Delirium in the Older Adult

1. Delirium in the Older Adult Matt Russell,MD, MSc Assistant Professor of Medicine Boston University School of Medicine Slide show courtesy of Drs. Lisa Caruso and Serena Chao

2. Objectives • To elicit key features of and define delirium • To review epidemiology, risk factors, and precipitants of delirium • To discuss management strategies around delirium.

3. Case: 2pm Admission • Agnes D: 88 year old female ALF resident with history of Dementia( MMSE 21/30), HTN, CAD, hearing loss, history of GI bleed (diverticulosis), hyperlipidemia, and COPD presents with a 3 day history of progressive dyspnea, purulent sputum, and wheezing. Per nursing home flow sheet, oxygen saturation was in the low 80s% on room air. She is admitted with COPD exacerbation. At baseline, she is AAOx2. She is minimal assist with some ADLs (dressing and toileting) and ambulates independently.

4. What is your first thought?

5. What could possibly go wrong? A case for contingency planning…

6. Case continued • Agnes is admitted to the inpatient medical service. She is placed on 2 liters NC. Her other admission medications are as follows: • ciprofloxacin, • Solumedrol IV, • Donepezil • Famotidine for GI prophylaxis • Advair 500/50 • Spiriva • zolpidem prn • D5 ½ NS at 75 cc/hour

7. Case cont’d • Because of history of GI bleed, the team puts her on venodyne boots for DVT prophylaxis. • She is placed on telemetry and continuous oxygen saturation monitoring • The patient is settled in and the medical team goes home

8. Beep Beep! Dear Dr.Nightfloat….

9. “Hi, are you covering for Agnes D?....” Delirium: She is OFF THE WALL!!

10. Delirium Definition?

11. Delirium = Syndrome Definition: An acute disorder of attention and cognition; acute confusional state “Delta MS” or “Mental Status Changes” are vague, inappropriate terms and should not be used—CALL IT WHAT IT IS!

12. Your next step is….

13. MEDICAL EMERGENCY!

14. Next steps • Go to bedside and see patient • Approach in comforting fashion-NOT GUNS A BLAZIN’!! • Obtain history of baseline mental status from all available sources • Perform bedside testing for delirium screening

15. Recognition • Delirium is unrecognized by physicians in 32-67% of cases in hospitalized patients • Reasons for this include • lack of awareness of syndrome as important • cognitive assessment not done • misdiagnosed or not detected Inouye SK. The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994; 97:278-88.

16. Acute change in mental status with a fluctuating course Inattention AND 3. Disorganized thinking OR 4. Altered level of consciousness Diagnosis: Confusion Assessment Method (CAM) Sensitivity > 94%; specificity > 90% ; gold standard used was ratings of psychiatrists Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion. The Confusion Assessment Method: A new method for detection of delirium. Ann Intern Med 1990; 113:941-8.

17. Assume it is delirium until proven otherwise: Delirium may be the only manifestation of a life-threatening illness in the elderly patient.

18. Please complete Agnes’ Delirium Map

19. Agnes’ Delirium Map • Risks: • Precipitants: • Your interventions:

20. Epidemiology • Complicates hospital stays for more than 2.3 million persons 65 years of age and older per year • Prevalence on admission to the hospital is 14-24% • Incidence of new cases arising during hospitalization is 6-56% • Independent predictor of mortality up to 1 year after occurrence; mortality in patients who develop delirium in the hospital is 25-33% • $$$

21. Etiology • Biology is poorly understood • “The development of delirium involves the interrelationship between a vulnerable patient and noxious insults.”1 1Inouye SK. Delirium in older persons. NEJM 2006;354:1157-65.

22. Approaches to Clinical Problem Solving “simpler explanations are, other things being equal, generally better than more complex ones"

25. Agnes’Delirium Map • Risks: • Age • Dementia • Medical illnesses • Hearing impairment- no hearing aids!! • Precipitants: • Change in setting • Hidden restraints (IV tubing, venodynes, oxygen) • Medications (solumedrol, cipro, ambien,famotidine) • Interventions: • Treat underlying process • Eliminate restraints • Maximize sensory input (hearing aids) • Eliminate unnecessary and/or harmful meds: • d/c famotidine and use PPI • d/c ambien • Additional Non-pharm: family presence, orient, remove overt and hidden restraints, soothing tones, reassurance • Pharm: haldol if necessary. Start low

26. Agnes’ case continued • Agnes’ daughter comes in to help settle her mother down. She asks to speak to the doctor…..

27. What the hell are you people doing to my mother??!!! A brief skills practice….

28. Management and Treatment • Treat medical illness, as possible • Always try non-pharmacologic treatment first • don’t change room if possible • encourage family visits….EDUCATE FAMILY MEMBERS!! • quiet room with low level lighting • make sure patients have their glasses and hearing aides • limit IV’s, catheters, other restraints

