1 Delirium Steven Levenson, MD, CMD

Front Cover Stuff—Yet Again 2

Common Reaction to Attempted Delirium Discussion 3

Delirium It can happen to anyone For example, alcohol withdrawal A “classic” geriatric syndrome Common among residents / patients in LTC and postacute facilities Prevalence in these settings may be increasing as hospitals reduce length of stay 4

Delirium: Example Example: 76-year-old practicing gynecologist experienced delirium after gall bladder surgery Described as resembling an unending nightmare Typical stories Was usual self until recent illness This is totally different from usual 5

Delirium Clinicians often fail to recognize Simple and practical tools exist to help identify it Those who work and practice in long- term care must be knowledgeable about risk factors, as well as how to recognize, diagnose, prevent, and treat Lyons W. Delirium in Postacute and Long-term Care. Jl Amer Med Dir Assoc 2006; 7:

Delirium: Definition and Key Features A syndrome of acute brain failure Synonyms: “acute confusional state,” “encephalopathy” Typically multi-factorial Results from interaction between vulnerable patient (usually with several predisposing factors) and one or more illnesses or conditions 7

Delirium: What Goes Wrong? One or more things cause or worsen brain failure Brain failure adversely affects human activities that depend on adequately balanced brain activity Typically presents as an acute change in attention, cognition, alertness, responsiveness, thinking, speaking, memory, or orientation 8

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Delirium and Dementia Go Together Complex but simple relationship between delirium and dementia Dementia is a risk factor for delirium Delirium is a risk factor for subsequent new or worsening dementia Delirium may Unmask previously hidden cognitive impairment Cause permanent cognitive decline alzheimers-like-problems-in-one-third-of-patients/ 10

Delirium and Dementia Go Together Delirium appears to worsen the prognosis of dementia and may accelerate its cognitive decline Dementia is probably the major predisposing factor Having dementia increases risk of delirium by 2 to 5 times 11

Healthy Adult’s Brain Pathways 12

The Brain is Like a Symphony 13

When Our Wiring Goes Wild 14

Delirium: Prevalence Extremely common, affecting over one third of hospitalized elders May relate in part to pressures to reduce hospital length of stay One retrospective study, using MDS Prevalence of delirium in the long-term setting 14% 15

Delirium: Consequences Many acutely confused elders transition from hospital to postacute facility Remain confused and suffer complications Delirium clearly associated with poor health outcomes Increased in-hospital mortality Longer hospital length of stay Functional decline Risk of institutionalization 16

Delirium: Several Subtypes Overactive Individual may appear anxious or agitated May lead to inappropriate sedation, rather than recognition and remediation of the episode of acute confusion Underactive Reduced activity; may resemble depression “Mixed” or even “normal” 17

Delirium: Presentation Important to prevent, identify, manage Delirium may be the only evidence of a serious medical problem Symptoms Altered attention, disorganized thinking, disorientation, altered consciousness, memory problems, perceptual disorders, overactive (e.g., aggressive, combative) Essential to recognize, diagnose, and work up promptly 18

Delirium: Recognition Suspect delirium in an unfamiliar, combative, uncooperative patient Assume it may be delirium until proven otherwise Newly diagnosed psychosis or mania may resemble delirium Staff and clinicians should not expect one obvious etiology Advisable not to stop looking for causes when a single one is found 19

20 Good Care Requires Excellent Detective Work

Problem Solving Process (Clinical and Otherwise) 21

Misguided Care Process 22

Delirium: Diagnosis Effective diagnosis requires Clear understanding of baseline cognitive functioning, behavior Staff who do not just defer to the psychiatric consultant or the MDS nurse Reliable informants (e.g., family) should be contacted Nursing staff’s knowledge of a resident’s routine cognitive abilities and behavior can be invaluable 23

Risk Factors as Fuel; Precipitants as Spark 24

Risk Factors: How Much Fuel? 25

Delirium: Risk Factors Demographic, clinical, functional risks Analogous to fire Predisposing factors are fuel Precipitating factors are the sparks needed for ignition Not much fuel needed to precipitate delirium in a highly vulnerable patient Patients with greater vulnerability require lesser insult to become delirious 26

Delirium: Predisposing Factors Many risk factors, for example Cognitive impairment Large number and severity of comorbid illnesses Advanced age Chronic renal insufficiency Vision/hearing impairment Adding new medications or abruptly stopping others 27

Delirium: Precipitating Factors Many things can set off the “spark” Medications and medication changes (including withdrawal) Acute medical illnesses Procedures or surgery Stroke Infections Major psychosocial stressor 28

Delirium: Recognition in Long- Term & Postacute Care Postacute and long-term care staff may be Unfamiliar with preadmission cognitive functioning Unaware or untrained in recognizing delirium, meaning and dangers of delirium 29

Delirium: Recognition in Long- Term & Postacute Care Vitally important for long-term care clinicians to be familiar with prevention, identification, and management Identification, evaluation, and management of delirium is potential medical emergency in long-term and postacute care setting Often the only manifestation of a life- threatening condition among elders 30

Delirium: Diagnosis Differential diagnosis includes a number of common clinical entities Dementia probably most easily confused with delirium Depression can resemble hypoactive delirium as well Very important not to rush to conclusions about causes of behavior without considering delirium 31

32 Search For Causes in All Dimensions PSYCHOSOCIAL FUNCTIONAL PHYSICAL

Delirium: Other Diagnostic Considerations Various conditions and situations may cause someone to become angry or “agitated,” raising concerns about possible delirium Examples Untreated pain Urinary retention Environmental stimuli 33

Delirium: Workup Get the (all-important) story! Meticulous history taking, employing multiple sources Onset and duration Frequency (including fluctuation) Current cognitive function and attention compared to baseline 34

Delirium: Prognosis Two important prognostic issues related to delirium First, how long does it take an episode of delirium to resolve? Second, does delirium predict other adverse health-related and functional outcomes? 35

Delirium: Time Course Typically resolves in days to weeks Sometimes requires weeks to months or longer for a patient to achieve baseline mental status again May also reoccur intermittently over extended period The acute medical problem (e.g., infection) may resolve before the confusional episode that it caused 36

Delirium Time Course Four factors associated with persistent delirium Older age (85 years and older) Presence of pre-hospital cognitive impairment More severe delirium at the time of facility admission Presence of more symptoms at admission 37

Delirium: Association With Health Outcomes In patients admitted to postacute facilities Persistent delirium was associated with poor recovery of basic and instrumental activities of daily living, even after adjustment for age, baseline functional status, comorbidity, and dementia 38

Delirium: Examples of Actions to Prevent and Intervene Cognitive impairment Reorientation to time, location, and care team Cognitively stimulating activities Sleep deprivation Caffeine-free beverages Noise reduction measures Minimize sleep disruption 39

Delirium: Good Supportive Care Frequent reorienting cues for time and place Attempts to maintain continuity of bed location, room location, and care staff Supervision to prevent injury to self and others Use of a room that is quiet and well lit Provision of eyeglasses and hearing aids as appropriate 40

Delirium: Challenge All settings have a responsibility to address the problem of delirium Focus on prevention, early detection, and prompt, aggressive management What can I do about this? Individuals can do many useful things 41