1. Geriatric Delirium: Impact of National Guidelines and Interactive Educational Modules
Dr. Peter Chan, MD, FRCPC
Consult-Liaison and Geriatric Psychiatrist,
Vancouver General Hospital.
Clinical Associate Professor,
UBC Dept. of Psychiatry

2. Collaborators UBC Care for Elders Module
Dr. Martha Donnelly, MD, FRCPC
Dr. Ram Randhawa, MD, FRCPC
VGH Nursing Education Module (VCHA)
Ms. Wendy Marr, RN
Ms. Maureen Shaw, RN, MN

3. Disclosure Honouraria for speaker engagements: Astra-Zeneca Eli-Lilly
Janssen-Ortho

4. Guidelines: Categories of Evidence:
Ia Evidence from meta-analysis of randomized controlled trials Ib Evidence from at least one randomized controlled trial IIa Evidence from at least one controlled study without randomization IIb Evidence from at least one other type of quasi-experimental study III Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies IV Evidence from expert committees reports or opinions and/or clinical experience of respected authorities Shekelle et al 1999

5. Guidelines: Strength of Recommendation
A Directly based on category I evidence
B Directly based on category II evidence or
extrapolated recommendation from category I
evidence
C Directly based on category III evidence or
extrapolated recommendation from category I or
II evidence
D Directly based on category IV evidence or extrapolated
recommendation from category I, II, or III evidence
Shekelle et al 1999

6. What’s in the Guideline
Background
Prevention
Detection, Assessment, Diagnosis & Monitoring
Management
Legal and Ethical Issues
Education
Systems of Care
Research on Delirium
Future Considerations

7. Canadian Coalition For Senior’s Mental Health: Practice Guidelines

8. Predisposing Factors Inouye, SK et al
Predisposing Factors Inouye, SK et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993; 119:
cognitive impairment
sleep deprivation
immobility
visual impairment
hearing impairment
dehydration

9. Screening Under-recognition, esp. in those:
Over 80 y.o. with hypoactive delirium with visual impairment and/or pre-existing dementia
Inouye et al. Arch Int. Med 2001
No reliable screening tool to differentiate delirium and dementia
Practically, acute-onset and/or fluctuation in cognition/function/abnormal behaviours
Others signs
New onset aphasia or dysarthria
New onset or worsening incontinence

10. Confusion Assessment Method (Inouye et al. Ann.Int.Med. Dec.15/90)
acute onset and fluctuation AND
inattention AND
disorganized thinking OR
altered level of consciousness
excellent sensitivity, good specificity

11. Screening Instruments
We recommend…
The Confusion Assessment Method is recommended for screening on acute medical/surgical wards and in the ER (C)
CIWA-Ar is recommended for monitoring symptoms of alcohol withdrawal (C)

12. Precipitating Factors in Hospital Inouye and Charpentier, JAMA 1996; 275: 852-57
Physical restraints (RR=4.4)
Malnutrition (RR=4.0)
More than 3 medications added (RR=2.9)
Use of bladder catheter (RR=2.4)
Any iatrogenic event (RR=1.9)

13. Use of Restraints We recommend…
Physical restraints for geriatric patients suffering from delirium should be applied only in exceptional circumstances when: (D)
a) There is a serious risk for bodily harm to self or others OR
b) Other means for controlling behaviours leading to harm have been explored first, including pharmacologic treatments, but were ineffective AND
c) The potential benefits outweigh the potential risks of restraints

14. Pharmacologic Management
We recommend…
Psychotropic medications should be reserved for older persons with delirium that are in distress due to agitation or psychotic symptoms, in order to carry out essential investigations or treatment, and to prevent older delirious persons from endangering themselves or others. (D)
In the absence of psychotic symptoms causing distress to the patient, treatment of hypoactive delirium with psychotropic medications is not recommended (D)
The use of psychotropic medications for the specific purpose of controlling wandering in delirium is not recommended (D)

15. Pharmacologic Management
We recommend…
Antipsychotics are the treatment of choice to manage the symptoms of delirium (with the exception of alcohol or benzodiazepine withdrawal delirium). (B)
Haloperidol is suggested as the antipsychotic of choice based on the best available evidence to date. (B) Initial dosages are in the range of 0.25 mg- 0.5 mg. Od-bid (D)
Atypical antipsychotics may be considered as alternative agents as they have lower rates of extra-pyramidal signs. (B)
Benztropine should not be used prophylactically with haloperidol in the treatment of delirium. (D)

16. Pharmacologic Management
We recommend…
In older persons with delirium who also have Parkinson’s Disease or Lewy Body Dementia, atypical antipsychotics are preferred over typical antipsychotics. (D)
Sedative-hypnotic agents are recommended as the primary agents for managing alcohol withdrawal delirium (B). Their use in other forms of delirium should be avoided (D).

