Understanding Delirium in Elderly Patients: Diagnosis, Treatment, and Risk Factors

1. Confusion, Delirium and Dementia Samira Khazravan, M.D. Geriatric Fellow Department of Geriatrics Mary Immaculate Hospital

2. DELIRIUM “Acute Confusional State”

3. DELIRIUM • Word delirium is derived from Latin term meaning "off the track“. • Not a disease but a syndrome with multiple causes that result in a similar constellation of symptoms. • The clinical hallmarks are ed attention span & a waxing & waning type of confusion. • A transient, usually reversible, impairment of consciousness with a ed ability to focus, sustain or shift attention. • Should be treated as a medical emergency (early diagnosis & resolution of symptoms are correlated with the most favorable outcomes).

4. CRITERIA FOR DIAGNOSING DELIRIUM • A ∆ in cognition or development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving Dementia. • Develops over a short period of time & tends to fluctuate during the course of the day. • There is evidence that the disturbance is caused by a medical condition, intoxication or med use. • There is no clear evidence of any underlying pathologic process.

5. EPIDEMIOLOGY • 14-56% of hospitalized elderly patients. • Delirium is present in 10-22% of elderly patients at the time of admission, with an additional 10-30% of cases developing after admission. • found in 40% of patients admitted to ICU. • Extremely common among nursing home residents. • Can occur at any age. • MC in pts who are elderly & have compromised mental status. • ed risk in pts w/dementia (2/3 of cases of delirium occur in pts w/dementia). • Delirium due to physical illness is MC among very young & those older than 60 years. • Delirium due to drug & alcohol intoxication or withdrawal is most frequent in persons aged mid teens to the late 30s.

6. RISK FACTORS • Advanced age • Dementia • Functional impairment in ADLs • Medical co morbidity • History of alcohol abuse • ♀ > or < ♂ • MC whites than in other races • Sensory impairment – decreased vision & hearing • Acute cardiac/pulmonary events • HIV/AIDS

7. MORBIDITY/MORTALITY • 10-fold risk of death. • 3-5-fold increase risk of nosocomial complications. • Poor functional recovery & ed risk of death up to 2 years • Some causes of delirium (Delirium Tremens, Severe Hypoglycemia, CNS infx, Heat stroke, Thyroid storm) may be fatal or result in severe morbidity if unrecognized & untreated. • With some exceptions, such as OD of TCAs, drug intoxications generally resolve fully with supportive care.

8. PATHOPHYSIOLOGY • Exact pathophysiological mechanisms unclear. • The main hypothesis is reversible impairment of cerebral oxidative metabolism & multiple NT abnormalities (Acetylcholine, Dopamine, Serotonin, GABA) • Postulated mechanisms: • Interruption of BBB • Inflammatory mechanism [cytokines (interleukin-1 & 6) are ed following infx, inflammation, toxic insults, head trauma & ischemia] • Stress rxn mechanism [psychosocial stress and sleep deprivation facilitate the onset of delirium].

9. ETIOLOGY  Intracranial causes • Neurodegenerative • Dementia w/Lewy bodies [only dementia that features transient episodes of impaired consciousness as a typical feature]. -No other dementias feature impairment of consciousness unless complicated by a delirium (i.e. 2° to infx, anoxia, etc).

10. ETIOLOGY  Intracranial causes • Space-occupying lesions • Tumor • Cyst • Abscess • Hematoma • Head injury (esp. Concussion)

11. ETIOLOGY • INTOXICATION • Alcohol (Delirium tremens, Wernicke-Korsakoff encephalopathy). • Sedative-Hypnotic use/abuse. • Poisons • Heavy metals (Lead, Mercury, Manganese) • Carbon monoxide

12. Amphotericin B Anticholinergics Anticonvulsants Antidepressants Antihistamines Antihypertensive drugs [-blockers] Antiparkinsonian drugs Antipsychotics Cannabis H2 Blocker (Cimetidine) Dopaminergic agents Disulfiram Digoxin Insulin Lithium Opiates Phenytoin Salicylates Steroids Sedatives (barbiturates & benzodiazepines) TCAs ETIOLOGY Drugs (ingestion or withdrawal)

13. ETIOLOGY  Intracranial causes • Infx • Meningitis & Encephalitis (Bacterial, Viral, Fungal, Parasitic or Tuberculosis organisms) • Neurosyphilis • Sepsis • Epilepsy • Cerebrovascular disorders • TIA • Cerebral thrombosis or Embolism • Intracranial or SAH • HTNive Encephalopathy • Vasculitis (e.g. From SLE)

14. Electrolyte disturbances (Na+, Mg2+, Ca2+) Acid-Base D/o Renal Failure & Uremia Hepatic encephalopathy Hypoglycemia (DM) DKA Insulinoma Thyrotoxicosis  &  thyroidism  &  parathyroidism  &  adrenocorticism (Cushing’s syndrome, Addison’s disease) Pheochromocytoma Hypopituitarism Wilson’s disease ETIOLOGY Metabolic & endocrine

15. ETIOLOGY • Nutritional Deficiencies • Thiamine (Wernicke’s encephalopathy) • Vitamin B12 (Pernicious Anemia) • Vitamin B1 (Beriberi) • Folic acid • Niacin • Anoxia • Respiratory failure (Hypoxia/Hypercarbia) • Heart failure • MI, A. Fib

16. ETIOLOGY • Neoplasms (1 or metastatic lesions of CNS; CA induced HyperCa2+) • Degenerative disease • Alzheimer’s, Pick’s Dz, Multiple Sclerosis, Parkinsonism, Huntington’s chorea, Normal Pressure Hydrocephalus)

17. ETIOLOGY • Major causes of delirium – HIDE • Hypoxia • Infections • Drugs • Electrolyte disturbances

18. SIGNS & SYMPTOMS • Usually acute onset • Fluctuating levels of consciousness (impairment usually least in AM) • Perceptual disturbances (hallucinations or illusions) • Impaired consciousness: • Reduced awareness of environment  clouding of consciousness  coma • Reduced ability to sustain attention (easily distracted)

19. SIGNS & SYMPTOMS • Impaired cognitive function • Impaired STM (1° memory) & recent memory. • Disoriented to time & often place [orientation to self seldom lost]. • Language abnormalities [rambling, incoherent speech & impaired ability to understand] common.

20. SIGNS & SYMPTOMS • Perceptual & thought disturbance • Ranging from misinterpretations (e.g. A door slamming is mistaken for an explosion)  illusions (e.g. A crack in the wall is perceived as a snake)  hallucinations (especially visual) • Psychomotor abnormalities • Patients may be hyper or hypoactive or fluctuate from one to the other • May also have an enhanced startle reaction

21. SIGNS & SYMPTOMS • Sleep-wake cycle disturbance • Daytime drowsiness  night-time hyperactivity  complete reversal of normal cycle • Nightmares of delirious patients may continue as hallucinations after awakening • Mood disturbance (Emotional Liability) • Depression, euphoria, anxiety, anger, fear & apathy • Lack of initiative, impaired impulse control, inability to reason thru problems, confabulation

22. A physical illness should always be ruled out whenever a patient presents with prominent visual hallucinations because patients with schizophrenia & other functional psychotic disorders usually experience auditory hallucinations.

23. DIFFERENTIAL DIAGNOSIS • Dementia • Primary psychiatric illnesses – Depression, Mania, Schizophrenia. • Sundowning (mild to mod delirium @ night—MC in pts w/preexisting dementia & may be precipitated by hospitalization, drugs & sensory deprivation)disturbance in circadian rhythm. • Focal syndromes – Wernicke’s aphasia, Anton’s syndrome & Bi-frontal lesions. • Non-convulsive status.

24. DIFFERENTIAL DIAGNOSIS • Delirium often is unrecognized or misdiagnosed & commonly is mistaken for dementia, depression, mania, an acute schizophrenic reaction or part of old age (patients who are elderly are expected to become confused in the hospital).

26. DIAGNOSIS • Under-recognition is a major problem – nurses recognize & document <50%; DSM-IV criteria is precise but difficult to apply. • History & Physical – focus on time course of cognitive changes, especially their association w/other symptoms or events; Note recently started meds, overdose, alcohol use, previous history, concurrent medical problems, signs of organ failure & infx (occult UTI is common in elderly), general medical evaluation, neurologic & mental status examination. • Remember: Delirium is not a final diagnosis: this syndrome indicates the presence of a very serious medical condition that should be managed on medical not psychiatric, ward.

27. DIAGNOSIS • Any pt who presents w/AMS needs a complete PE, w/particular attn to: • General appearance (unkempt, tattooed &/or malnourished) may suggest the possibility of drug or alcohol abuse) • Vital signs • Hydration status • Evidence of physical trauma • Evidence of neurological signs • The delirious or obtunded patient should be evaluated for Pupillary, Fundoscopic & extraocular abnormalities; nuchal rigidity; thyroid enlargement & heart murmurs or rhythm disturbances.

28. DIAGNOSIS • Other clues to etiology on PE: • A pulmonary exam  wheezing, rales or absent breath sounds • An abdominal exam  Hepato/Splenomegaly • A cutaneous exam  rashes, icterus, petechiae, ecchymosis, track marks or Cellulitis (often hidden under clothing, particularly pants & socks; checking these areas in pts with diabetes is critical; any serious infx can lead to mental status ∆s)

29. CLUES TO DIAGNOSIS • Smell for alcohol • Musty odor of Fetor Hepaticus • Fruity smell of DKA • Icterus &/or asterixis liver failure w/ serum ammonia • Agitation & tremulousness sedative or A/C withdrawal • Fever infx, heat illness, thyroid storm, ASA toxicity or extreme adrenergic overflow of certain drug overdoses & withdrawal syndromes (Esp. delirium tremens) • Extreme hyperthermia (w/pinpoint pupils)  pontine strokes • BP = common in delirium b/c of resulting adrenergic overload • Hemotympanum, battle sign, raccoon eyes or otorhinorrhea  basilar skull fracture (2° to occult head trauma)

30. DIAGNOSIS • A rapid RR  DKA (Kussmaul respiration), sepsis, stimulant drug intoxication & ASA OD • A slow RR  narcotic OD, CNS insult or various sedative intoxications • A rapid PR  fever, sepsis, dehydration, thyroid storm & cardiac dysrhythmias & stimulants, anticholinergics, quinidine, theophylline, TCAs or ASA OD • A slow PR  ICP, asphyxia, complete heart block, CCBs, Digoxin & beta-blockers • Pupillary dilation  intoxication w/ hallucinogen, amphetamine, cocaine or anticholinergic med • Pupillary constriction  narcotic intoxication • Pupillary inequality  late sign of uncal herniation • A funduscopic examination: • Loss of venous pulsations  early  ICP elevation • Papilledema  severe  ICP

31. DIAGNOSIS -- Special cases: • In pts w/delirium & severely  BP, check ocular fundi for arteriolar spasm, disc pallor, papilledema, flame hemorrhages & exudates ( Malignant HTN). • In pregnant pts w/diastolic pressure >75 mm hg in 2nd trimester or >85 mm hg in 3rd trimester  Pre-eclampsia (Hyperreflexia, Edema, Proteinuria). • In pts w/HTN & Bradycardia  ICP • With Delirium & Hypotension  dehydration, diabetic coma, hemorrhage due to trauma, aneurysmal rupture, GI bleeding, adrenergic depletion (2° to cocaine, amphetamine or TCA OD) & Addisonian crisis (particularly in steroid dependent pts).

32. DIAGNOSIS • A brief bedside neurologic exam, to include mental status testing, is essential for workup of delirium when a rapidly treatable cause (hypoglycemia or narcotic OD) is not immediately apparent • The mini-mental status examination (MMSE) (a formalized way of documenting severity & nature of mental status ∆s) • In addition, or as an alternative to the MMSE, correctly drawing the face of a clock (to include the circle, numbers & hands) is a sensitive test of cognitive function • Other simple screening tests include "serial 7's,"

33. LABORATORY/RADIOLOGICAL • CBC, electrolytes, BG levels, BUN/Cr • Also helpful – UA, LFTS (serum ammonia & PT), toxicology screen, ABG, CXR, O2 Sat & cultures • Consider: Vitamin B-12 & Folate levels, VDRL test (r/o Neurosyphilis) & thyroid function studies • Head CT scan [done b/f LP to r/o CNS infx, trauma, CVA, SAH, hematomas, toxoplasmosis or abscess (especially in pts w/HIV who present w/H/A)] • LP (CSF studies including India ink prep & VDRL) • Plain abdominal x-ray swallowed bags of drugs ("body packing") or radiodense substances (iron tablets) • EKG (MI or a. fib; low voltages  Hypothyroidism & pericardial effusion; Tachycardia, widened QRS or prolonged QT interval  TCA overdose)

34. MANAGEMENT • ABC’s + Normalize fluid & electrolyte status • Provide Thiamine when administering glucose [or else may lead to acute Wernicke syndrome (ataxia, confusion, oculomotor palsies in the setting of malnutrition)] • Physical or pharmacologic restraints (may be necessary to prevent pts from harming self or others) • Low dose Haloperidol (Typical Antipsychotic doc for severe agitation, acute psychosis & severe delirium when no CIs exist)[sedative qualities + effect on DA-Ach balance; Assess for akathisia & EPS; Avoid in elderly w/parkinsonism; in ICU, monitor for QT prolongation, torsades, neuroleptic malignant syndrome & withdrawal dyskinesias; antidote: Dantrolene] • Avoid sedative meds if possible [use BenzodiazepinesLorazepam (Ativan) -- doc in ED (if unable to control a dangerous patient; may obscure the MMSE)] • Treat underlying cause • Multi-factorial approach is most successful

35. MANAGEMENT • Highly distressing for pts & anxiety provoking for medical ward staff. • Hospitalization is essential. • To limit confusion, foster trust & provide reassurance, try to ensure that pt is nursed by same staff consistently. • Maximize visual acuity (e.g. Glasses, appropriately lit environment) & hearing ability (e.g. Hearing aid, quiet environment) to avoid misinterpretation of stimuli. • Involve friend or family member to remain w/pt to help comfort & orientate them. • Avoid complications of delirium – remove indwelling devices ASAP, prevent or treat constipation, urinary retention & encourage proper sleep hygiene.

36. COURSE & PROGNOSIS • Average duration of delirium is 7 days • Inpatients who develop delirium have an ed mortality, with elderly pts having up to a 75% chance of dying during that admission • Delirium is fully reversible in most cases with proper recognition & treatment of the etiology • Failure to dx & manage delirium is costly, life-threatening & can lead to loss of function

37. DEMENTIA

38. 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

39. Dementia • DSM IV criteria: Development of cognitive deficits manifested by both -impaired memory -aphasia, apraxia, agnosia and disturbed executive function Significantly impaired social and occupational function Gradual onset and continuing decline Not due to CNS and other physical or psychiatric conditions

40. Prevalence • 10% percent of persons over age 70 • 20 to 40% of individuals over age 85 • Affects more than 4 million Americans • Costs more than $50 billion annually

41. Causes of Dementia & the differential diagnosis: • Alzheimer’s disease • Vascular (multi-infarct) dementia • Dementia associated with Lewy bodies • Delirium • Depression OTHER: • ETOH, exposure to heavy metals (arsenic, antimony, bismuth) • Parkinson’s disease, Pick’s disease, frontal lobe dementia • Infectious diseases: These infections may be caused by viruses (HIV, viral encephalitis); spirochetes (Lyme disease, neurosyphilis); or prions (Creutzfeldt-Jacob disease) • Abnormal brain structure: Hydrocephalus, subdural hematoma

42. Most common REVERSIBLE causes • Hypothyroidism • Vitamin B-12 • Folate deficiency • Dementia of depression • Drugs • Alcoholism

43. Assessment History Onset and Duration of the memory loss A) Elderly person with slowly progressive memory loss over several years AD B) Change in personality with disinhibition and intact memory may suggest FTD C) History of sudden stroke with an irregular stepwise progression suggests Multi-infarct dementia D) Rapid progression with rigidity and myoclonus suggests CJD

44. Assessment (cont.) E) Gait disturbances+memory problems+resting tremors may suggest PD F) Multiple sex partners or intravenous drug use may indicate CNS infection G) Hx of Recurrent head trauma suggests Subdural Hematoma H) Alcoholism Thiamine deficiency I) Gait disturbances,urinary incontinence and memory problems suggest NPH

45. Assessment (cont.) Physical Examination • Cogwheel rigidity, bradykinesiaPD • Inability to initiate and coordinate stepsNPH • Myoclonic jerks are present in CJD • Hemiparesis or other focal neurologic deficits MID • Dry cool skin,hair loss,bradycardiaHypothyroidism

46. Cognitive assessment • MMSE • most widely used screening exam • used in assessment and follow up • score interpretation depends on patients age and education level • Clock drawing • test of visuospatial skills • draw numbers within a pre-drawn circle 3 inches in diameter to make that circle look like the face of a clock • Normal score 0-3 • Dementia 4-7

47. MMSE Orientation Name: hospital/floor/town/state/country 5 (1 for each name) Registration Identify three objects by name and ask patient to repeat3 (1 for each object) Attention and calculation  Serial 7s; subtract from 100 (e.g., 93-86-79-72-65) 5 (1 for each subtraction) Recall Recall the three objects presented earlier 3 (1 for each object) Language Name pencil and watch 2 (1 for each object) Repeat "No ifs, ands, or buts“ 1 Follow a 3-step command (e.g., "Take this paper,, fold it in half and place it on the table") 3 (1 for each command) Write "close your eyes" and ask patient to obey 1 written command Ask patient to write a sentence 1 Ask patient to copy a design (e.g., intersecting pentagons) 1 TOTAL30

48. Clock drawing

49. Cortical dementias • Alzheimer’s • Vascular • Diffuse Lewy body • Pick’s disease • Creutzfeldt-Jacob disease

50. Alzheimer’s Slowly progressive dementing illness associated with diffuse cortical atrophy, amyloid plaques and neurofibrillary tangles CLINICAL MANIFESTATIONS • Progressive memory impairment (predominantly short term) • Language impairment • Complex deficits in visual and spatial abilities • Acalculia • Personality changes - progressive passivity to marked hostility • Increased stubbornness & suspiciousness • Delusions • Hallucinations • Symptoms of depression and anxiety