1. DELIRIUM Barbara Power, MD FRCP(C) Division of Geriatrics Ottawa Hospital April 2008

2. Delirium - Objectives Main diagnostic criteria Common Symptoms and Signs of presentation of Delirium Differential Diagnosis Risk Factors Investigations Management - Non-pharmacological and Pharmacological

3. Delirium Latin ”de” and “lira”, together mean “off track” over 30 synonyms: acute brain syndrome, acute confusion state, metabolic encelopathy, toxic psychosis,”reversible madness”

4. Epidimiology Prevalence 10-40% Incidence 25-60% 3-31% on medical wards, 30% of open heart surgery patients, over 50% of hip fracture admissions Hospital Mortality 10-65%

5. Delirium -Prognosis Increased mortality (25-33%) Permanent impairment (~25%) Recovery (50%) Following recovery, annual incidence of dementia is 20% ( George J et al:Age and Aging 1997;26:423-427 Rockwood K)

6. Impact Of Delirium (US data) 35 % of US population >65 hospitalized yearly Assuming delirium rate 20%  7% of persons >65 will develop delirium annually estimated cost > $8 billion $6000.00 US per episode delirium

7. RECOGNITION Acute onset and fluctuating course Inattention Disorganized thinking Altered level of consciousness

8. (Un)Recognition 32% -66% of cases unrecognized by physicians 43% of cases unrecognized by RN’s

9. Diagnosis Confusion Assessment Method(CAM) 1. Acute Onset & Fluctuating course: - change from baseline and does the behavior fluctuate 2. Inattention: - difficulty focusing attention, distractible, difficulty keeping track of conversation

10. Diagnosis (cont’d) 3. Disorganized thinking: - speech disorganized/incoherent, rambling 4. Altered level of Consciousness: - vigilant, lethargic, lethargic, stupor, coma * for delirium diagnosis recquire(1),(2), and either (3) or (4) ref. Innouye SK, et al. Ann Intern Med 1999;113:941-8

11. CAM-validation Sensitivity 94-100% Specificity 90-95% good screening instrument

13. Delirium vs Dementia Delirium Dementia ONSETDevelops abruptlyDevelops slowly DURATIONBrief, hours to daysChronic, months to years ATTENTIONImpairedNormal, except severe cases CONSICOUSNESSFluctuating, reducedClear SPEECHIncoherent, Ordered, disorganizedanomic/aphasic NOTE: Disorientation and memory impairment may be present with both

14. Delirium-Risk factors Old age(esp. >80) low level of albumin electrolyte disturbances hepatic or renal dysfunction alcohol/sedative dependence previous episode of delirium visual impairment fractures – (Trzepacz PT Psych Clin North Am;19(3):429-49

15. Etiology-Multifactorial Dementia (multi-infarct, AD) Electrolytes Lungs,liver,heart,kidney,brain(ex.PD) Infection Rx Injury Unfamiliar Metabolic

16. Medications and delirium Sedative Hypnotics (Dalmane,Valium,Chloral Hydrate) Narcotics (Demerol) Anticholinergics(TCA,AntiPD,antihistamines, Antispasmodics;Belladona,lomotil) Cardiac (digoxin,lidocaine) Antihypertensives (B-blockers) Miscellaneous: H2 blockers, steroids, Lithium, Anticonvulsants, NSAIDS

17. Delirium-Prevention Risk Factor Intervention Cognitive impairment Reality Orientation,Therapeutic Therapeutic Activities Sensory Impairment Vision/Hearing Aids Adaptive Equipment (HA, glasses,dentures) Immobilization Early Mobilization, avoid bed rest orders Minimize Immobilizing equip. Psychoactive Medications Nonpharmacologic approach to sleep/anxiety Dehydration Early Recognition,volume repletion Sleep Deprivation Noise Reduction Strategies, sleep enhancement strategies (Inouye SK et al., JAGS 2000;48:1697-1706)

18. Delirium- The Hospital Elder Care Program n=852 (426 intervention and 426 usual care)  new delirium cases: 9.9% vs 15% usual care (OR.6, p=.02)  total days of delirium episodes(105 vs 161, p=.02  total number of delirium episodes (62 vs 90, p=.03)  targeted risk factors per patient once delirium occurred, intervention ns for severity or recurrence of delirium; ie. 1  prevention most effective (Inouye SK et al., JAGS 2000;48:1697-1706)

19. Delirium: multidisciplinary care n=113 intervention vs. 114 usual care intervention: seen by geriatric consultant and followed by intervention nurse overall no difference in MMSE, delirium or function subgroup analysis: those without dementia potentially could benefit the most, but study lacked power study flawed in some respects (Hawthorne effect, lack of adherence with recommendations etc.) emphasizes importance of prevention, once delirium starts hard to treat (RCT Cole et al. CMAJ October 1, 2002;176(7):753-759)

20. Delirium-Evaluation 1. Cognitive evaluation: MMSE,CAM,collateral history 2. Search for underlying cause: review medication list (especially anticholinergic drugs)

21. Evaluation (con’d) 3. Metabolic workup: CBC, Lytes, BUN/Cr, glucose, LFT’s, Calcium, pO2 4. Search for infection; urine C&S, CXR, blood culture 5. EKG +/- abdomen flat plate, PVR 6. CNS work up (if indicated): LP, CT head (<10% need this)

22. Delirium - Treatment Indicated when severe agitation could cause interruption of essential medical therapy or pose safety hazard to pt or staff Haloperidol 0.5-1.0 mg i.m. or p.o. (maintenance dose 3-5mg/24hrs) 50% loading dose in divided doses over next 24 hours taper dose over few days

23. Delirium: Newer treatment options Risperidone: 0.25-0.5 mg bid to start, to a max. of 1.0 mg bid – caution re DM (follow wt gain, B/S) Seroquel(quetiapine): 25 mg bid – most sedating, least EPS Zyprexa (olanzepine):2.5-5 mg daily – +++ sedating, blood work q weekly – wt gain

24. Delirium: withdrawal states Benzodiazepines indicated for delirium associated with: – alcohol withdrawal – benzodiazepine withdrawal

25. Delirium-Conclusions An acute medical emergency!! Under-recognized Treatment: – address the underlying cause – often multifactorial in etiology – may require several trials with neuroleptics, often of limited efficacy Prognosis guarded