1. Delirium Medical Emergencies Series Internal Medicine – July 2011 Royal Victoria Hospital – McGill U J Verdon MD MSc FRCPC

2. Scenario …NIGHT FLOAT You are called at 5 am 82 y.o. women admitted for pneumonia Nurse found her all a sudden agitated Pulled her iv out Not keeping her O2 on What do you do???

3. Confusion is not always Delirium! ALL confused Older patients Do NOT NECESSARILY have DELIRIUM

4. Confusion is not always Delirium! It could be a SHOCK Stroke Encephalitis / meningitis Seizure & Post ictal Dementia with behavior disturbance Speech or hearing impairment

5. Delirium in NOT normal …. URBAN LEGEND: It is normal to be confused when you are older… They won’t remember anyways

6. The Problem with delirium… it is often missed BUT easy to screen there is no ‘deliriumin’ level BUT excellent criteria! it is hard to treat BUT treatable! it is reversible anyways BUT NOT ALWAYS! It is mostly preventable BUT prevention measures not taken!

7. What you may learn about delirium.. Update on Management Drugs & Delirium in ED Delirium and Prognosis Delirium is a lethal condition that needs attention

8. Delirium Management

9. Delirium is ……….? A) problem with memory mainly B) problem of agitation, tremor, hallucinations mainly C) problem with attention mainly

10. Delirium is... ? The A.D.D. of older persons Disturbance of consciousness with ATTENTION DEFICIT Change in cognition or perceptual disturbance Develop over a short period Evidence that related to medical condition DSM IV -

11. Delirium & neurochemical explanation: Cholinergic Buzz Theory Cholinergic deficiency is most plausible Dopaminergic and/or Noradrenergic imbalance may give different types of delirium

12. Delirium: Who is at risk? Patients with, severe illness, cognitive impairment, Dehydration, impaired vision are more likely to develop delirium

13. Delirium: What triggers it! Metabolic derangement Change in environment, use of restraints & catheter Rx, Rx, Rx

14. Who is at risk x what we do = DELIRIUM or NO DELIRIUM

15. Delirium: think about it! look for it! THE MORE YOU’LL LOOK, THE MORE YOU’LL FIND!!!

17. How could I manage delirium

18. What about getting the history for delirium…. History limited with patient ASK for PAIN ASK the nurse or room mates History hard to get from family 90% undiagnosed MCI or mild dementia Look for change from baseline Concentrate on the Rx history New, change, accidental overdose, compliance

19. How do I assess someone with delirium ?

20. The ABC of Delirium Assessment 4 A - Airway 4 B - Breathing 4 C - Circulation

21. The ABC of Delirium assessment 4 A - Airwayaspiration, obstruction, O2 non compliant 4 B - Breathing pneumonia, pulm oed, PE 4 C - CirculationMI, tachy, low BP, shock

22. and DEF of Delirium! 4 A - Airway 4 B - Breathing 4 C - Circulation in DELIRIUM 4 D - Drugs new, d/c, error, anticholinergic 4 E - Electrolytes dehydration,glycemia,Na,Ca 4 F - For the restINFECTION, acute ischemia, neurological problem

23. Assessment of patient with delirium: DIFFICULT! Exam limited and often impossible THINK ABOUT YOUR SAFETY & Get some help

24. Delirium - STOP and OBSERVE !!! HANDS OFF ! Before The patient get their HANDS ON YOU!

25. Delirium - STOP and OBSERVE Observe for - Agitation – anxiety - Apathy- lethargy - Hallucination – delusions - Main physical findings

26. Focus your physical exam Focus on 6 Vitals 6 Sensorium, attention 6 ask about PAIN! 6 …….

27. Focus your physical exam then ; 6 Lungs (& heart) 6 Abdo (urin retention, gallbladder, rebound) 6 Limbs (swelling, skin, dvt) 6 then, neuro if possible and SAFE for you!

