1. Delirium A Medical Emergency Allison J. Batchelor, MD, CMD Geriatric Medicine

2. Delirium vs. Dementia

3. Definition Delirium Disturbance of consciousness with reduced ability to focus, sustain, or shift attention A change in cognition, a perceptual disturbance not accounted for by preexisting, established or evolving dementia Occurs over a short time period and fluctuates during the day Has a causal component—acute illness, medications, metabolic Dementia Chronic acquired decline in memory and at least on other cognitive function Decline usually evident over longer periods with mild to severe cognitive decline, hallucinations, and delusions

4. How to Distinguish Delirium from Dementia Features seen in both: Disorientation –Acute onset –Impaired attention –Altered level of consciousness –Memory impairment –Paranoia –Hallucinations –Emotional lability –Sleep-wake cycle reversal Key features of delirium: –Acute onset –Impaired attention –Altered level of consciousness

5. Delirium  An acute state of confusion  A medical emergency  Indicates there may be a serious underlying medical condition  Patients describe the delirium experience as: twilight zone, fog bank, state of constant terror

6. Dementia C Comes on over time, short term memory loss loss becomes evident May progress slowly or quickly May affect younger persons as well as elderly Different kinds of dementia—Alzheimer’s, Multi- infarct, Lewy Body, Parkinson’s, etc Treatment generally depends on the stage/ severity of the disease Is terrifying while the patient is still able to realize that they are not thinking properly

7. Delirium can be described as:  Starting suddenly  Lasting a few hours, a few days or a few weeks  Patient’s alertness fluctuates  Patient knows self (person) but not time and place  Patient’s attention is distracted easily, can not stay on one subject for very long  They have NO short term memory  Their thinking is disorganized and they ramble  They have delusions and visual hallucinations

8. 4 Key Features of Delirium 1. Difficulty concentrating 2. No short term memory, disorientated, seeing things 3. Sudden onset, can go from very active to very sleepy 4. Delirium is caused by a medical problem such as an infection, new medication or alcohol withdra EXAMPLE– MOM on first night post- op after TKR surgery….

9. 3 Types of Delirium Hyperactive  Agitated state with increase activity and increased verbal behaviors Hypoactive  More comment in elderly. Lethargic--Quietly confused with some anxiety. Tired and withdrawn Mixed  Patients move from hyperactive to hypoactive states

10. https://www.youtube.com/watch?v=9QURzexhWP4 MAJOR ACUTE CHANGE IN BEHAVIOR --Agitiation This is not my mom! Delirium Awareness PSA 0:57 minutes

11. https://www.youtube.com/watch?v=zv38U8SNJFs Delirium Quiet and Excited YouTube—VAMC 5:50min Start at 1:24 to 4:45 DISTINGUISH HYPOACTIVE (QUIET) VS. HYPERACTIVE (EXCITED) DELIRIUM

12. https://www.youtube.com/watch?v=0Wvm_GdjOkg What is Delirium? Causes, Signs, Symptoms, Treatment of Delirium - Acute Confusional State 3:29 minutes

13. What Causes Delirium Outside hospital  Illness  Pneumonia, UTI’s  Depression  Metabolic imbalances  New medications  Alcohol and drug withdrawal  Post operative  Previous delirium Inside hospital  Dehydration, malnutrition  Surgery  Infections  Not sleeping  Not mobilizing  Unfamiliar environment  Sensory overload  Isolation and no windows  New Medications/esp pain meds

14. Delirium Diagnosis: Confusion Assessment Method (CAM) Inouye SK et al. Ann Intern Med. 1990; 113: 941-948 (1) Acute change in mental status with a fluctuating course (2) Inattention AND (3) Disorganized thinking OR (4) Altered level of consciousness Sensitivity: 94-100%, Specificity: 90-95%

15. https://www.youtube.com/watch?v=lJH1AoVuVS0 Delirium in elderly patient: Assessment 4:41

16. Incidence Among Elderly Patients is HIGH 1/3 of patients presenting to ER 1/3 of inpatients aged 70+ on general med units Peri-operative incidence is very high (like MOM) Incidence ranges 5.1% to 52.2% after noncardiac surgery ( Dasgupta M et al. J Am Geriatr Soc 2006;54:1578-89) Highest rates after hip fracture and aortic surgeries

17. Delirium: Increased Risk of… Functional decline New nursing home placement Persistent cognitive decline: –18-22% of hospitalized elders with complete resolution 6-12 months after discharge –CAVEAT: Many subjects with preexisting cognitive impairment (Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704)

18. Delirium: Increased Mortality  One-year mortality: 35-40%  Independent predictor of higher mortality up to 1 year after occurrence