17. Pharmacologic Management: Guidelines
Frequency:
Regular vs. Prn; nighttime dosing
Dosages:
haloperidol bid (watch QTc)
risperidone initiated at 0.25 mg od-bid
olanzapine at mg per day
quetiapine at mg per day

18. Haloperidol in Delirium Management
“Evidence” based on 1 RCT (Breitbart 1996)
AIDS Dementia population
Comparator to atypicals (3 RCT’s in Cochrane)
Prolonged QTc, especially I.V.– baseline ECG
Risk of Extrapyramidal Symptoms, esp. elderly
>4.5 mg/day in Cochrane Review

19. Loxapine in Delirium Management
Conventional antipsychotic with atypical properties
Singh et al Journal of Psychiatry and Neuroscience, 21:29-35
Mid-potency in D2 receptor blockade
Effect on D1, D4, 5-HT2, NMDA receptors
Parenteral IM/SC (IV in monitored setting)
Widespread use in Vancouver
Over 3500 VGH inpatients with Delirium since 1989
Use in all settings, including CCU, CSICU, ICU, ACE units
Dosing mg/d (B.I.D. dosing at 1600h and 2000h)

20. Subsequent Considerations
Risks of Atypical Antipsychotics
Mortality
CVA or related events
Metabolic syndrome (less likely if short duration)
Use of Cholinesterase Inhibitors
Treatment of Hypoactive Delirium

21. Summary of Key Points in Managing Geriatric Delirium
Screening is important in identifying cases.
Haloperidol is recommended based on available evidence, but atypicals are alternatives, esp. in those sensitive. Loxapine a viable alternative.
The elderly can have prolonged delirium, and slower to recover in cognition and function when delirium has cleared.

22. Guideline and Literature Review
American Psychiatric Association. Practice guideline for the treatment of patients with delirium
British Geriatrics Society. Guidelines for the diagnosis and management of delirium in the elderly
Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30(3):
Management of alcohol withdrawal delirium: an evidence-based guideline. Arch Intern Med 2004;164(13):
Iowa Veterans Affairs Nursing Research Consortium. Research-based protocol: acute confusion/delirium. Iowa City, Iowa: The University of Iowa Gerontological Nursing Interventions Research Centre: Research Dissemination Core; 1998.
Screening for delirium, dementia and depression in older adults. Toronto (ON): Registered Nurses Association of Ontario; 2003.
Caregiving strategies for older adults with delirium, dementia and depression. Toronto (ON): Registered Nurses Association of Ontario; 2004.
Sharon Inouye. Delirium in Older Persons. NEJM 354: March 16, 2006 Number 11
Gregory Fricchione. Postoperative Delirium. Am J Psychiatry 165: , July 2008

23. Web Resources Care for Elders Interactive Delirium Module
UBC Division of Geriatric Psychiatry
VIHA Delirium information
Virginia Case Study

24. A Quality Improvement Project
M. McKnight, H. Nagi, K. Ng, C. Reid, P. Tam Sponsored by Dr. A. Hill and Dr. P. Lee

25. Delirium Working Group
Collaboration of experts at VGH and the region, established Nov 2006
Why:
Problem of idiosyncratic & disparate patterns of practice
Mission:
Use literature & expert opinion to establish best practice Standardize approach to patient care Implement best practice through PPOs and staff education
Nurses
Psychiatrists & Geri-psychiatrists
General Surgeons
Intensivists
Geriatricians & Internists

27. 1 1

28. 2 2

29. 3 3

30. PRISME: Maureen Shaw, RN, MN
P - PAIN
R- RESTRAINT, RETENTION
I - INFECTION
S - SENSORY IMPAIRMENT, SLEEPLESSNESS
M - MEDICATION, METABOLIC
E - ENVIRONMENT, EMOTIONS

32. PPO: Pg 1

33. PPO: Pg 1

34. PPO: Pg 2

35. PPO: Pg 2