Recognition and Treatment of Delirium

1. Recognition and Treatment of Delirium Devon Neale, MD Geriatric and Palliative Medicine Dept of Internal Medicine, UNM SOM

2. Objectives of Presentation • Develop familiarity with risk factors for development of delirium • Become familiar with an easy clinical tool to diagnose delirium (CAM) • Review evidence-based prevention and treatment algorithms

3. Delirium: Why do we care?

4. Delirium: Why Do We Care? • VERY COMMON1: • General hospital population: • 14-23% delirious on admission • 6-56% incidence • 15-53% of older post-op patients • highest for hip fracture and cardiac surgery • 70-87% ICU patients • Up to 60% patients in NH / PAC setting 1. SK Inouye. Delirium in Older Persons. NEJM 354:1157 – 65, 2006

5. Why Do We Care? • BAD OUTCOMES: • Increased mortality1: • 22-76% in hospitalized pts with delirium • 1 yr mortality 35-40% • Increased LOS2 • Poor cognitive outcomes • 1yr: MMSE : -3.363 1. Inouye SK. Delirium in Older Persons. NEJM 354:1157 – 65, 2006 2. Lundstrom et al. A Multifactorial Intervention Program Reduces the Duration of Delirium, Length of Hospitalization, and Mortality in Delirious Patients. J Am Geriatr Soc 53:622–628, 2005. 3. McCuster J et al. Delirium in Older Medical Inpatients and Subsequent Cognitive and Functional Status: a Prospective Study. Canadian Medical Association Journal 165(5):575-83, 2001

6. Why Do We Care? BAD OUTCOMES: • Poor functional recovery • >60% decline ADL after hip-fracture repair3 (OR 1.9)4 • OR 4.39 loss of pre-fracture ability to walk 15 feet independently5 • Permanent placement in facility: 75% vs 42% at 1yr (OR 1.8)6 3. Marcantonio et al. Delirium Severity and Psychomotor Types: Their Relationship with Outcomes after Hip Fracture Repair. J Am Geriatr Soc 50:850–857, 2002 4. Marcantonio ER, Flacker JM, Michaels M et al. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc 2000;48:618–624. 5. Givens et al. Functional Recovery After Hip Fracture: The Combined Effects of Depressive Symptoms, Cognitive Impairment, and Delirium. J Am Geriatr Soc 56:1075–1079, 2008. 6. McAvery GJ et al. Older Adults Discharged from the Hospital with Delirium: 1-yr Outcomes. J Am Geriatr Soc 54:1245-50, 2006

7. Why Do I Care? • PREVENTABLE AND TREATABLE: • Geriatric consultation for hip fracture patients: 32% vs 50% delirium (p=0.04), 12% vs 29% (p=0.02) severe delirium7 • Nursing and staff education for medical patients >70yo: 30.2% vs 59.7% (p=0.001)2 • Demonstrated decreased LOS: 9.4 vs 13.4days (p<0.001) [for delirious pts: 10.8 vs 20.5days (p<0.001)] and decreased inpatient mortality • 6 point intervention for medical patients: Matched OR 0.6 (0.39 -0.92)8 7. Marcantonio et al. Reducing Delirium After Hip Fracture: A Randomized Trial J Am Geriatr Soc 49:516-522, 2001 2. Lundstrom et al. A Multifactorial Intervention Program Reduces the Duration of Delirium, Length of Hospitalization, and Mortality in Delirious Patients. J Am Geriatr Soc 53:622–628, 2005. 8. Inouye et al. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. N Engl J Med 1999;340:669-76

8. What is Delirium? • Acute confusional state • “Acute brain injury” similar to “acute kidney injury” • Metabolic encephalopathy • Due to a medical problem • Generally considered reversible (identify and treat the medical problem)

9. How Do We Diagnose Delirium? • Confusion Assessment Method (CAM) • Delirium Observation Screening Scale (DOSS) • Memorial Delirium Assessment Scale (MDAS) • Delirium Rating Scale – Revised 98 (DRS) • Global Attentiveness Rating (GAR)

10. Confusion Assessment Method (CAM) Diagnostic Algorithm9 • Of the 9 characteristics of delirium (DSM-IV), the combination with the highest predictive accuracy: • Acute change in MS, fluctuating course MUST HAVE • Inattention MUST HAVE • Disorganized thinking either • Altered level of consciousness or 9. Inouye SK. Clarifying Confusion: The Confusion Assessment Method. Ann Intern Med 113:941-8, 1990

