1. ACUTE CONFUSION IN THE ELDERLY
Dr. Barbara Power
April, 2013

2. Major Objectives from the LMCC
Describe common causes of delirium
Recognize risk factors, and means of prevention of delirium
Identify the difference between Delirium and Dementia
Work up and treatment of delirium when it does occur, and management of behavioral problems

3. Synonyms for Delirium Acute confusional state Organic brain syndrome
Toxic/metabolic encephalopathy
Out of it
Uncooperative

4. So What? Why is Delirium Important?
3 criteria:
Common, Morbidity & Costly!
Death ~20-35%
Cognitive drop in 40%
Premature institutionalization
on admit? 15-24%
in hospital?14-31%
Ortho? 25-65%
ICU: 70%!
LOS doubles
++ hospital $
Caregiver burden

5. Case - Delirium Mrs G. 79 year old lady
lives alone, manages own apartment
slightly forgetful (according to daughter)
PMed Hx: HTN; Insomnia
Meds:
Hydrochlorothiazide 25 mg OD
Amitriptyline 50 mg qhs
Oxazepam mg qhs
Occasional alcohol use

6. Case - Delirium Admisssion to Hospital
Tripped on rug, sustained a hip fracture
Brought to hospital. Spends 12 hours in ER waiting for bed
What are the risk factors that make Mrs. F vulnerable to developing delirium?
Suggest actions that could be initiated to reduce her risk of developing delirium

7. Case - Delirium Admisssion to Hospital ORIF the following day 1st POD
climbing over bedrails
shouting all night
sleeping in day
pulling out her IV’s
What are the key features of delirium that the MD should elicit in Mrs. G?

8. The First Question –What is this?
Is this Delirium?
Dementia??
Or something else???

9. Delirium
Definition:
a disturbance of consciousness with inattention that develops over a short time & fluctuates

10. Delirium (DSM-IV) A: Disturbance of consciousness (reduced clarity of
awareness of the environment) with reduced ability to focus,
sustain or shift attention
B: Change in cognition (eg. memory deficit, disorientation,
language disturbance) or development of a perceptual
disturbance not due to pre-existing, established or
developing dementia
C: The disturbance develops over a short period of time
(hours to days) and tends to fluctuate during the course of
the day.
D. Evidence of aetiology

11. Delirium versus Dementia?
Acute
Inattention
AbN LOC
Fluctuations/minutes
Reversible
Hallucinations common
DEMENTIA
Gradual
Memory disturbance
N LOC
None/days
Irreversible
Hallucinations common only in advanced disease
It is common for Delirium to be superimposed on Dementia!

12. Confusion Assessment Method (CAM)
1. History of acute onset of change in patient’s normal mental status & fluctuating course?
AND
Lack of attention?
AND EITHER
3. Disorganized thinking?
Altered Level of Consciousness?
Sensitivity: %
Specificity: 90-95%
Kappa: 0.81
Inouye SK: Ann Intern Med 1990;113(12):941-8
Arch Intern Med. 1995; 155:301

13. Testing Attention Formal methods: Affects all other areas of cognition
MMSE: Serial 7’s, WORLD backwards
Digit Span: 5 forwards, 4 backwards
Days of Week, Months of Year backwards
Affects all other areas of cognition

14. Delirium: Cognitive Evaluation
MMSE:
inaccurate tool to diagnose delirium as the patient:
fluctuates
has poor attention/concentration
helpful tool to demonstrate improvement in cognitive status when following patient.

15. Psychomotor Variants of Delirium :
Hyperactive ("wild man!"); 25%
Hypoactive ("out of it!“, “pleasantly confused”); 50% - Individuals often not recognized as they may not cause a disturbance so they don’t get ATTENTION
Mixed delirium (features of both), with reversal of normal day-night cycle (“sundowning”)

16. Case – Delirium: CAM Acute /Fluctuating Course
Altered level of Consciousness
Inattention
Disorganized Thinking
9 am
1 pm

17. What are the risk factors that make Mrs
What are the risk factors that make Mrs. F vulnerable to developing delirium?

18. Top 4 Independent Risk Factors for Delirium
Vision impairment:
RR=3.5 ( )
Any severe illness:
RR=3.5 ( )
Cognitive impairment: RR=2.8 ( )
High Urea/Creatinine:
RR= 2.0 ( )
Inouye S. Ann Intern Med 1993:

19. What causes delirium: Inouye Delirium Model
Frail 89 y.o. with baseline dementia
Fit 65 y.o. who plays senior’s hockey
Minimal precipitant needed
Strong or repeated precipitant needed
Mental status is considered the 4th vital sing, because what the brain needs to function is what keeps us all alive.
In general, we a good at recognizing acute medical conditions producing a confusional state.
However, as we heard this morning, delirium is often the result of a complex interaction between susceptibility factors of the host, and precipitating external factors

20. Causes of Delirium?
brain’s way of demonstrating “acute organ dysfunction”
Anything that hurts the brain or impairs its proper functioning can provoke a delirium!