19. Assume it is Delirium until Proven Otherwise  Delirium may be the only manifestation of life-threatening illness in the elderly patient  May herald MI, pneumonia, UTI/urosepsis, med toxicity, etc

20. A Model of Delirium A multifactorial syndrome that arises from an interrelationship between:  Predisposing factors  a patient’s underlying vulnerability AND  Precipitating factors  noxious insults

22. Predisposing Factors i.e. baseline underlying vulnerability  Baseline cognitive impairment  2.5 fold increased risk of delirium in dementia patients  25-31% of delirious patients have underlying dementia  Medical comorbidities:  Any medical illness Visual impairment Hearing impairment Functional impairment Depression Advanced age History of ETOH abuse Male gender

23. Precipitating Factors i.e. noxious insults  Medications  Bedrest  Indwelling bladder catheters  Physical restraints  Iatrogenic events  Uncontrolled pain  Fluid/electrolyte abnormalities  Medical illnesses  Urinary retention and fecal impaction  ETOH/drug withdrawal  Environmental influences  Infections

24. Some drugs that are associated with delirium Medications with psychoactive effects : –3.9-fold increased risk –2 or more meds: 4.5-fold Sedative-hypnotics : 3.0 to 11.7-fold Narcotics : 2.5 to 2.7-fold Anticholinergic drugs : 4.5 to 11.7-fold Risk of delirium increases as number of meds prescribed rises

25. Prevention=Good Hospital Care for the Elderly Patient (Inouye SK et al. NEJM. 1999;340:669-76) Risk Factor  Cognitive impairment  Sleep deprivation  Immobility  Visual Impairment  Hearing Impairment  Dehydration Intervention  Orientation, cognitive stimulating activities through day  Nonpharmachologic approaches, noise reduction  Ambulation/ Active ROM, minimize equipment if safe to do so  Glasses or magnification lens  Portable amplifying devices/earwax disimpaction  Early recognition and volume repletion

26. Keys to Effective Management Find and treat the underlying disease(s) and contributing factors –Comprehensive history and physical—time course, level of consciousness, behavior, vital signs, –interview pt to determine attentiveness, orientation, memory, –interview family re: baseline function, personality, psych history –Do careful neurological and mental status exams –Screen for substance abuse to determine risk of withdrawl –Choose lab tests and imaging studies based on the above –Review medication list—often the culprit!

27. Always Try Nonpharmacologic Measures First– COMMON SENSE IF YOU THINK ABOUT IT Delirium was 40% less likely in subjects who received a regimen of nonpharmacologic measures, compared to subjects who received usual care Presence of family members at bedside Interpersonal contact and reorientation Provide clean glasses and working hearing aids Remove indwelling devices: i.e. Foley catheters Mobilize patient A quiet environment with low-level lighting- Uninterrupted sleep as much as possible Look for signs of pain and treat as needed Check for constipation / urine retention and treat as needed Bed and chair alarms to alert staff to patient trying to get up alone

28. Nonpharmachologic Approaches Communication  Eye contact at eye level  Identify self  Call patient by preferred name  Be calm and speak slowly  Validate fears and concerns  Use short and simple sentences  Re-orient frequently Environment  Minimize noise and staff changes  Provide food/fluids and assist with feeding as needed  Familiar objects from home/family  Promote sleep –noise control  Music  Clocks and calendars to re- orient  Limit visitors –but family member at bedside is beneficial

29. Management: Hyperactive, Agitated Delirium Use drugs only if absolutely necessary: harm, interruption of medical care First line agent: haloperidol (IV, IM, or PO) –For mild delirium: Oral dose: 0.25-0.5 mg IV/IM dose: 0.125-0.25 mg –For severe delirium: 0.5-1 mg IV/IM repeated q30 min until calm Patient will likely need 2-5 mg total as a loading dose –Maintenance dose: 50% of loading dose divided BID May use olanzepine and risperidone (Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD05594)  Some data now supports use of atypical antipsychotics: Risperdal 0.5- 2mg, Quetiapine 12.5-50mg, Olanzapine 2.5-10mg.

30. What about lorazepam? Second line agent Reserve for : –Sedative and ETOH withdrawal –Parkinson’s Disease –Neuroleptic Malignant Syndrome

31. AVOID RESTRAINTS AT ALL COSTS: they only increase agitation

32. Take Home Points: Delirium in the Elderly A multifactorial syndrome: predisposing vulnerability and precipitating insults Delirium can be diagnosed with high sensitivity and specificity using the CAM Prevention should be our goal If delirium occurs, treat the underlying causes Always try nonpharmacologic approaches Use low dose antipsychotics only in severe cases if absolutely necessary to prevent harm to self or others

33. https://www.youtube.com/watch?v=dKCqdOoYb38 Delirium In Health Care "Thriller" Style 5:58 minutes

34. Case 1 Mr E is a 71 yo gentleman with hx of asthma, BPH and HTN admitted to medicine 3 days ago for bilateral lower extremity cellulitis. A the time of admission he was cooperative and oriented but over the past 24 hours has become occasionally confused, agitated, uncooperative and somnolent. He appears to be talking to someone in his room when no one is there.

