1. Delirium in the Elderly
Didactics Lecture
Belinda Setters, MD, MS

2. Delirium Learning Objectives:
Define delirium & describe the various forms
Review the pathophysiology of delirium
Utilize objective tools to diagnose delirium
Recognize the risk factors for the development of delirium and measures to take for prevention
Learn pharmacologic and non-pharmacologic treatment of delirium

3. Delirium
Delirium Defined:
What is Delirium?
What is “not” Delirium ?

4. Delirium

5. Delirium Delirium Defined: DSM IV Criteria
Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
Change in cognition (memory deficit, disorientation, language disturbance) or a perceptual disturbance not better accounted for by existing dementia
Development over a short time (hours to days) and fluctuation during the day
Evidence from history, physical, or labs that the disturbance is a direct physiologic consequence of a medical condition or a drug

6. Delirium Delirium Defined: DSM-IV Criteria for Delirium
A. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with
educed ability to focus, sustain or shift attention.
___yes___no
B. A change in cognition or the development of a perceptual disturbance that is not better
accounted for by a preexisting, established or evolving dementia.
C. The disturbance develops over a short period of time (usually hours to days) and tends to
fluctuate during the course of the day
D. There is evidence from the history, physical examination or laboratory findings that the
disturbance is caused by the direct physiological consequences of a general medical
condition.
Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
Copyright © 2000, American Psychiatric Association.

7. Delirium Delirium Defined:
DSM-IV criteria precise but difficult to apply
Confusion Assessment Method (CAM)
Clinically more useful
>95% sensitivity and specificity
Can be administered by RN or other care provider
ICU version available for intubated, critically ill patients

8. Delirium Delirium Defined: Confusion Assessment Method (“CAM”)
1. Acute change in mental status w/ fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness

9. Delirium Delirium Defined: CAM-ICU
1. Acute Onset or Fluctuating Course
A. Is there evidence of an acute change in mental status from baseline? (or)
B. Did the abnormal behavior fluctuate during the past 24 hours (e.g., tend to come and go, or increase and decrease in severity as evidenced by fluctuation of the VAMASS, GCS or previous delirium assessment)?
2. Inattention
Did the patient have difficulty focusing attention as evidenced by scores less than 8 on either the auditory or visual component of the Attention Screening Examination (ASE)
Use the 5+5 pictures, or recognize a letter intermixed in a sequence of 10 letters

10. Delirium Delirium Defined: CAM-ICU 3. Disorganized Thinking
Does the patient have disorganized or incoherent thinking as evidenced by incorrect answers to 2 or more of the following 4 questions and/or demonstrate an inability to follow commands?
Set A
Will a stone float on water?
Are there fish in the sea?
Does 1 pound weigh more than 2 pounds?
Can you use a hammer to pound a nail?
Set B
Will a leaf float on water?
Are there elephants in the sea?
Does 2 pounds weigh more than 1 pound?
Can you use a hammer to cut wood?

11. Delirium Delirium Defined: CAM-ICU 4. Altered Level of Consciousness
Is the patient’s level of consciousness anything other than alert (e.g. vigilant, lethargic or stuporous), or is VAMASS < or > 3 (and not decreased due to sedation)?
Alert: Looks around spontaneously, fully aware of environment, interacts appropriately.
Vigilant: Hyper-alert.
Lethargic: Drowsy but easily aroused. Unaware of some elements in the environment, or no appropriate spontaneous interaction with interviewer. Becomes fully aware and appropriate with minimal noxious stimulation.
Stupor: Becomes incompletely aware with strong noxious stimulation. Can be aroused only by vigorous and repeated stimuli. As soon as stimulus removed, subject lapses back into
unresponsive state

12. Delirium

13. Delirium BRAIN FAILURE Delirium Defined:
An Alias by any other name . . .
Acute confusional state
Acute mental status change
Altered mental status
Organic brain syndrome
Reversible dementia
Toxic or metabolic encephalopathy
BRAIN FAILURE

