1. Today's activity You and your colleagues will evaluate 3 geriatric patients for delirium. Each group will rotate to 3 patient stations. You will have 10 minutes with the patient, 5 minutes to develop a management plan based on your diagnoses, and 5 minutes for feedback. Each group member should "take the lead" with one patient. Prior to "seeing" the patient: --review the face-sheet to learn the history and presentation --come up with a "pretest" probability of how likely it is that the patient will have or develop delirium --identify any predisposing or precipitating factors Then, evaluate the patient --use CAM to determine if the patient has delirium --discuss your assessment and plan with the family at the bedside

2. Goals 1. Define delirium and understand concept of precipitating and predisposing factors 2. Recognize that delirium is common, under-diagnosed, and associated with significant morbidity and mortality 3. Regarding delirium, know ways to: diagnose evaluate manage

3. Goals 1. Define delirium 2. Understand model that uses predisposing and precipitating factors

4. Delirium Definition Medical condition characterized by acute onset of confusion (, i.e. not chronic) Has following features: Fluctuating course Altered level of awareness/consciousness Inattention Disorganized thinking Increased or decreased psychomotor activity Disturbance of sleep-wake cycle

5. Predisposing factors Dementia Age Male sex Frailty Malnutrition Depression Terminal illness Functional impairment Immobility Alcohol abuse Sensory impairment High medical comorbidity Polypharmacy

6. Precipitating factors Medications Neurologic disease Surgery Uncontrolled pain Hypoxia Metabolic derangements Severe illness/infection Low Hct Bed rest Indwelling devices Restraints Sleep deprivation Dehydration

7. Tipping the scale... The greater the predisposing factors, the fewer precipitating factors required to initiate the delirium. Delirium is usually MULTIFACTORIAL.

8. Goals 2. Recognize that delirium is common, under-diagnosed, and associated with significant morbidity and mortality

9. How many geriatric patients have delirium? Common but underdiagnosed... At presentation to the ED: 7-33%. At hospital admission: 14-25%. Postoperatively: 15-53%. In the ICU: 70-87%. In the community, ages 65-85: 1-10%, those >85: 14%. At the end of life: Up to 83%.

10. Prognosis: It's a big deal! May persist weeks, months- 44% at 1 month, 33% at 3 months. Has a waxing and waning course. Has been associated with a 10-fold increased risk of death in the hospital 3-5 increased risk of nosocomial complications prolonged length of stay impaired physical and cognitive recovery at 6 and 12 months need for post-acute nursing home placement Has an associated one-year mortality rate of 35-40%!

11. Goals 3. Regarding delirium, know ways to: diagnose evaluate manage

12. Diagnosis *****CAM: Confusion Assessment Method***** Based on the 4 cardinal elements of the DSM-3 criteria for delirium: 1.Acute onset and fluctuating course 2.Inattention 3.Disorganized thinking 4.Altered level of consciousness Must have have 1 and 2 and either 3 or 4 Sensitivity 94%-100% Specificity 90-95% Positive LR 9.6 Negative LR 0.16 Inouye SK et al. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990: 113 (13): 941-948.

13. Feature 1. Acute Onset or Fluctuating Course: Must have this one! This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: 1.Is there evidence of an acute change in mental status from the patient’s baseline? 2.Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?

14. Feature 2. Inattention: Must have this one! This feature is shown by a positive response to the following question: 1.Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?

15. Feature 3. Disorganized thinking This feature is shown by a positive response to the folllowing question: 1.Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

16. Feature 4. Altered Level of Consciousness This feature is shown by any answer other than “alert” to the following question: 1. Overall, how would you rate this patient’s level of consciousness? -alert -vigilant/hypervigilant -lethargic -stuporous -comatose

17. Evaluation: D.E.L.I.R.I.U.M Drugs!! Electrolyte/endocrine disturbances (dehydration, sodium imbalance, uremia, hypercalcemia, hypoglycemia, thyrotoxicosis) Lack of drugs (withdrawal from ETOH, benzos or poor pain control, B12 deficiency) Infection (sepsis, meningitis, encephalitis) Reduced sensory input (can't see or can't hear) Intracranial (infection, hemorrhage, stroke, tumor) Urinary, fecal (urinary retention, fecal impaction--can be a cause!) Major organ system issues-- infarction, arrhythmia, shock, COPD, hypoxia, hypercapnia, renal failure, liver failure, hypertensive encephalopathy

18. Evaluation Basics: History Physical exam Targeted labs Careful medication history Alcohol, illicit drug use Vital signs Multiple factors likely involved rather than a single "cause" but delirium can be the sole manifestation of serious underlying disease.

19. If still looking... LP Blood cultures UA/Urine culture Urine toxicology Cardiac enzymes and EKG Arterial blood gas Blood alcohol Head CT EEG

20. Management of delirium First, try to remove/treat precipitants of delirium. Provide frequent orientation and therapeutic activities. Provide glasses and hearing aids. Avoid constipation/urinary retention/dehydration/electrolyte imbalances. Avoid complete bed rest. Educate family and nursing support staff of ways to comfort patient. Try scheduled tylenol, ice/heat packs, warm milk in place of meds.

21. Medications to reduce or eliminate... particularly if they are not needed or are not working or there are other alternatives! Anticholinergics Diuretics Antidepressants Benzos Opioids** Anticonvulsants Antiparkinsonian agents Nonbenzodiazepine hypnotics (zolpidem) Fluroquinolones (levaquin) Muscle relaxants Antiemetics Steroids **Don't over-treat pain but also don't under-treat it!

22. About restraints... We DO NOT recommend restraints as they can cause bad outcomes (even death!). Always, evaluate the patient first. Always, try other interventions first: --Have family stay with patient --Use a sitter --Demonstrate calming the patient to those involved in the patient care. If medically necessary to the patient, use restraints for the least amount of time possible and always inform the family about why they are needed. Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4): 405-8.

23. Pharmacologic Therapy, ie chemical restraints Consider only if safety is in issue or if patient's symptoms are very distressing to the patient High-potency antipsychotics (haldol) usually first-line Use low dose and go slow ex. 0.25 mg IV haldol or 0.5 mg po haldol Use for shortest duration possible Can see akathisia, which can be mistaken for worsening delirium

24. Take-home points Delirium is common, under-recognized and serious (increased risk of death)!!!!! Use the CAM to diagnose delirium: Acute onset+Inattention and either disorganized thinking or altered level of consciousness Remember D.E.L.I.R.I.U.M. for differential diagnosis. Use your H&P to guide you evaluation and management. Try to avoid physical and chemical restraints.

25. Works cited Botts, Angela. Delirium in Hospitalized Older Patients. Clinical Geriatrics 2010: Volume 18 (10): 28-33. Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R.(1990). Clarifying confusion: the confusion assessment method. Annals of Internal Medicine, 113(12), 941-948.. Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM 1999; 340(9): 669-676. Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission characteristics. Ann Intern Med 1993: 119 (6); 474-481. Inouye SK. Delirium in Older Persons. NEJM 2006: 354 (11); 1157-1165. O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997; 45(4): 470- 473. Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4): 405-8 Wong et al. Does this patient have delirium? Value of bedside instruments. JAMA Aug 18, 2010- Vol 304.

26. Questions? THANK YOU! Contact information: Lindsay Wilson lwilson3@unch.unc.edu 919-966-5945 ext 256