35. His current meds include: lisinopril, naproxen, cimetadine, albuterol/ipratroprium inhaler, levofloxacin, oxygen via nasal canula prn He has no known psych history, drinks 1-2 glasses of wine/night The medicine service is concerned he is psychotic and requests help managing his behavior.

36.  When you speak to him he is difficult to rouse and falls asleep several times. He struggles to maintain focus on questions and is unable to perform the mental status exam. He believes he is in Oklahoma and that you are his cousin.

37. What points to delirium?  Altered mental status developing over a short period of time  Alternating agitation, confusion and somnolence  Auditory hallucinations in a 70 yo with no previous psych history  Several of his meds could cause delirium including cimetadine, inhalers, naproxen. He is also needs O2 which indicates hypoxia at times– which can also cause delirium

38.  Multiple medical possibilities including: Meds including cimetadine, inhalers, naproxen. Meds including cimetadine, inhalers, naproxen. Hypoxia- he is needing O2 at times Hypoxia- he is needing O2 at times Cellulitis Cellulitis Stroke with his history of HTN Stroke with his history of HTN UTI with history of BPH UTI with history of BPH Metabolic abnormalities including electrolyte or glucose disturbances, liver or renal dysfunction, thyroid dysfunction Metabolic abnormalities including electrolyte or glucose disturbances, liver or renal dysfunction, thyroid dysfunction Alcohol withdrawal Alcohol withdrawal

39. Case 2  Mr R is 83 yo gentleman with a long history of hypertension, diabetes with peripheral neuropathy and occasional angina admitted to medicine 4 days ago for failure to thrive. Two weeks prior to admission he missed his weekly bridge game which he has not done in 12 years. The day prior to admit his friend found him asleep in front of the TV and was difficult to rouse. He was minimally communicative, had been incontinent of urine and hadn’t eaten in several days. His friend denied history of mental illness, substance abuse and noted he is usually social and friendly.

40.  On admission he was calm, cooperative but withdrawn. He was hyponatremic and had a UTI –both of which have been treated but he remains somnolent and withdrawn. Medicine is requesting assistance for evaluation of depression.  Current meds: insulin, atenolol, lisinopril, temazepam, azithromycin, aspirin.  On exam he is quite, answers questions with monosyllabic answers, has poor eye contact and scores a 9/30 on MMSE with very poor effort.

41. He is presenting as a classic example of hypoactive delirium however:  Urinary incontinence with altered mental status should prompt concerns about normal pressure hydrocephalus  He could have had a stroke or fall given his diabetes, hypertension and peripheral neuropathy- he needs a head CT  The UTI and hyponatremia could cause delirium and even with appropriate treatment mental status may take weeks and even months in the elderly- some may never return to baseline

42. Other possible contributing factors:  Meds such as benzodiazapines  Glycemic abnormalities- how are his blood sugars?  Would need to rule out alcohol withdrawal or overdose-always do a urine tox screen  Is he depressed?  Is he demented?  The low MMSE reveals severe impairment which is common in delirium. His poor effort could signal inattention or depression.

43. A Multicomponent Intervention to Prevent Delirium (Inouye SK et al. NEJM. 1999;340:669-76)

44. Delirium vs. Dementia Delirium  Acute change in mental status  Reversible  Consciousness: fluctuating  Decreased awareness of self  Perceptions: illusions, hallucinations common  Speech: slow, incoherent  Disorientation: time, others  Cognitive dysfunction  Illness, med. toxicity: often  Diurnal disruptions  Outcome: excellent if corrected early Dementia Gradual Gradual Irreversible Irreversible Consciousness: rarely alters Consciousness: rarely alters Decreased awareness of self Decreased awareness of self Perceptions: Hallucinations not common Perceptions: Hallucinations not common Speech: repetitive difficulty finding words Speech: repetitive difficulty finding words Disorientation: time, person, place Disorientation: time, person, place Memory impairment Memory impairment Illness, med. toxicity: rarely Illness, med. toxicity: rarely Diurnal disruptions-day-night reversal Diurnal disruptions-day-night reversal Outcome: poor Outcome: poor

45. https://www.youtube.com/watch?v=hwz9M2jZi_o Agitated delirium in elderly patient– How to recognize it! 2:23 minutes