11. CAM algorithm: • MUST HAVE: Acute / fluctuating • Evidence of acute change in mental status from baseline? • Did abnormal behavior fluctuate during the day? (come/go, increase/decrease) • MUST HAVE: Inattention • Difficulty focusing attention: easily distractable, difficulty keeping track of what was being said? Difficulty following questions or conversation? AND • Either: Disorganized or incoherent thinking • Rambling or irrelevant conversation, unclear or illogical flow of ideas, unpredictable subject change? • Or: Altered Level of Consciousness: • Any LOC other than alert: vigilant (hyperalert), lethargic, stuporous, comatose

12. Important aspects of CAM • What is baseline mental status? REQUIRES FAMILY OR CAREGIVER INPUT • Most reliable with formal cognitive evaluation (mini-cog or MMSE) • Evaluation of ATTENTION: • Days of week or months of year backwards • Digit span (5 digits) • Raise hand when hears a certain letter in a list • Spell WORLD backwards • Serial 7’s or serial 3’s (5 items)

13. Key Points About Delirium • Dementia is chronic progressive, irreversible “brain failure” while delirium is acute, fluctuating and reversible • Hypo-active form more common than hyper-active • Alteration of day / night cycle may be first symptom. “Waking dreams” • Hallucinations, perceptual mis-interpretations: Are you seeing things that you think are not really there? Picking at bedclothes, interacting with the air

14. General Risk Factors • Advanced Age • Dementia or cognitive impairment • Brain disease (CVA, Parkinsons, alcohol abuse) • Multiple co-morbidities • Impaired vision or hearing • Functional impairment (Activities of Daily Living) • Male sex

15. Modifiable Risk Factors or “Precipitating Factors” • Impaired vision / hearing • Change in medications • Poorly controlled pain • Environmental change • Poor sleep • Urinary retention/ fecal impaction • Electrolyte disturbance • Dehydration / constipation • Infection (UTI, PNA, sepsis) • Use of restraints (intentional or unintentional)

16. PREVENTING DELIRIUM • Medications (anti-psychotics) • Single-intervention programs • Multi-intervention programs

17. Easier to prevent than to reverse. . .

18. PREVENTING DELIRIUM • Medications: anti-psychotics • Pre-operative haldol in hip fracture patients >70yo10 • No effect on incidence of delirium, but decreased severity, duration and LOS • Pre-operative olanzapine in joint replacement pts >65yo6 • Decreased rate of delirium: 14.3% vs 40.2% (p<0.001) • Increased severity and duration of delirium: 2.2 vs 1.6 days (p=0.02) • Higher percent discharged to home: 40.8% vs 29.9% (p=0.02) 10. Kalisvaart et al. Haloperidol Prophylaxis for Elderly Hip-Surgery Patients at Risk for Delirium: A Randomized Placebo-Controlled Study. J Am Geriatr Soc 53:1658–1666, 2005. 11. Larsen et al. Administration of Olanzapine to Prevent Postoperative Delirium in Elderly Joint-Replacement Patients: A Randomized, Controlled Trial. (Psychosomatics 2010; 51:409–418

19. PREVENTING DELIRIUM • Single-intervention programs • Multi-intervention programs2,7,8,12 • Focus on modifiable risk factors • There is often more than one contributing factor 2. Lundstrom et al. A Multifactorial Intervention Program Reduces the Duration of Delirium, Length of Hospitalization, and Mortality in Delirious Patients. J Am Geriatr Soc 53:622–628, 2005. 7. Marcantonio et al. Reducing Delirium After Hip Fracture: A Randomized Trial. J Am Geriatr Soc 49:516-522, 2001 8. Inouye et al. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. N Engl J Med 1999;340:669-76 12. Friedman et al. Geriatric Co-management of Proximal Femur Fractures: Total Quality Management and Protocol-Driven Care Result in Better Outcomes for a Frail Patient Population. J Am Geriatr Soc. 2008; 56(7):1349-1356.

