosis: Confusion Assessment Method (CAM) 1.Acute change in mental status with a fluctuating course 2.Inattention AND 3. Disorganized thinking or 4. Altered level of consciousness Inouye SK et al. Ann Intern Med. 1990; 113: 941-948 Sensitivity: 94-100%; Specificity: 90-95%

9. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation How to Distinguish Delirium from Dementia Features seen in both: –Disorientation –Memory impairment –Paranoia –Hallucinations –Emotional lability –Sleep-wake cycle reversal Key features of delirium: –Acute onset –Impaired attention –Altered level of consciousness

10. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Delirium may be the only manifestation of life-threatening illness in the elderly patient. Assume it is Delirium until Proven Otherwise

11. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation A Model of Delirium A multifactorial syndrome that arises from an interrelationship between: Predisposing factors  a patient’s underlying vulnerability AND Precipitating factors  noxious insults

12. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Predisposing Factors (vulnerability) versus Precipitating Factors (insults)

13. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Predisposing Factors i.e. baseline underlying vulnerability Baseline cognitive impairment –2.5 fold increased risk of delirium in dementia patients –25-31% of delirious patients have underlying dementia Medical comorbidities: –Any medical illness Visual impairment Hearing impairment Functional impairment Depression Advanced age History of ETOH abuse Male gender

14. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Precipitating Factors i.e. noxious insults Medications Bed rest Indwelling bladder catheters Physical restraints Iatrogenic events Uncontrolled pain Fluid/electrolyte abnormalities Infections Medical illnesses Urinary retention and fecal impaction ETOH/drug withdrawal Environmental influences

15. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Some Drug Classes Associated with Delirium Medications with psychoactive effects : –3.9-fold increased risk –2 or more meds: 4.5-fold Sedative-hypnotics : 3.0 to 11.7-fold Narcotics : 2.5 to 2.7-fold Anticholinergic drugs : 4.5 to 11.7-fold Risk of delirium increases as number of meds prescribed rises

16. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Prevention of Delirium: It can be done! Find patients with 1 to 4 of the following predisposing characteristics: Visual impairment (worse than 20/70 corrected) Severe illness Cognitive impairment (MMSE<24/30) High BUN/Cr ratio (>18) Inouye SK et al. Ann Intern Med. 1993; 119:474-481

17. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Prevention = Good Hospital Care for the Elderly Patient RISK FACTORINTERVENTION Cognitive impairment Orientation protocol, cognitively stimulating activities 3x/day Sleep deprivation Nonpharmacologic protocol, noise reduction, schedule adjustments Immobility Ambulation or active ROM exercises; minimize equipment Visual impairmentGlasses or magnifying lens, adaptive equipment Hearing impairmentPortable amplifying devices, earwax disimpaction DehydrationEarly recognition and volume repletion Inouye SK et al. NEJM. 1999;340:669-76

18. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation A Multicomponent Intervention to Prevent Delirium Outcome (n=852) Intervention group Usual care group Statistical analysis 1 st delirium episode9.9%15% OR=0.60 (95% CI 0.39 to 0.92) Total days delirium105161P=0.02 # delirium episodes6290P=0.03 Inouye SK et al. NEJM. 1999;340:669-76

19. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Find and treat the underlying disease(s) and contributing factors –Comprehensive history and physical –Including neurological and mental status exams –Choose lab tests and imaging studies based on the above –Review medication list Keys to Effective Management

20. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Always Try Nonpharmacologic Measures First Presence of family members Interpersonal contact and reorientation Provide visual and hearing aids Remove indwelling devices: i.e. Foley catheters Mobilize patient A quiet environment with low-level lighting Uninterrupted sleep

21. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Use drugs only if absolutely necessary: harm, interruption of medical care First line agent: haloperidol (IV, IM, or PO) –For mild delirium: Oral dose: 0.25-0.5 mg IV/IM dose: 0.125-0.25 mg –For severe delirium: 0.5-1 mg IV/IM repeated q30 min until calm Patient will likely need 2-5 mg total as a loading dose –Maintenance dose: 50% of loading dose divided BID May use olanzepine and risperidone Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD05594 Management: Hyperactive, Agitated Delirium

22. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation Second line agent Reserve for: –Sedative and ETOH withdrawal –Parkinson’s Disease –Neuroleptic Malignant Syndrome What about Ativan (lorazepam)?

23. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation AVOID RESTRAINTS AT ALL COSTS: Measure of LAST(!!!) resort Delirium in the Elderly: Take Home Points

24. UMMS CRIT 2010 Module II: Delirium Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation A multifactorial syndrome: predisposing vulnerability and precipitating insults Delirium can be diagnosed with high sensitivity and specificity using the CAM Prevention should be our goal If delirium occurs, treat the underlying causes Always try nonpharmacologic approaches Use low dose antipsychotics in severe cases Delirium in the Elderly: Take Home Points