14. Delirium Delirium Diagnosis: Nurses document < 50% of cases
MD document < 20% of cases

15. Delirium Delirium Defined: Numbers don’t lie . . .
1/3 of older patients presenting to the ED
1/3 of inpatients aged 70+ on general medical units, half of whom are delirious on admission
Up to 50% postoperatively will become delirious
70 – 87% of those in ICU will develop delirium

16. Delirium hypo hyper Delirium Defined: Variations on a theme . . .
Hypoactive
Mixed
Hyperactive
hypo
hyper

17. Delirium Delirium Defined: Hyperactive Only 25% of delirium
But most commonly recognized
Heightened response to stimuli
Heightened psychomotor behavior
Hypervigilance, restlessness, excitable
Fast and/or loud speech
Distractable
Irritable
Combative, uncooperative

18. Delirium Delirium Hypoactive Much less recognized
Reduced response to stimuli
and reduced psychomotor behavior
Apathy, lethargy
Sparse or slowed speech
Limited awareness
But usually cooperative with staff
Behaviors often attributed to “old age” or dementia
About 40% of delirium

19. Delirium hypo hyper Delirium Defined: Mixed
Fluctuations between hyperactive & hypoactive states
hypo
hyper

20. Delirium Pathophysiology: Cholinergic deficiency
Delirium is associated with  serum anticholinergic activity
Anticholinergic activity is found in delirious patients taking no anticholinergic drugs
Acetylcholine is an important neurotransmitter for cognitive processes
Delirium: caused by anticholinergic drug poisoning, reversed by physostigmine

21. Delirium Pathophysiology:
Serotonin excess or deficiency: result of altered tryptophan-to-phenylalanine ratio
Cytokines (interleukin-2, tumor necrosis factor), as seen in patients with cancer or infections
Other neurotransmitters: GABA and dopamine
Different mechanisms may pertain in different situations
Bottom line: pathophysiology remains unknown

22. Delirium Delirium Cholinergic Activation Cholilergic Inhibition
Meds
Med/Sx Illness
Meds
ETOH w/d
Benzos
ETOH w/d
Meds
Stroke
Cholinergic
Activation
Cholilergic Inhibition
Reduced GABA Activity
Dopamine
Benzos
Liver failure
Cytokine
Excess
GABA
Activation
Delirium
Serotonin
Activation
Glutamate
Activation
Serotonin
Deficiency
Cortisol
Excess
Liver Failure
ETOH w/d
Meds
Subst w/d
Med/Sx
Illness
Cushings/Stroke
Sx/Stroke

23. Delirium Pathophysiology:
The sum is greater than the individual parts . . .
Delirium “caused” by “sum” of predisposing and precipitating factors
The more predisposing factors present, the fewer precipitating factors required to cause delirium

24. Delirium Predisposing Factors:
“Honey, what do you expect I’m 85.”
Advanced age
Dementia
Functional impairment in ADLs
Medical comorbidity
History of alcohol abuse
Male sex
Sensory impairment ( vision,  hearing)

25. Delirium Predisposing Factors (Etiologies): Acute cardiac events
Acute pulmonary events
Bed rest
Drug withdrawal (sedatives, alcohol)
Fecal impaction
Fluid or electrolyte disturbances
Indwelling devices
Infections (esp. respiratory, urinary)
Medications
Restraints
Severe anemia
Uncontrolled pain
Urinary retention

26. Delirium Evaluation: History Physical examination
Focus on time course of cognitive changes, esp. their association with other symptoms or events
Medication review, including OTC drugs, alcohol
Physical examination
Vital signs
Oxygen saturation
General medical evaluation
Neurologic and mental status examination

27. Delirium Evaluation: Based on history and physical
Include CBC, electrolytes, renal function tests
Also helpful: UA , LFTs, serum drug levels, arterial blood gases, chest x-ray, ECG, cultures
Cerebral imaging rarely helpful, except with head trauma or new focal neurologic findings
EEG and CSF rarely helpful, except with associated seizure activity or signs of meningitis

