1. Subacute Befuddlement: The Identification of Delirium

2. Learning Objectives
List 4 key factors to distinguish dementia and delirium
Use the CAM tool for rapid identification of elderly patients with delirium in the hospital or clinic setting
Identify “flavors” of delirium:
Hyperactive (agitated)
Hypoactive
Mixed

3. Origins… Latin: De = away from Lira = furrow in a field
“going off the plowed track”
coined by Roman author Celsus in 1AD?

4. Why does delirium matter to patients?
In hospital: After discharge:
longer LOS more institutionalization
greater mortality persistence of cog sx
functional disability higher 2 yr mortality

5. Delirium is common & missed (throughout the hospital course)
“Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes”
Patients in emergency dept >65 years N=303
25 (8.3%) were found CAM + for delirium
19 were missed in emergency dept
16 admitted to hospital
15 missed on hospital admission
Han JH, Zimmerman EE, Schnelle J, Morandi A, Dittus RS, Ely EW, Acad Emerg Med, 2009 Mar; 16 (3): Epub 2009 Jan 20.

6. Delirium vs. Dementia Onset Abrupt Gradual Symptoms Fluctuate
Slow progression
Consciousness
Impaired
Normal
Attention
Decreased
Perceptual Disturbances
Possible
Rare (late)
Tremors/
Asterixis
Rare

7. Flavors of delirium
Quiet withdrawn state – hypoactive delirium – lethargy and decreased activity
More common in older patients.
Also more common in ICU patients.

8. Flavors of delirium Acutely agitated – hyperactive delirium
more commonly seen in younger patients
but can present in elderly patients

9. Flavors of delirium
Both hypoactive and hyperactive delirium in the same patient at various times:
Mixed delirium

10. DSM IV criteria for delirium due to a general medical condition:
1. Disturbance of consciousness with a reduced ability to focus, sustain, or shift attention.

11. DSM IV criteria for delirium due to a general medical condition:
1. Disturbance of consciousness with a reduced ability to focus, sustain, or shift attention.
2. A change in cognition or a perceptual disturbance that cannot be explained by a coexisting dementia.

12. DSM IV criteria for delirium due to a general medical condition:
1. Disturbance of consciousness with a reduced ability to focus, sustain, or shift attention.
2. A change in cognition or a perceptual disturbance that cannot be explained by a coexisting dementia.
3. It develops quickly, and fluctuates during the course of the day.

13. DSM IV criteria for delirium due to a general medical condition:
1. Disturbance of consciousness with a reduced ability to focus, sustain, or shift attention.
2. A change in cognition or a perceptual disturbance that cannot be explained by a coexisting dementia.
3. It develops quickly, and fluctuates during the course of the day.
4. There is evidence that this is caused by a medical condition.

14. Medical problems can contribute to delirium:
Acute cardiac events
Acute pulmonary events
Bed rest
Sedative or EtOH withdrawal
Fluid/lyte abnormalities
Infections
Intracranial events
Meds
Anemia
Uncontrolled pain
Urinary retention or fecal impaction
Indwelling devices
Restraints

15. Drugs we give patients may contribute to delirium:
Anticholinergic agents
Antipsychotics
Antidepressants
Anxiolytics, especially benzodiazepines
Cardiac
H2 blockers
Narcotic analgesics
Sedative hypnotics
Antichol: antihyst. [benadryl, atarax]; antispasmotics [belladonna, lomotil], TCA, Parkinsonian Rx [cogentin, artane]
Cardiac: dig, lidocaine

16. Pathophysiology: of our drugs
Cholinergic inhibition: meds, medical/surgical illness
GABA activation: meds, hepatic failure
Serotonin deficiency: med/surg illnesses -> phenylalanine elevation/tryptophan depletion
Cytokine excess
Dopamine activation: meds, CVA
Cortisol excess: glucocorticoids, Cushings, CVA, surgery
GABA: benzodiazepines
Flacker JM. J Geront Biol Sci 1999;54:B

17. On top of predisposing risk factors:
age (>70 y/o)
dementia
functional ADL impairments
high medical co-morbidity
EtOH abuse
Male
Sensory impairment
Marcantonio ER: Delirium. In: Rakel RE Conn’s Current Therapy 2001.

18. How do you identify Delirium? Assess the patient using the CAM test
To be “CAM Positive” for delirium, the patient must meet the following criteria: Mental status changes: acute onset or fluctuating course & Inattention Disorganized thinking OR Altered level of consciousness

19. #1 Acute onset or fluctuations?
Do not use the current hospital status to define the baseline.
Establish the temporal course and severity to distinguish pre-existing dementia from delirium.
Knowing baseline level of function can help.

20. #2 Is there inattention?
Is the patient having difficulty focusing attention, easily distractible, having difficulty tracking?

21. #3 Is there disorganized thinking?
Is there disorganized thinking, rambling, irrelevant conversation, unclear flow of ideas, tangential or loose associations?
Screened by:
Yes/No logic questions.
Simple conversation if verbal.
Simple commands.

22. #4 Decreased (or changed) level of consciousness?
Agitation? Somnolence?

23. Delirium prevention through “Hospital Elder Life Program” principles
Inouye, SK. Delirium in older persons. NEJM 2006;354:1157-6
Cognitive stimulation: Keep oriented/Current events
Word games
Vision/Hearing: Glasses, hearing aids
Mobility: Ambulate/Ex/ROM
Avoid restraints, catheters
Sleep: Quiet! Avoid disruptions
Avoid hypnotics – try behavioral techniques
Hydration: Assess (consider oral vs. IV)

24. Identification & treatment of underlying causes:
Find & treat delirium underlying cause(s) (30% may be unknown)
Through:
History taking
Physical exam
Labs
Imaging (when clinically indicated)

25. In the meantime— non-pharmacologic measures first
General Support
Hydration
Nutrition
Comfort
Safety
Review/reduce medications
Avoid restraints!

26. Management of Delirium Sx: (Pharmacologically)
Currently there is controversy over the use and efficacy of medications to manage agitation associated with delirium
Could consider antipsychotic medications
Only If agitated & risk of harm to self or others
Side effects may include: extrapyramidal side effects, long QT syndrome, hypotension, anticholinergic effects, confusion, cardiac effects

27. Summary approach to delirium
Recognize the urgency of delirium in geriatric patients
Prevent delirium when possible
Recognize delirium Act!
Keep patient safe
Initiate evaluation
Treatment:
Underlying causes
Non-pharmacologic support
Pharmacologic (when necessary only)