Delirium Medical lessons from Star Trek

1. Delirium(Medical lessons from Star Trek) COL Brian Unwin, M.D. Uniformed Services University USAFP 2010 New Orleans

2. Goals Background Historical Definition Impact Pathophysiology Diagnosis Treatment Prevention

3. References Star Trek Medical Manual Jacobi J, et. al. �Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult.� Critical Care Medicine, 2002 Vol. 30, No. 1. Ely EW. �The impact of delirium in the intensive care unit on hospital length of stay.� Intensive Care Medicine 2001; 27: 1892-1900 Dubois MJ. �Intensive care associated delirium: A prospective study of risk factors.� Intensive Care Medicine 2001; 27: 1297-1304. Geriatrics Review Syllabus, Fifth Edition, 2002-2004

4. References Gleason OC. �Delirium.� AFP. 2003, Vol 67:5, 1027-1034. Inouye SK, et al. �A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients.� NEJM. 1999, 340:9, 669-676 Kane RL. Essentials of Clinical Geriatrics, 4th Edition. 129-134. Hazzard WR. Principles of Geriatric Medicine and Gerontology, 4th Edition. 1229-1237 Schwartz TL. �The Role of Atypical Antipsychotics in the Treatment of Delirium.� Psychosomatics. 2002:43(3).

5. Background: Historical Described by the Greeks Phrenitis (frenzy) Lethargus (lethargy) Time of Celsus �de lira� or �off the path� No definition until 1980

6. Background: The Confusion about Confusion AKA Acute Confusional State Acute Mental Status Change Altered Mental Status Organic Brain Syndrome Reversible Dementia Toxic or metabolic encephalopathy Dysergastic Reaction Subacute Befuddlement

7. Background: DSM IV Definition Criterion A Disturbance of consciousness, with Reduced ability to focus, sustain or shift attention Criterion B A change in cognition (memory deficit, disorientation, language disturbance) Development of perceptual disturbance (misinterpretations, illusions, hallucinations) Criterion C Develops rapidly and tends to fluctuate during the day Criterion D History, physical examination or lab findings indicate that the disturbance is a consequence of a general medical condition.

8. Distinguishing Characteristics

9. Background:�Flavors� of Delirium Hyperactive or agitated delirium 25% of cases Hypoactive delirium Less recognized and treated Mixed Other: emotional, psychotic symptoms or sundowning

10. Background: Recognizing Delirium Nurses recognize and document <50% of cases Physicians recognize and document only 20%

11. 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 Background: Incidence of Delirium Among Elderly

12. Delirium Superimposed on Dementia: A Systematic Review, 50: 1723-1732, 2002 Background:Delirium on Dementia 22-89% prevalence in hospitalized and community populations Higher in hospitalized patients 88% of delirium superimposed on dementia missed by nursing and hospital staff Staff do better with recognition when dementia is not present

13. Delirium Superimposed on Dementia: A Systematic Review, JAGS 50:1723-1732, 2002 Background:Delirium on Dementia Four risk factors for under-recognition of delirium by nurses: Hypoactive delirium, age greater than 80, vision impairment and dementia Delirium associated with subsequent development of dementia Case reports of improvement with treatment with donepezil Prevention strategies work

14. Background: Incidence of post-operative delirium

15. JAMA, Apr 2004, 291(14): 1753-1762 Background: Impact 10-65% associated mortality Longer hospital stays Increased risk of institutionalization (16% vs. 3%) 3-5 fold increased risk of nosocomial complications Predictor of cognitive and functional decline and death up to 2 years after

16. Cascade to Dependency

17. Geriatrics Review Syllabus Pathophysiology Usually a multifactorial syndrome of predisposing problems and hospital insults Non-specific, generalized disturbance of neurotransmitters: Acetylcholine (most important) Anticholinergics precipitate delirium Serotonin excess or deficiency Cytokines (IL-2, TNF): cancer pts and infected patients Dopamine Excess dopamine is implicated (haldol is a dopamine blocker) GABA Over stimulation of receptors results in somnolence; under stimulation hyperactive delirium

18. Risk factors Risk factors (patient characteristics): Hospitalized elderly MMP Polypharmacy Terminal Illness Sensory deprivation Sleep deprivation Risk Factors (medical conditions): Dementia Post-surgical Burns Drug/alcohol cessation Malnourishment Liver/kidney disease Parkinson�s HIV Post-stroke

19. Risks for post-operative delirium

20. Gleason. AFP. 2003:67(5) Differential Diagnosis:�I WATCH DEATH� Infection and Indwelling (pulmonary/ urinary), Impaction, Withdrawl: sedatives/ alcohol Acute Metabolic and Anemia Trauma Uncontrolled pain CNS pathology Hypoxia Deficiencies- vitamins Endocrinopathies Acute Vascular and Pulmonary Events CVA/MI Toxins (Medications) Meds associated with 40% of episodes Heavy Metals Lead, mercury, manganese

21. Diagnosis and Assessment Heightened awareness and recognition Understand elderly patient�s cognition before big decisions: sending home, operating, admitting, etc. Interview caregivers (premorbid functioning) Review nursing notes. Look for doc-nursing disconnects Beware of learning effect with serial MMSEs Use CAM method

