1. Delirious … You or the Patient?

2. Questions to ponder… What risk factors are associated with delirium?
What tools are available to assess delirium?
What is the importance of diagnosing delirium?
What is the appropriate workup?
What medications are associated with confusion in the hospitalized older patient?
Can delirium be prevented?
Is delirium a marker for bad outcomes?
Once delirium occurs, can multitargeted strategies change the outcome?
Are medications useful for the management of patients with hyperactive or agitated delirium?
Is preventing delirium cost effective?

3. Overview Background and definition Risk factors Screening tools Workup
Preventing delirium
Delirium as a marker of bad things to come
Treating delirium
Multitargeted strategies
Medications

4. Definition and Background
DSM IV: reversible state of confusion with reduced level of consciousness manifest as inability to focus, sustain or shift attention
Acute confusional state
Acute onset, fluctuating course
Attention impairment
Up to 60% hospitalized elders
Often iatrogenic, often misdiagnosed

5. Risk Factors Advanced age Underlying dementia/cognitive impairment
Acute medical illness
Alcohol abuse
Male gender
Depression
Malnutrition
Terminal illness
ICU stay (up to 80%)

6. Iatrogenic Risk Factors
The things we do…
Physical restraints
Polypharmacy
Malnutrition
Other restraints…
Foley catheters
IV lines
Telemetry boxes
Oxygen tubing

7. Screening or Assessment Tools
DSM IV definition
Serial MMSE
Confusion Assessment Method (CAM)
CAM-ICU

8. DSM –IV Definition Acute confusional state associated with:
Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
Change in cognition (memory impairment, disorientation, language deficits) or development of perceptual disturbance that is not due to underlying/established dementia
Development during hours/days with fluctuating course

9. MMSE
Pro: familiarity
Con: not specific (deficits may be due to underlying dementia, limitations due to low literacy level)
How to use: serial MMSE during hospital course; change in performance suggests delirium

10. Confusion Assessment Method
Quick and easy
Sensitivity 94–100%, specificity 90–95%

11. CAM
Acute onset and fluctuating course (history can be obtained from family/friends or staff)
Inattention (did the patient have difficulty keeping track of conversation?)
Disorganized thinking (was conversation rambling or incoherent, unclear, illogical or unpredictable?)
Altered level of consciousness (vigilant, lethargic, stupor, coma; anything other than “alert”)

12. Disorganized Thinking
Set A
Will a stone float on water?
Are there fish in the sea?
Does 1 lb weigh more than 2 lbs?
Can you use a hammer to pound a nail?
Set B
Will a leaf float on water?
Are there elephants in the sea?
Do 2 lbs weigh more than 1 lb?
Can you use a hammer to cut wood?

13. Workup: Delirium is a Marker!
Medication review
Labs: Na, glucose, ca, creat/BUN
Infection (UTI, pneumonia)
Hypoxemia
Neuroimaging for subdural
EEG
Sleep apnea
Pain (skin, urinary retention)
Myocardial ischemia
Alcohol or benzo withdrawal
Consider LP (arboviral infections/encephalitis in elderly!)
Review for underlying dementia

14. Medications Associated with Delirium: First Think Drugs!
General: anticholinergics and benzodiazepines!
Opioids (especially meperidine)
Tricyclic antidepressants
Antihistamines (DO NOT USE BENADRYL FOR SLEEP!!!!)
Anti-Parkinsonian meds: levodopa/carbidopa, amantadine, bromocriptine)
H2 receptor blockers
Antibiotics (ciprofloxacin)
Anticonvulsants
Prednisone
Clonidine

15. Perioperative Delirium
Orthopedic and vascular surgeries: 40–50% incidence
Vascular surgeries: associated with underlying hyperlipidemia, amputation, age over 65, depression

16. Cardiac Surgery and Delirium
Associated with delirium and persistent memory impairment
Microembolism, hypoperfusion, inflammatory responses
Highest risk: history of cerebrovascular disease, PVD, diabetes, cardiomyopathy, urgent operation, long surgery time, high transfusion requirement
CABG with “beating heart/off pump” technique associated with less delirium