21. I WATCH DEATH Mnemonic
I  Infection:   Most common are pneumonias & UTI in elderly, but sepsis, cellulitis, SBE and meningitis can also occur

22. I WATCH DEATH
I  Infection 
W  Withdrawal: benzodiazapines, ETOH,

23. I WATCH DEATH I Infection W Withdrawal
A  Acute metabolic: electrolytes, renal failure, acid-base disorders, abnormal glycemic control, Calcium

24. I WATCH DEATH I Infection W Withdrawal A Acute metabolic
T Trauma: head injury (SDH, SAH), pain, vertebral or hip fracture, urinary retention, fecal impaction

25. I WATCH DEATH I Infection W Withdrawal A Acute metabolic T Trauma
C  CNS pathology
H  Hypoxia from COPD exacerbation, CHF

26. I WATCH DEATH I Infection D Deficiencies W Withdrawal E Endocrine
A  Acute metabolic
T Trauma
C  CNS pathology
H  Hypoxia 
D  Deficiencies
E  Endocrine
A Acute vascular/MI
T  Toxins-drugs:
H Heavy metals 

27. Medication review: Look at all prescriptions
include PRNs, regular, ETOH and OTC meds
Ask if anything has been added, changed or stopped
Watch for sleeping meds ie Gravol; Nytol,

28. In other words, anything that makes an older person very very sick…
…can cause a delirium in a vulnerable older person!

29. Delirium Workup On History: time course of mental status changes?
association with other events (i.e.. meds, illness)?
Pre-existing impairments of cognition or sensory modalities?

30. Physical Exam Vitals: normal range of BP, HR Spo2, Temp?
Good physical exam: particular emphasis on Cardiac, pulmonary and neurologic systems
Hydration status ? (dry axilla=dehyd!; + LR ~3)
Also rule out
fecal impaction (DRE)
urinary retention (bladder U/S, in-and-out catheter)
Infected decubatis ulcer

31. Delirium workup: Lab testing
Basic labs most helpful!
CBC, lytes, BUN/Cr, glucose
TSH, B-12, LFTs Calcium, & albumin
Infection workup (Urinalysis, CXR) +/- blood cultures
Other investigations based on Hx- EKG/CT Scan/Drug levels

32. Case - Delirium Admisssion to Hospital ORIF the following day 1st POD
climbing over bedrails
shouting all night
sleeping in day
pulling out her IV’s
What are the main immediate treatments you would initiate?

33. Delirium Reduction:
You can get improvement of delirium with such simple measures as:
Glasses
Using hearing aids
Fluids/nutrition
reducing noise
Early mobility
Familiar faces
S Inouye A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med Mar 4;340(9):

34. Can We Prevent Delirium
Multi component intervention strategy targeted to 6 delirium risk factors
Ref: Inouye SK, NEJM ;340:

35. Yale Delirium Prevention Trial Risk Factors Intervention
Cognitive Impairment Reality orientation / therapeutic activities program
Vision/Hearing impairment Vision / hearing aids / adaptive equipment
Immobilization Early mobilization / Reduce immobilizing equipment
Psychoactive medication Non pharmacologic approaches to sleep / anxiety / Restricted use of sleeping medication
Dehydration Early recognition / Volume expansion
Sleep deprivation Noise reduction strategies/sleep enhancement program
Ref: Inouye SK, NEJM ;340:

36. Yale Delirium Prevention Trial Significance
Practical intervention towards evidence based risk factors
Significant reduction in risk of delirium
( 9.9% in intervention group vs 15% in usual care)
Significant reduction in total delirium days

37. Pharmacological Rx: Goals
Reverse psychotic signs and symptoms
stop dangerous or potentially dangerous behavior
To calm the patient sufficiently to conduct the necessary evaluation and treatment

38. Drug Treatment of Agitation
Only 4 RCTs (largest N=73):
Neuroleptics preferable to benzodiazepines in most cases (except: PD, DLBD, ETOH)
Low dose high potency neuroleptics (e.g., starting at haloperidol mg)
Newer “atypical” agents: no better than haloperidol
Avoid Combination Drugs – SINGLE Drug is better
Lacasse et. al., Ann Pharm, 2006

39. IF SEVERE AGITATION consider Rx w/ high potency antipsychotic:
Haloperidol: po/IM/(IV short acting):
start with mg initial dose
Repeat dose of mg Q30 minutes if patient remains unmanageable without adverse events until sedation achieved and continue monitoring
repeat cycle until acceptable response or adverse events occur
max suggested Haldol dose in frail elderly 3-4mg/24 hr
Maintenance: 50% loading dose in divided doses over next 24 hrs
Taper the dose as soon as possible
Avoid in individuals with Parkinson’s Disease

40. Benzodiazepines
1. Avoid use in combination with antipsychotics - SINGLE drug is better.
2. May cause disinhibition/increased agitation.
3. Best reserved for Delirium 2o to alcohol / Benzodiazepine withdrawal.
4. Relatively contraindicated in Delirium from Hepatic Encephalopathy.

41. Summary - Recognition of Delirium
Delirium is Common
Yale- New Haven study
65% of cases unrecognized by Physicians
Don’t be part of that group!