Dementia: a Risk Factor for Delirium

1. Dementia: a Risk Factor for Delirium Linda DeCherrie, MD Geriatrics Fellow Brookdale Department of Geriatrics and Adult Development Mount Sinai School of Medicine April 19, 2004

2. MKSAP Question: An 88 yo woman is hospitalized because of a UTI. She has a history of mild dementia, and her husband states that her confusion often worsens at night. She takes no medications at home. Antibiotic therapy is begun in the hospital. Which one of the following measures is most likely to be effective in avoiding the development of delirium in this patient in the hospital?

3. MKSAP Question: • Place a foley catheter, restrain the patient physically, and limit fluids after super. • Provide bright illumination in the room at all times, repeated orientation by her nurses whenever the patient is awake, and benzodiazepines hypnotics at night as needed. • Reduce ambient noise at night, enable the patient to move about during the day, and disimpact earwax • Reduce ambient noise, encourage family members to stay with her, and give benzodiazepine hypnotics at night. • Provide visual aids and adaptive equipment for low vision and bedrails and haloperidol at night.

4. MKSAP Question: • Place a foley catheter, restrain the patient physically, and limit fluids after super. • Provide bright illumination in the room at all times, repeated orientation by her nurses whenever the patient is awake, and benzodiazepines hypnotics at night as needed. • Reduce ambient noise at night, enable the patient to move about during the day, and disimpact earwax • Reduce ambient noise, encourage family members to stay with her, and give benzodiazepine hypnotics at night. • Provide visual aids and adaptive equipment for low vision and bedrails and haloperidol at night.

5. Objectives • Distinguish between dementia and delirium • Learn ways to decrease the incidence of delirium in patients with dementia when they are admitted to the hospital • Understand the differential for delirium

6. Topics Covered • What is dementia • What is delirium • Who is at risk for delirium • Strategies to reduce the incidence of delirium • Differential of delirium • Treatments of delirium

7. WHAT IS DEMENTIA? • An acquired syndrome of decline in memory and other cognitive functions sufficient to affect daily life in an alert patient • Progressive and disabling • NOT an inherent aspect of aging • Different from normal cognitive lapses GRS

8. What Diseases Cause Dementia? • Alzheimer’s Disease • Vascular Dementia • Frontal Dementia • Dementia with Lewy Body • Others: Huntington’s disease, Jakob-Creutzfeld disease, progressive supranuclear palsy, and Parkinson’s disease

9. THE DEMOGRAPHY OF DEMENTIA • 4 million in U.S. currently • 14 million in U.S. by 2050 • 1 in 10 persons aged 65+ and nearly half of those aged 85+ have dementia • Life expectancy of 8-10 years after symptoms begin GRS

10. DELIRIUM vs DEMENTIA Delirium and dementia often occur together in older hospitalized patients; the distinguishing signs of delirium are: • Acute onset • Cognitive fluctuations over hours or days • Impaired consciousness and attention • Altered sleep cycles GRS

11. CAM: Confusion Assessment Method 1. Acute onset and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness (Alert, vigilant, lethargic, stupor, coma) Diagnosis of delirium requires 1 and 2 and either 3 or 4

12. DEPRESSION vs DEMENTIA The symptoms of depression and dementia often overlap; patients with primary depression: • Demonstrate  motivation during cognitive testing • Express cognitive complaints that exceed measured deficits • Maintain language and motor skills GRS

13. Who is at risk for delirium? • Dementia • Advanced age • Male gender • Poor functional status • Severe Illness • Depression • Sensory Impairment • Fever • History of ETOH use • Pain at rest Elie M et al. Delirium risk factors in elderly hospitalized patiente. J Gen Intern Med 1998; 12:204-12.

14. Case 71 yo male with A fib presents a few day prior to a revision of THR to switch from coumadin to heparin. Patient has no current complaints, THR from 20 years ago “worn out” and causes pain Had had multiple falls recently Recently started on memantine for memory and ditropan for urge incontinence

15. Case, Cont PMH: A fib CVA – R minimal weakness OA Multiple basal cell ca of skin

16. Case, Cont Meds: SH: Acidophilus Lives with wife Coumadin Retired Digoxin Ind. ADL’s Ditropan Walks with cane Memantine + tob, 2-3 drinks/day

17. Case, Cont PE: 36.9 69 20 98/64 Gen: NAD Neck: no JVD Lungs: CTA bilat CV: irreg irreg nl S1S2 Abd: + NABS, soft, ecchymosis R flank Ext: No Edema, 2+ DP Neuro: A&O X3, strength 5/5 Left, 5/5 left UE, 4/5 left LE