28. Delirium

29. Delirium Treatment: Prevention is still the best medicine . . .
Maximize Prevention / Minimize Risk
Environment
Medications
Predictors
Family & RN Support
“Restraints”

30. Delirium
Treatment:
Interventions for cognitive impairment, sleep deprivation, immobility, sensory impairment, dehydration
Focus on nonpharmacologic approaches (eg, sleep protocol involving warm milk, back rubs, soothing music)
Limit or avoid psychoactive and other high-risk medications

31. Delirium Treatment: Treat the underlying disease
Address contributing factors
Avoid the complications of delirium:
Remove indwelling devices ASAP
Prevent or treat constipation and urinary retention
Encourage proper sleep hygiene, avoid sedatives
Optimize medication regimen

32. Delirium Meds, Meds, Meds . . . Alcohol Barbituates
Anticholinergics Benzodiazepines
Anticonvulsants Chloralhydrate
Antidepressants (anticholinergic only) Opiods
Antihistamines (anticholinergic only) Antipsychotics
H2-blocking agents Parkinson meds

33. Delirium Treatment: Provide “social” restraints
consider a sitter or allow family to stay in room
Avoid physical or pharmacologic restraints
If absolutely necessary, use haloperidol
Mild delirium: 0.25–0.5 mg po or 0.125–0.25 mg IV/IM
Severe delirium: 0.5–2 mg IV/IM
Additional dosing q 60 min, as required
Assess for akathisia and extrapyramidal effects
Avoid in older persons with parkinsonism
Monitor for QT interval prolongation, torsade de pointes, neuroleptic malignant syndrome, withdrawal dyskinesias

34. Delirium Delirium Outcomes: Marker for poor prognosis
Not an independent risk factor for outcome
Problems
Increased costs of hospitalization
Longer length of stay (LOS)
Increased risk of functional decline
Predisposing factors (present on admission)
Dementia Depression Altered Na+ level
Decreased basic functional level (ADLs)
Precipitating factors (occur during hospitalization)
Medications Immobilization Catheters
Infection Restraints Metabolic disturbance

35. Delirium Delirium Outcomes: Financial Disclosures. . .
Delirium increases hospital costs on the average by about $2500
Which expands to about $6.9 billion in Medicare hospital expenditures

36. Delirium

37. Delirium
References
Castle C, Leipzig R, Cohen HJ, Larson E & Mier DE. Geriatric Medicine. Springer. New York, 2003.
Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. CMAJ 1993; 149:41–6
Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29(7):
Ferreira FL, Bota DP, Bross A, et al. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001;286(14):
Gunther ML, Morandi A, Ely EW. Pathophysiology of Delirium in the Intensive Care Unit. Crit Care Clin 2008;45-65.
Hazard W, Blass JP, Halter JB. Delirium. Principles of Geriatric Medicine & Gerontology. McGraw Hill, York, PA. 2003:
Inouye SK, Viscoli CM, Horwitz RI, et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993;119:474–81

38. Delirium
References
Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275:852–7
Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999;106(5):
Inouye SK, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941–8.
McNicoll L, Pisani Margaret et al. Detection of Delirium in the Intensive Care Unit: Comparison of Confusion Assessment Method for the Intensive Care Unit with Confusion Assessment Method Ratings. JAGS 2005;53:495–500.
Pandharipande P, costabile S, Cotton B, et al. Prevalence of delirium in surgical ICU patients. Crit Care Med 2005;33(12)A45.

39. Delirium
References
Pandharipande P, Ely EW,. Sedative and analgesic medications: risk factors for delirium and sleep disturbances in the critically ill. Crit Care Clin 2006;22(2):
Pompei P, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42:809–15. Pompei P, et al.
Pompei P, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42:809–15. Pompei P, et al. Delirium in hospitalized older persons: outcomes
and predictors. J Am Geriatr Soc 1994;42:809–15.