22. The Confusion Assessment Method (CAM) >95% sensitivity and specificity Requires features 1 and 2 and either 3 or 4 Acute change in mental status and fluctuating course Inattention Visual or auditory recall Disorganized thinking Logic questions Following commands Altered level of consciousness

23. Diagnosis and Assessment A complete review of history, events, meds and a complete physical Vitals, sats, MMSE, CAM Urinary retention, fecal impaction Direct lab at history and physical Cerebral imaging rarely helpful unless trauma or focal neurologic findings EEG or CSF rarely helpful unless associated seizure activity or meningitis

24. Delirium Management:Treatment Treat/modify underlying causes Use non-pharmacologic measures Use physical and chemical restraints for only severe agitation and patient safety (lines and tubes) Regular clinical review and follow-up

25. Management: General Principles Interdisciplinary effort by MDs, nurses, family, others Multifactorial approach because multiple factors contribute to delirium

26. Keys to effective management Address contributing factors Remove indwelling devices ASAP Prevent or treat constipation and urinary retention Encourage proper sleep hygiene, avoid sedatives Optimize medication regimen

27. Slide 27 Management: Offending Medications Alcohol Anticholinergics Anticonvulsants Antidepressants (anticholinergic only) Antihistamines (anticholinergic only) Antiparkinsonian agents Antipsychotics Barbiturates Benzodiazepines Chloral hydrate H2-blocking agents Opioid analgesics (esp. meperidine)

28. Delirium Management:Pharmacologic Treatment Start low and go slow Drugs of choice: Haldol Fewer cholinergic effects Less hypotension Atypical Less EPS symptoms Beware of: dystonic reactions, akathesia, tardive dyskinesia, malignant catatonia, NMS, and caution with patients with Lewy Body Dementia and Parkinson's

29. Haldol START LOW AND GO SLOW 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 minutes, as required Assess for EPS and akathisia IV: monitor for QT prolongation, torsade de pointes. Neuroleptic malignant syndrome may be underreported

30. Schwartz TL. The Role of Atypical Antipsychotics in the Treatment of Delirium. Psychosomatics. 2002: 43(3) Atypical Antipsychotics Preferential serotonergic (5HT2a) blockade with lower EPS Literature is scarce, no randomized-controlled trials Complicated by fact that delirium improves if you treat the underlying condition Lots of potential drug-drug interactions Concerns for QT prolongation

31. Atypical Antipsychotics Risperidone Case studies only 0.25-0.5 mg bid (mild to severe agitation), may be increased to 4mg/day if sxs fail to clear As needed: 0.25-0.5mg every four hours Olanzipine (Zyprexa) Case studies only 2.5-5 mg at bedtime, may be increased to 20mg/day if symptoms don�t clear

32. Atypical Antipsychotics Quetiapine (Seroquel) Retrospective study (11 patients compared to haldol) 25-50 mg bid, may be increased to 100mg bid, up to 600 mg/day As needed: 25-50mg every four hours Ziprasidone (Geodon) No geriatric studies 40mg PO/IM bid, can increase by day three per the manufacturer

33. Atypical Antipsychotics WARNING

34. Benzos Treatment of choice only when agitation is associated with sedative-hypnotic withdrawl Lorazepam (Ativan) IV, intermediate half-life, no active metabolites Dose: Mild/moderate 1-2 mg orally or 0.5-1 mg IM Moderate/severe: 1-2 mg IM or 0.5-1 mg IV

35. Benzos Midazolam (Versed) Short half life (1-2 hours) Higher risk pf benzo-withdrawl symptoms Paradoxical agitation

36. Delirium Management:Prevention Control pain but titrate Physical activity ASAP Remove foley ASAP Soft continuous lighting so they can see clearly when woken

37. MANAGEMENT: Prevention Orienting stimuli (clocks, calendar, family, staffing continuity) Provide adequate socialization Use eyeglasses and hearing aids appropriately Lighter sedation perioperatively?

38. MANAGEMENT: Prevention Mobilize patient as soon as possible Ensure adequate intake of nutrition and fluids, by hand feeding if necessary Educate/support the patient and family Allow for sleep Preoperative haldol?

39. Inouye SK. NEJM. 1999:340(9). 669-676 Delirium Management: Prevention Inouye et al. Intervention vs. usual care study at Yale-New Haven Hospital Six targeted risk factors Interventions: Orientation protocol, nonpharmacologic sleep protocol, early mobilization, vision protocol, hearing protocol, and dehydration protocol 9.9% vs. 15% incidence of delirium, fewer episodes of delirium and fewer total days of delirium Average cost of intervention:$327 per patient Cost per delirium prevented: $6341 (favorable when compared to falls prevention, MI prevention, etc) Intervention possibly paid for itself when additional hospital days factored in

40. Summary Delirium is common with associated morbidity and mortality in the aged CAM can diagnose delirium with high sensitivity and specificity Prevention works Treatment of underlying cause treats delirium Meds used only if necessary

41. Case 1:

42. Case 2: