Duke GEC Delirium Teaching Rounds “Itching for a Fight!” November 4, 2011

Duke GEC Objectives Identify risk factors and key presenting features of delirium Appreciate the role of different professions in recognition and management Identify medications that contribute to the development of delirium

Duke GEC A BIG Problem Hospitalized patients over 65: – 10-40% Prevalence – 25-60% Incidence ICU: 70-87% ER: 10-30% Post-operative: 15-53% Post-acute care: 60% End-of-life: 83% Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009.

Duke GEC Costs of Delirium In-hospital complications 1,3 – UTI, falls, incontinence, LOS – Death Persistent delirium– Discharge and 6 mos. 2 1/3 Long term mortality (22.7mo) 4 HR=1.95 Institutionalization (14.6 mo) 4 OR=2.41 – Long term loss of function Incident dementia (4.1 yrs) 4 OR=12.52 Excess of $2500 per hospitalization 1-O’Keeffe 1997; 2-McCusker 2003; 3-Siddiqi 2006; 4-Witlox 2010

Duke GEC Clinical Features of Delirium Acute or subacute onset Fluctuating intensity of symptoms Inattention Disorganized thinking Altered level of consciousness – Hypoactive v. Hyperactive Sleep disturbance Emotional and behavioral problems

Duke GEC Common Risk Factors for Delirium Predisposing Advanced age Preexisting dementia History of stroke Parkinson disease Multiple comorbid conditions Impaired vision Impaired hearing Functional impairment Male sex History of alcohol abuse Precipitating New acute medical problem Exacerbation of chronic medical problem Surgery/anesthesia New psychoactive medication Acute stroke Pain Environmental change Urine retention/fecal impaction Electrolyte disturbances Dehydration Sepsis Marcantonio, 2011.

Duke GEC Itching for a Fight! Mr. S is an 81 year old retired Baptist minister admitted for an exploratory laparotomy….. Gather in a group with students representing all professions Read the case and discuss the questions Designate a spokesperson Have fun!

Duke GEC Common Risk Factors for Delirium Predisposing Advanced age Preexisting dementia History of stroke Parkinson disease Multiple comorbid conditions Impaired vision Impaired hearing Functional impairment Male sex History of alcohol abuse Precipitating New acute medical problem Exacerbation of chronic medical problem Surgery/anesthesia New psychoactive medication Acute stroke Pain Environmental change Urine retention/fecal impaction Electrolyte disturbances Dehydration Sepsis Marcantonio, 2011.

Duke GEC Anticholinergic Exposure in Geriatric Patients Smaller reserve of neurotransmitters + Increased blood brain barrier permeability = ↑ Sensitivity to adverse effects of anticholinergic medications Fundamentals of Geriatric Pharmacotherapy 2010

Duke GEC Adverse Effects of Anticholinergics Central Confusion Memory Impairment Cognitive Dysfunction Drowsiness Dizziness Contributing to: Delirium Unsteady gait Increased falls risk Peripheral Urinary retention Constipation Dry mouth Dry eyes Worsening of glaucoma Impaired sweating Tachycardia Pharmacotherapy 2005; 25 (11):1592–1601

Duke GEC Anticholinergic Risk Score (ARS) Ranks medications for anticholinergic potential on a 3-point scale: 0= no or low risk 3 = high anticholinergic potential To calculate the patient’s ARS score: identify anticholinergic medications and add the total points for each medication. Anticholinergic effects are cumulative! Arch Intern Med 2008; 168:

Duke GEC Game time: Anticholinergic Medications! The Game Anticholinergic Medications! The Game

Duke GEC Anticholinergic risk scale 3 points AmitriptylineHydroxyzine Atropine productsImipramine BenztropineMeclizine CarisoprodolOxybutynin ChlorpheniraminePerphenazine ChlorpromazinePromethazine CyproheptadineThioridazine DicyclomineTizanidine DiphenhydramineTrifluoperazine FluphenazineHyoscyamine Arch Intern Med 2008; 168:

Duke GEC Anticholinergic Risk Scale 2 points AmantadineLoperamide BaclofenLoratadine CetirizineNortriptyline CimetidineOlanzapine ClozapineProchlorperazine CyclobenzaprinePseudoephedrine DesipramineTolterodine Arch Intern Med 2008; 168:

Duke GEC 1 point Carbidopa-levodopaPramipexole EntacaponeQuetiapine HaloperidolRanitidine MethocarbamolRisperidone MetoclopramideSelegiline MirtazapineTrazodone ParoxetineZiprasidone Anticholinergic Risk Scale Arch Intern Med 2008; 168:

Duke GEC Anticholinergic Activity 0/+ (No or minimal) CelecoxibFentanyl HydrocodonePropoxyphene DuloxetineAmoxicillin CephalexinLevofloxacin DigoxinFurosemide DonepezilPhenytoin TopiramateDiphenoxylate JAGS 2008; 56 (7):

Duke GEC Non-Pharmacologic Management of Pruritus Wearing sheer clothing Avoiding hot baths, alcohol, spicy foods Maintain proper humidity of rooms Avoid contact with wool or animal fur Prevent dry skin (moisturize and apply emollients) Apply cold wet dressings Keep fingernails short “Happiness is having a scratch for every itch.” –Ogden Nash Reich, 2011; Patel, 2010.

Duke GEC Pharmacologic Management of Pruritus Medication/ClassDrawbacks Topical Agents Menthol Short-acting, may be irritating to skin Anesthetics (lidocaine) May cause allergic contact dermatitis Antihistamines Limited efficacy and contact allergies Capsaicin Burning sensation when initiating Corticosteroids May only be effective if inflammation involved Systemic Agents Antihistamines Sedation, delirium, etc. Opioid Receptor Antagonists (naloxone) Reverse opioid effects (pain management) Antidepressants May only be useful in psychiatric conditions Reich, 2011; Patel, 2010.

Duke GEC Summary Maintain a high level of suspicion – Watch out for precipitating medications Discuss with other members of the team – Involve pharmacists Consider non-pharmacologic strategies for treating common problems (e.g. pruritis) Inform/educate patients and families

Duke GEC A better way…. Medicine Nursing PT/OT Pharmacy Social work Nutrition PA’s Patients and Caregivers Administrators NP’s