20. Modify Risk Factors = Prevent Delirium

21. Most Common Causes:

22. MEDICATIONS • SPECIFIC MEDICATIONS: • Benzodiazepines “DEVIL DRUGS.” • Ativan / lorazepam, ambien /zolpidem, temazepam/restoril, alprazolam / xanax, clonazepam / klonipin, diazepam/valium • try trazodone instead for sleep: 50-100mg po qhs • Antihistamines: NO BENADRYL FOR SLEEP • Anticholinergic: oxybutynin, amitriptyline, imipramine • OPIOIDS: start low, go slow. ½ -1 tab oxycodone 5mg q4h • Over-medication: Anti-hypertensives, hypoglycemic agents • Adjust for RENAL FUNCTION • WITHDRAWAL: Discontinuing long-term medications: • Benzodiazepines, anti-depressants, pain medications

23. If Delirium Develops: • Review modifiable risk factors as precipitating events • Perform a thorough medical evaluation

24. Assess and Treat Risk Factors = Treat Delirium

25. Thorough Medical Evaluation

26. Thorough Medical Evaluation

27. Treatment of Delirium • Address underlying issues • Avoid complications • Address patient safety

28. Environmental / Behavioral Management • Re-orientation • Introduce self, explain where pt is and why • Clock and calender, RN call button • Day/night: Daytime: open blinds, lights on, OOB. Overnight: lights/TV off, no disruptions for vitals. • Comfortable environment • Glasses, hearing aids, water nearby • Family member, photo-albums, familiar objects • NO RESTRAINTS, NO BEDRAILS UP

29. Pharmacologic Management:

30. Pharmacologic Management: When to consider anti-psychotics • Patient is risk to themselves or others • Disturbing hallucinations • Not responding to environmental interventions

31. The 2am call . . . • Mrs R is agitated, trying to get out of bed, not paying attention, currently talking to “the messiah” • RN asks, “Can I give her some ativan?”

32. AVOID THE BENZO – REFLEX! • Ativan / lorazepam, • Zolpidem / ambien, • Temazepam / restoril, • Alprazolam / xanax, • Clonazepam / klonipin, • Diazepam / valium • ASSOCIATED WITH WORSENING DELIRIUM, FALLS, COGNITIVE IMPAIRMENT, ALTERED MENTAL STATUS

33. Which Medications? • Low-dose haldol, risperidone and olanzapine have been studied for the treatment of delirium • Equivalent efficacy and no difference in side effect profile13 13. The Cochrane Collaboration. Antipsychotics for Delirium. The Cochrane Library 2009, Issue 1

34. LOW DOSE! • Haldol 0.5mg IV or 1mg PO q6h • Risperidone 1mg PO • Usually start at bedtime, can be sedating • Side effects very rare at low dose (<4.5mg haldol/day): extra-pyramidal syndrome, prolongation of QT

35. British National Institute for Health and Clinical Excellence Guidelines for Diagnosis, Prevention, and Management of Delirium14 • Assess for signs of delirium on admission and daily: Changes in behavior: -Cognitive function -Perception -Physical function -Social behavior • If changes present, perform delirium evaluation (CAM) 14. Young et al on behalf of Guideline Development Group. Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ 2010;341:c3704

36. British National Institute for Health and Clinical Excellence Guidelines for Diagnosis, Prevention, and Management of Delirium • Assess for signs of delirium on admission and daily • At admission, assess for RF delirium: • Age >65 • Cognitive impairment (clock draw) • Current hip fracture • Serious / unstable medical condition • If RF present, institute prevention measures

37. NICE Guidelines: Delirium Prevention Measures • Continuity / familiarity of staff and environment • Assess for clinical factors (that could contribute to delirium) and develop a tailored intervention provided by a multi-disciplinary team -Cognitive Impairment / Disorientation -Hypoxia -Dehydration / Constipation -Immobility -Infection -Pain -Multiple medications -Nutrition -Sensory Impairment -Sleep

38. NICE Guidelines: Treatment of Delirium • Identify and manage the underlying cause(s) • Reorientation • Continuity / familiarity of staff and environment • If distressed / dangerous: short-term haldol or olanzapine at lowest dose possible

39. Resources: • Marcantonio ER. In the Clinic: Delirium. Annals of Internal Medicine. June 7, 2011 • PIER: • Delirium, Diagnosis, Post-op, Prevention Post-op • Cochrane Library • Prevention, Multidisciplinary team interventions, Antipsychotics, Terminally ill, ICU, Long term care

40. Questions or Comments?