Delirium in the Elderly M. Andrew Greganti, MD March 19, 2009

Outline of Discussion Case Presentation Distinguishing characteristics Prevalence Etiology/Pathogenesis/Risk Factors Prodrome Clinical Presentation Diagnosis/Evaluation Prognostic Implications Prevention and Treatment

Case Presentation 86 yo woman presents with confusion post hip fracture surgery. Medical Problems: –Hypertension –CHF - compensated –Sick sinus syndrome S/P pacemaker –Chronic atrial fibrillation –Chronic anxiety about health

Case Presentation Long-term resident of life care community living in an intermediate care facility Severe anxiety with tendency to obscess over health issues –Increasing anxiety level recently Less intellectually “sharp” over previous 6 months

Hospital Course In the ED could not understand that she had broken her hip No immediate perioperative complications Postop day 2: Confused, agitated, waxing and waning of sensorium –Difficulty recognizing family –Misinterpreted environmental stimuli –“Sundowning” requiring a sitter

Hospital Course Hypoxia secondary to aspiration Improved post antibiotics Confusion and difficulty understanding directions - effective PT impossible Poor hearing exacerbated confusion.

Hospital Course After 10 days, cognition improved but not back to baseline Discharged to skilled nursing floor of her life care community with persisting: –Confusion –Disorientation –Severe anxiety –Poor recent memory

Post Hospital Course Fell 2 months post discharge, fracturing R ankle –Severe delirium postop marked by episodic yelling out Never returned to baseline: –Intermittent confusion –Somnolence followed by agitation –Repetitive vocalizations No response to re-orientation – partial response to clonazepam, then olanzapine

Characteristics of Delirium Disturbance of consciousness Abnormal attention Abnormal cognition –Orientation –Memory –Thought processing –Executive function –Perception Acute in onset and fluctuating in course Precipitated by acute medical illness, medication, or substance intoxication Hyperactive, hypoactive, and mixed forms

Other Characteristics Misdiagnosis is frequent – unrecognized in up to 70% May develop over hours to days. –Abrupt onset more common. –The line between dementia and delirium is often unclear.

How common is delirium? On admission to medical wards, 15 to 20% of older patients meet criteria for delirium. –Incidence during medical hospitalization: 5 to 10% - in some studies 30%. –Prevalence higher in surgical patients: 10 to 15% post general surgery 30% post cardiac surgery 50% post hip fracture Very common in terminally ill patients – 90%

Etiology Etiology - Multifactorial in a patient predisposed by underlying dementia: –Infections –Toxins, including drugs –Substance withdrawal –Organ failure: heart, liver, kidney, etc. –Metabolic derangements –Primary brain disorders

Pathogenesis No specific structural brain lesion identified but subcortical and cortical dysfunction Changes in perfusion pressure Depleted acetylcholine Dopamine excess Dopamine, GABA, serotonin, acetylcholine imbalance Cytokine activation

Risk Factors Dementia: the strongest risk factor – 25 to 75% Other predisposing brain diseases: stroke, Parkinson’s Advanced age Severe medical illness Metabolic disturbances: Hyponatremia, dehydration Drugs: anticholinergics, sedative hypnotics, narcotics

Other Risk Factors Immobility, low activity level Hearing or vision impairment Number of hospital room changes Environmental high noise level

Prodrome Patients may describe and/or manifest: –Decreased concentration –Irritability, restlessness, anxiety, depression –Hypersensitivity to light and sound –Perceptual disturbances –Sleep disturbance - daytime somnolence and nocturnal agitation

Clinical Presentation Disorientation to place, time, situation Impaired consciousness –Reduced awareness –Reduced or clouded consciousness with or without overt hallucinations

Clinical Presentation Decreased ability to focus, sustain, or shift attention –Decreased selective attention –Distractibility Cognition is made worse by inattention. Speech: –Tangential –Poorly organized –Slowed, slurred –Word finding difficulties: dysnomia, paraphasia, aphasia

Clinical Presentation Impaired registration, recent/remote memory with associated confabulation Perceptual abnormalities: –Micropsia –Macropsia –Frank auditory or visual hallucinations, distortion of body image –May take action in response to hallucinations

Diagnosis History from family and/or caregivers Bedside observations Diagnostic errors are common in: –Hypoactive form –The setting of rapid fluctuations of cognition. Those with the patient the entire day (nurses) or less likely to be deceived. Reliable diagnostic instruments –Confusion Assessment Method (CAM)

Confusion Assessment Method Are these features present? –Acute onset and fluctuating course –Inattention, distractibility –Disorganized thinking, illogical or unclear ideas –Alteration in consciousness

Differential Diagnosis Dementia –Alzheimer dementia –Lewy body dementia Delusional psychosis –Psychosis is associated with normal attention, orientation, and sleep/wake cycle –Schizophrenia has a more chronic hx with highly systematized delusions. Depression and Mania –Misdiagnosed as depression in as many as 40% of cases

Evaluation Search for causative medication is especially important – up to 40% of cases. –Psychotropics, narcotics, anticholinergics –Digoxin, prednisone, furosemide, cimetidine have anticholinergic properties.

Evaluation CBC, electrolytes, BUN, Cr, glucose, LFTs O2 Saturation Urinalysis TSH, B12 Toxin screen CXR CNS imaging LP in febrile patient with meningeal signs Cause not identified in 15 to 25%

Prognosis Delirium is independently associated with: –Increased functional disability –Increased LOS –Admission to long-term care Hospital mortality of 22 to 76% - one year mortality of 35 to 40% –Highest in the hypoactive subtype May persist for months or indefinitely – more likely in dementia Two factors related to better outcomes: –Admission from home –Better premorbid functioning

Preventive Measures Supportive overall approach with constant reorientation Effective management of anxiety Effective management of pain Early mobilization Focus on assuring optimal vision and hearing. Haloperidol and donepezil prophylaxis not effective

Treatment Recognize and treat the prodromal stage Focus on re-orientation – bedside sitter Reduce or discontinue psychotropic, anticholinergic, sedative, and narcotic meds. Optimize nutrition. Physical therapy to increase mobility

Treatment Nonpharmacologic measures: –Increase interpersonal contact and environmental support. ? use of around the clock sitters –Provide clocks, calendars, soft lighting. –Place family pictures in clear view. –Reduce noise levels. –Maximize visual and auditory acuity. –Minimize room changes in the hospital.

Treatment Use medications only as a last resort: –Antipsychotics: haloperidol –Atypical antipsychotics: risperidone, aripiprazole, ziprasidone, quetiapine, olanzapine –Benzodiazepines - lorazepam

Treatment Future therapies: –Cholinergic drugs: donepezil, rivastigmine, physostigmine –Selective dopamine antagonists –Benzodiazepine receptor (GABA) antagonists –Antiplatelet and anti-inflammatory agents

Summary of Key Points Delirium is an acute or subacute change in mental status marked by a waxing and waning course. The etiology is multifactorial superimposed on dementia and precipitated by acute medical illness. Risk factors include age, drug Rx, and metabolic derangements. It is associated with increased LOS, institutionalization, and increased mortality.

Summary of Key Points Evaluation should focus on ruling out infection, medication toxicity, neurological events, metabolic abnormalities, and new cardiorespiratory problems. Prevention is the best therapy – focus on interpersonal and environmental support. Use medications as a last resort.