1. ACUTE CONFUSION IN THE ELDERLY Dr. Barbara Power April, 2010

2. Major Objectives 1.Describe common causes of delirium 2.Recognize risk factors, and means of prevention of delirium 3.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. Epidemiology in Elderly Prevalence : On Admission 10 - 30% ER 10 -18% Incidence: In Hospital10 - 56% Post-operatively15 - 53% Cardiac Surgery17 - 73% ICU70 - 87%

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

6. Recognition of Delirium Previous studies 32%-66% of cases unrecognized by MD’s Yale- New Haven study –65% unrecognized by Physicians –43 % unrecognized by nurses

7. 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 15-30 mg qhs –Occasional alcohol use

8. Case - Delirium Admisssion to Hospital Tripped on rug, sustained a hip fracture Brought to hospital. Spends 12 hours in ER waiting for bed 1)What are the risk factors that make Mrs. F vulnerable to developing delirium? 2)Suggest actions that could be initiated to reduce her risk of developing delirium

9. 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 3.What are the key features of delirium that the MD should elicit in Mrs. G?

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

11. All Confusion is Not Dementia Always Consider Delirium

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

13. 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

14. Delirium versus Dementia? DELIRIUM 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!

15. Confusion Assessment Method (CAM) 1. History of acute onset of change in patient’s normal mental status & fluctuating course? AND 2.Lack of attention? AND EITHER 3. Disorganized thinking? 4.Altered Level of Consciousness? Inouye SK: Ann Intern Med 1990;113(12):941-8 Arch Intern Med. 1995; 155:301 Sensitivity: 94-100% Specificity: 90-95% Kappa: 0.81

16. Testing Attention Formal methods: –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

17. 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.

18. 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”)

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

20. Top 4 Independent Risk Factors for Delirium Vision impairment: RR=3.5 (1.2-10.7) Any severe illness: RR=3.5 (1.5-8.2) Cognitive impairment: RR=2.8 (1.2-6.7) High Urea/Creatinine: RR= 2.0 (0.9-4.6) Inouye S. Ann Intern Med 1993: 119-474

21. What causes delirium: Inouye Delirium Model Fit 65 y.o. who plays senior’s hockey Frail 89 y.o. with baseline dementia Strong or repeated precipitant needed Minimal precipitant needed

22. Added Independent Precipitating Factors in Hospital For Delirium (i.e.. bad things WE do to elderly patients): Restraints (RR 4.4) NPO status (RR 4.0) 3+ new med/24 hr (RR 2.9) Foley catheter (RR 2.4) Any iatrogenic event (RR 1.9) Inouye SK, Charpentier PA, Precipitating Factors for Delirium in Hospitalized Elderly Persons. JAMA. 1996;275:852-857

23. 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!

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

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

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

27. 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

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

29. 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,

30. Miscellaneous Causes of Delirium Pain Fecal Impaction Urinary Retention

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

32. 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?

33. How to find out more? One of the most useful and underused medical tools:

34. 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

35. 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

36. 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 5.What are the main immediate treatments you would initiate?

37. Helping to improve Delirium Once it starts, needs to ride its course; but you can make a difference!

38. 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. 1999 Mar 4;340(9):669-76.

39. Can We Prevent of Delirium Multi component intervention strategy targeted to 6 delirium risk factors Ref: Inouye SK, NEJM. 1999;340:669-676

40. Yale Delirium Prevention Trial Risk FactorsIntervention 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. 1999;340:669-676

41. 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

42. 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

43. 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 0.25-1 mg) –Newer “atypical” agents: no better than haloperidol Avoid Combination Drugs – SINGLE Drug is better Lacasse et. al., Ann Pharm, 2006

44. IF SEVERE AGITATION consider Rx w/ high potency antipsychotic: Haloperidol: po/IM/(IV short acting): –start with 0.5 - 1 mg initial dose –Repeat dose of 0.25-0.5 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

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

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

47. Now! …That should clear up a few things around here!