17. Preventing Delirium, Can It Be Done?
Inouye NEJM 1999
Randomized trial of 852 patients
Multicomponent intervention plan
Delirium developed in 9.9% intervention group vs 15% usual care group
Total number days with delirium: 62 intervention group, 90 in control group
NO DIFFERENCE in severity or recurrence of delirium once it developed: KEY IS PREVENTION

18. Preventing Delirium
Recognizing patients at risk (screening high risk patient)
Avoiding risky medications
Close observation for infection
Family/friend involvement
Decrease isolation: hearing aids, glasses
Decrease sleep disturbances
Environmental cues (opening blinds…)
Avoiding restraints
Avoiding “restraints” (foley catheters, oxygen, IV fluids, telemetry boxes) that are not needed
Vigilance for withdrawal syndromes (benzo, ETOH, SSRI)

19. Delirium, Bad Things to Come?
Observational data suggests that delirium associated with adverse outcomes including loss of independence, need for placement, cognitive decline, increased mortality
Problem: confounding… (those at highest risk for delirium are also the oldest and the sickest)

20. Prognostic Significance of Delirium…
Prospective studies do demonstrate delirium and dementia being associated with decline in cognitive and functional status, even up to 12 months after hospital stay
Highest decline in patients with both dementia and delirium

21. Can Multi-targeted Strategies Change Outcomes of Patients with Delirium?
Lack of data
Several studies have failed to demonstrate a difference in patients with delirium treated with various strategies compared to “usual care”
Problem: “Hawthorne Effect”
Studies randomized, but “usual care” group likely benefited from presence of study itself

22. Antipsychotic Use Commonly used… maybe too commonly
Care to ensure not missing underlying pain, urinary retention, psychiatric disorder, withdrawal syndrome, infection!
If used, use atypicals in very, very low dose!
Remember, no great data to support this use… so use care
Avoid benzodiazepine use (unless for withdrawal)

23. Typical Antipychotics
Haloperidol
Try to avoid
High risk of tardive diskinesia and EPS with long term use (over 50% in elderly)
If used, use low dose (0.5 mg), and limit to 1–3 days
Newer routes of atypical agents (IV, sublingual, IM) should make use of haloperidol in this setting obsolete

24. General Risks of Antipyschotics…
Much less risk of EPS and TD with atypicals
Orthostasis
Sedation
Cardiovascular effects (QT prolongation)
Weight gain
Edema

25. Risperidone (Risperdal)
Begin 0.25 mg – 0.5 mg, 1–2 times/day
Effectiveness at low doses in elderly (max 1–3 mg/day)

26. Olanzepine (zyprexa) 2.5– 5 mg
Sedation (usually started at night) with more anticholinergic side effects
Routes: PO or rapidly dissolving tablet (Zydis)
Link with weight gain and diabetes

27. Quetiapine (seroquel)
Start at 25 mg
Can rapidly increase up
Sedating, use at night
More commonly used longer term for behavior problems with dementia (limited EPS and TD effects)

28. Ziprasidone (Geodon) Restricted use at UNC IV form 20–80 mg
Contraindicated with acute CV disease (nondose dependent QT prolongation)

29. Clozapine
Great with underlying Parkinsonian symptoms due to little risk of increasing tremor
Significant rate of agranulocytosis
Restricted use

30. Antipsychotic Use FDA Black Box warning
Increased association with stroke and sudden death
Do not improve delirium; may increase LOS; likely just makes your delirious patient a more sedated delirious patient
May benefit a subset of patients with psychotic symptoms or aggressive behavior patterns
Chemical restraints

31. Anticholinesterase Inhibitors??
Agents such as donepezil being studied
Observational data suggest benefit with behavioral disturbances with dementia

32. Is Preventing Delirium Cost Effective?
Probably cost neutral…

33. Take Home Points
Delirium is very common and often missed in hospitalized older patients (15% on a general medical unit, up to 50% undergoing surgeries)
Think drugs, lines, sleep deprivation, pain, infection
Think prevention!

34. Take Home Points: Avoid drugs such as benadryl for sleep!
Avoid benzodiazepines!
When using narcotics, stay with one narcotic and try to avoid agents such as darvocet
Prevent
Treat WITHOUT ADDING MORE DRUGS
Avoid antipsychotics!