18. Tests for Dementia that can be Performed Inpatient • Orientation questions • MMSE • Clock drawing

21. Why is it important to recognize delirium? • Symptom of an unrecognized medical problem (cause of delirium) • Increases length of stay • Increases readmission rates • At risk for other iatrogenic problems (ie falls, pressure ulcers) • Prognosis for family: Only 5% of delirium resolved at discharge, 62% still have symptoms at 6 months Levkoff, SE et al. Delirium: The occurrence and persistence of symptoms among elderly hospitalized patients. Arch Intern Med 1992; 52 (2) 334-76

22. How can we avoid inpatient delirium? • Orientation strategies • Maintain day/night schedule • Avoid restraints • Avoid sedative/hypnotics • Ensure assistive devices are working (eyes and ears) • Avoid immobility • Avoid dehydration

23. Multicomponent Intervention to Prevent DeliriumInouye, S. K. et al. N Engl J Med 1999;340:669-676 • Interventions on 6 risk factors for delirium • 852 patients enrolled, half in treatment group, half in usual care • Risk–factor intervention reduced number of episodes of delirium and deceased the length of episodes of delirium

24. Multicomponent Intervention to Prevent Delirium • Orientation: 1-3 times a day • Orientation board with team names and schedule • Communication to orient • Cognitively stimulating activities: word games, current events

25. Multicomponent Intervention to Prevent Delirium • Sleep • Non pharmacologic sleep protocol: warm drink, relaxation music, back-massage • Sleep enhancement protocol: decreased noise on unit (d/c night time floor washes, etc)

26. Multicomponent Intervention to Prevent Delirium • Immobility • Ambulation or ROM exercises TID • Minimize use of restrictive equipment (bladder catheters, IV’s)

27. Multicomponent Intervention to Prevent Delirium • Visual impairment • Visual aids (glasses magnifying glass) • Adaptive equipment (call bells with florescent tape, large key pads on telephone)

28. Multicomponent Intervention to Prevent Delirium • Hearing impairment • Portable amplifying equipment • Earwax removal

29. Multicomponent Intervention to Prevent Delirium • Dehydration (BUN/Cr ratio> 18) • Encourage oral intake

30. Differential for Delirium C-Cognitive deficit O-Organ dysfunction (lung, heart, liver, kidney) N-Neuro (SZ, ICP) F-Fever/infection, fecal impaction U-Urinary retention/UTI S-Sensory impairment (eyes/ears) E-EtOH, endocrine, electrolytes D-Drugs – narcotics, anticholinergics, anti-inflammatory etc.

31. Differential for Delirium D-Drugs, dementia, depression E-Endocrine/electrolytes, Environment L-Liver I-Intracranial (bleed, mass, hydrocephalus) R-Restriction in senses/mobility I-Infection/Impaction U-UTI/uremia M-Myocardial infarction, hypoxemia

32. Treatment of Delirium • Determine and treat underlying cause • Used non pharmacologic strategies (the ones used for prevention) • Medication

33. Treatment of Delirium • Medication (agitation or aggression) • Haloperidol – high potency antipsychotic • Advantages: low cost, multiple routes • Disadvantages: EPS, TD • Dose: 0.5mg - 2mg PO, IM/IV twice as potent • Resperidone (risperdol) • Advantages: Less EPS • Disadvantages: Orthostasis, EPS at high doses, recent concern with stroke • Dose:0.25-1mg QD

34. Treatment of Delirium • Olanzapine (Zyprexa) • Advantages: Less EPS • Disadvantages: sedation, weight gain, possible association with diabetes • Dose: 2.5-10mg QD • Benzodiazepines – for delirium cause by ETOH withdrawl • Disadvantage – can cause delirium • Dose: Ativan 0.5 – 2mg q3-4 hours

35. Summary • Dementia is common in older adults but is NOT an inherent part of aging • Delirium is common when patients with dementia are admitted to the hospital

36. Summary, Cont • Consider a broad differential for delirium • Treatment of delirium starts with determining underlying cause and correcting it • Other treatments include the non-pharmacologic measures and if absolutely necessary, medications

37. MKSAP Question 2: An 88 yo man is hospitalized for pneumonia and poor nutritional intake. He has no known family members and no medical records. He is tachypneic, tachycardic, febrile, and coughing continuously. PE and CXR confirm lobar pneumonia, and antibiotic therapy is begun. The fever resolves promptly and leukocytosos resolves by the third day of treatment.

38. MKSAP Question 2: His vital signs return to normal, and the cough nears resolution. He is not treated with any other medications. On the sixth hospital day, the patient becomes inattentive, confused, and drowsy with apparent hallucinations and fluctuating mental status. His vital signs remain normal.

39. MKSAP Question 2: Which one of the following is the most likely cause of this patient’s delirium? • Hyponatremia • Meningitis • Alcohol abstinence syndrome • Hypoxemia • Drug reaction

40. MKSAP Question 2: Which one of the following is the most likely cause of this patient’s delirium? • Hyponatremia