29. Management and Treatment • Pharmacologic management • indicated if the patient is endangering him- or herself or others • AVOID BENZODIAZEPINES except for alcohol withdrawal (delirium tremens) • mainstay is the antipsychotic, haloperidol (Haldol); start with 0.5-1 mg, check vitals in 20 min, repeat dose as needed • olanzapine (Zyprexa) may be a useful alternative

30. Features seen in both: Disorientation Memory impairment Paranoia Hallucinations Emotional lability Sleep-wake cycle reversal Key features of delirium: Acute onset Impaired attention Altered level of consciousness How to distinguish Delirium from Dementia Slide courtesy of Serena Chao, MD

31. Haldol: advantages readily available PO, IM, IV quick onset of action high therapeutic index Haldol: disadvantages extrapyramidal SE contraindicated in pts with Parkinson’s disease or parkinsonism neuroleptic malignant syndrome Management and Treatment

32. Conclusions Identify risk factors Implement prevention strategies Recognize syndrome when occurs Determine etiology and treat if possible

33. When in acute fevers, pneumonia, phrenitis, or headache, the hands are waved before the face, hunting through empty space, as if gathering bits of straw, picking the nap from the coverlet, or tearing chaff from the wall--all such symptoms are bad and deadly. Hippocrates, [460-375 BC]

34. Acknowledgements • Dr. Lisa Caruso • Dr. Serena Chao

35. Thank You

36. Some drug classes that are associated with delirium • Medications with psychoactive effects: • 3.9-fold increased risk • 2 or more meds: 4.5-fold • Sedative-hypnotics: 3.0 to 11.7-fold • Narcotics: 2.5 to 2.7-fold • Anticholinergic drugs: 4.5 to 11.7-fold • antihistamines (Benadryl, Atarax) • antispasmodics (Lomotil) • tricyclic antidepressants • antiparkinsonian agents (Cogentin, Artane) • antiarrhythmics (Quinidine, Norpace)

37. Etiology: Medications • Cardiac (digoxin, lidocaine) • Antihypertensives (beta-blockers, Aldomet) • Miscellaneous • H2-blockers • steroids • metoclopramide • lithium • anticonvulsants • NSAIDS

38. Evaluation • Recognize syndrome • History • establish patient’s cognitive and functional baseline • thorough medication review: drug toxicity may account for up to 30% of all cases of delirium

39. Evaluation • Physical Exam • vital signs including O2 saturation • search for signs of infection • neurological exam • include cognitive evaluation (ex. MMSE) • other tests for attention • forward digit span (able to repeat 5 digits forward) • months of the year or days of week backwards

40. Evaluation • Individualized work-up • Metabolic: CBC, electrolytes, BUN/Cr, glucose, Ca2+, phosphate, LFT’s, magnesium. Consider also TSH, drug levels, tox screen, ammonia. • Infection: urine cx, CXR, blood cultures, consider LP • If no obvious cause, ABG, ECG, brain imaging, EEG

41. Prevention: It can be done! • Objective: To evaluate the effectiveness of a multicomponent strategy for the prevention of delirium • Design: Controlled clinical trial. Randomization not possible but pts meeting criteria admitted to intervention unit were prospectively matched by age, sex and base-line risk of delirium (meaning for number of risk factors). • Subjects: 852 patients >70 yrs old admitted to general medicine service at a teaching hospital • 426 usual care, 426 intervention Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.

42. Prevention: Modify Risk Factors • Intervention was standardized protocols to manage six risk factors for delirium • Risk factors targeted were: cognitive impairment, sleep deprivation, immobility, vision impairment, hearing impairment, dehydration • Intervention unit staffed by a trained team (geriatric nurse specialist, two specially trained Elder Life specialists, a certified therapeutic-recreation specialist, a physical therapy consultant, a geriatrician and trained volunteers.) • Outcomes: Delirium by Confusion Assessment Method, severity, recurrence

43. Prevention: Modify Risk Factors Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.

44. Prevention: Modify Risk Factors • Intervention did not change the severity of the delirium episode. • Rates of recurrence of delirium did not differ in the two groups. • Adherence rates high; lowest in non-pharm sleep protocol at 71%. • Cost of intervention per case of delirium prevented was $6,341. Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340:669-76.

45. Risk Factors Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. J Gen Intern Med. 1998;13:204-12.

46. Risk Factors Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium Risk Factors in Elderly Hospitalized Patients. J Gen Intern Med. 1998;13:204-12.

47. Etiology • 1940’s: Cortical function on EEG characterized by abnormal slow-wave activity. • Exception: alcohol and sedative withdrawal showing predominately low-voltage, fast-wave activity • Subcortical structures important, also. • Patients with subcortical strokes and basal ganglia abnormalities are more susceptible to delirium.

48. Etiology Role of Acetylcholine (Ach) • Neurotransmitter involved in multiple aspects of cognitive functioning including memory • Anticholinergic medications are frequent causes of delirium • Patients with Alzheimer’s disease are particularly susceptible • Serum anticholinergic activity (SACA) is increased in older pts with delirium and in postoperative delirium • Some evidence that certain patients with delirium improve with administration of acetylcholinesterase inhibitors, such as physostigmine and donepezil