28. What work-up to be done? CBC SMA7 Glucose O2sat urine MINIMAL CBC SMA7 Glucose LFT Trops Rx serum level Urine c&s ECG O2sat CXR URGENT CBC SMA7 Glucose LFT Trops Druglevel Urine c&s ECG O2sat CXR Ca Mg TSH B12 Folate CT-head COMPLETE

29. How do I treat Delirium?

30. 1- Tx acute conditions REMEMBER: 3 There is USUALLY more than 1 acute condition causing delirium: If you only have 1 cause, you are missing 2 others! Look for and treat them ALL! 3 Try limiting the LINES: be inventive! 3 Don ’t forget retention, infection!

31. 2- Review and Simplify all Rx Discontinue or taper all anticholinergic Rx Substitute if necessary

32. 3- Institute the non pharmacological treatment Sleep enhancement Reorientation Early mobilisation Compensation for hearing, visual impairment Hydration Safe environment Inouye, Cole

34. DRUGS & DELIRIUM

35. Rx are a commonly missed cause of delirium A good internist MUST look for this!

37. Famously unfamous delirium related prescriptions! Drug withdrawal Benzos, Rivotril, Drug intoxication Dilantin, Digoxin Drug interaction Over the counter Benadryl Gravol Ranitidine

39. Rx adjustment are needed in delirium A good internist knows this!

40. Individualize the prescription! STOP what needs to be stopped anticholinergic RESTART what should not have been stopped Benzos, ADJUST doses for WEIGHT and Renal Fx USE P.O. route, to avoid lines AVOID possible Rx interaction

41. Delirium and Rx for symptoms The internist survival kit!

42. The urgent prescription! Different options Haldol 0.25-0.5mg po or im q6h prn + regular seroquel 12.5-25 mg po qHS Or Haldol 0.25-0.5mg po or im q6h prn + regular risperdal 0.25 mg bid po

43. Treat Delirium symptoms For Rx 3 Tx as Tx for acute pain 3REGULAR doses with some prn x 72 hours and r/a 3 Tx symptoms (psychosis, hallucin, or anxiety) with most appropriate PSYCH Rx 3 Tx small dose short acting benzos occasionnally ALSO 3 Tx PAIN with regular analgesics IMPORTANT

44. Atypical Antipsychotics Olanzapine(zyprexa) 2.5 mg qD ( also ZYDIS) up to 10 mg tot /day Quietapine (seroquel) 12.5mg qHS to bid - up to 150 mg tot/day Risperidone (risperdal) 0.25 mg daily up to 2 mg tot/day

46. Delirium & Prognosis

47. Delirium is lethal… Delirium associated risk of mortality/ nursing home up to 3 months after discharge is…. increased by 2-3 O.R. for death/nursing home, adjusted for age, gender, apache score, functional status, dementia at discharge; 2.1 (1.4-4) at 3 months; 2.6 (1.4-4.5)

49. Delirium is a Medical Emergency! Delirium can be easily diagnosed The more you’ll look, The more you’ll find Look and Treat all causes and symptoms Always think Rx! Multidisciplinary approach makes a difference!

50. References. N Engl J Med Volume 340:669–676 1999. A multicomponent intervention to prevent delirium in hospitalized older patients. Inouye SK et al. J Am Geriatr Soc Volume 48:1697–1706, 2000.The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in hospitalized older patients. Inouye SK et al Cleveland Clinic Journal of medicine Volume 71(11): 890-896, 2004. A practical program for preventing delirium in hospitalized elderly patients. Inouye SK et al. Journal of Psychosomatic Research Volume 65; 273–282, 2008. Drug treatment of delirium: Past, present and future. Age and Ageing 2011; 40: 23–29. Which medications to avoid in people at risk of delirium: a systematic review. JAMA. 2010;304(4):443-451. Dementia: A Meta-analysis Ann Intern Med. 2011;154:746-751. Guideline for Prevention of Delirium THANK YOU