Approach to Delirium in Primary Care Settings

1. Approach to Delirium in Primary Care Settings Andrea Moser, MD, MSc, CCFP(COE), FCFP Baycrest Health Sciences (OCFP Strategy for Physician Education on Dementia)

2. Objectives • Describe ways to mitigate the risk of delirium and be able to educate seniors and caregivers • List the main factors which predispose the elderly to delirium • Differentiate clinical presentation of delirium from dementia • Apply knowledge of common etiologies, pharmacological and non-pharmacological strategies through a case study

3. Putting Delirium into Context • Common • On admission to acute care 10-18% • During hospital stay 20-40% • Increased with dementia • Mortality increased 3-5 times • Recovery: 1/3 die, 1/3 partial, 1/3 complete • Increased Length of Stay (up to 2x)/ALC/LTC placement • Independent predictor of poor cognitive and functional status one year post admission

4. Delirium often unrecognized • Failure to recognize delirium as medical emergency • Hyperactive/hypoactive/mixed • Frequently missed by health care workers • ‘failure to thrive’, ‘social admission’, ageism • 30-65% unrecognized by md, 43% by nurses • Factors associated with under-recognition • Hypoactive • >80 years old • Vision impairment • Co-existing Dementia (delirium superimposed on dementia)

5. In-hospital delirium • 25% of patients >70 years without delirium or dementia on admission will develop delirium during hospitalization • Innouye, SK, 2000 • Precipitating factors • Physical restraint use • Malnutrition • Adding more than 3 drugs • Catheter use • Other iatrogenic events

6. Case - Delirium Mrs G. 89 year widow • Living independently • MCI, Hypertension, osteoarthritis, osteoporosis, cataracts, incontinence • recent shingles and post-herpetic neuralgia • Medications: • Hydrochlorothiazide 25mg daily • Calcium 500mg daily, Vitamin D 1000 iu daily • NEW**amitriptyline 50mg hs, Naproxen 500mg bid, Tylenol #2 prn • ditropan 5mg hs • Is she at risk for delirium?

7. Risk factors for delirium • Pre-existing cognitive impairment RR 2.8 • Severe medical illness RR 3.5 • Impaired vision RR 3.5 , (hearing impairment) • High urea/creatinine RR 2.0 • Advanced age • Multiple medications (anticholinergics, narcotics, BDZ, psychotropics, EtOH) • Hypoalbuminemia • Past psychiatric history • Risks have additive effect.

8. Case Mrs. G • Daughter calls your office with concern • Mother is confused • Not getting dressed as usual • Suspicious of neighbours • Calling daughter during the night • What are the features of delirium for Mrs G?

9. Delirium prior to DSM • ‘acute confusional state’ • ‘acute brain failure’ • ‘ICU psychosis’ • ‘encephalopathy’ • ‘subacute befuddlement’

10. DSM V Criteria for Delirium A. Disturbance in attention and awareness B. The disturbance develops over a short period of time, represents an acute change from baseline attention and awareness and tends to fluctuate in severity over course of day C. An additional disturbance in cognition (ie memory, orientation, language, visuospatial, perception) D. The disturbances in A – C are not better explained by a pre-existing neurocognitive disorder E. Evidence from the history, physical exam, or laboratory findings that there is an underlying medical cause., substance…..

11. Key Clinical Features of Delirium • Cognitive function • drowsiness, poor attention, disrupted sleep cycles, distractibility • confusion • Perception • Visual or auditory hallucinations • Physical Function • Altered psychomotor activity (increased or decreased) • Insomnia, change in appetite • Restlessness, agitation • Behavioural signs • anxiety, mood • Communication, withdrawal

12. Delirium versus dementia – how do they present different clinically?

13. Delirium vs Dementia **WITH A NEW BEHAVIOUR PROBLEM, FIRST RULE OUT DELIRIUM**

14. What factors may be contributing to Mrs. G.’s delirium?

15. Common causes of Delirium • Infection * • Withdrawal * (benzodiazepines / alcohol) • Acute metabolic* (fluids/electrolytes/glucose) • Trauma (pain) * • CNS pathology (CVA, bleed, tumour) • Hypoxia • Deficiencies • Endocrine • Acute vascular • Toxin/Drugs * (anticholinergics, narcotics, OTC) • Heavy metals

16. What is your approach for Mrs. G? • How do you initiate delirium assessment in the community?

17. Approach to Delirium: • Medical Conditions (acute and chronic) • Medication review • Best Possible Medication History • include OTC, Etoh, anticholinergics, Narcotics, psychotropics….. • Recent changes (new, stopped), compliance • Mental Status assessment • Executive function, attention • Clock drawing, word list generation • Concentration, Calculation • Physical Examination • Vitals, postural BP • Cardiorespiratory, MSK, Neuro, Skin,…

18. Approach to Delirium: History • Onset of symptoms • Functional ability now and prior • Cognition – tests of attention • Mood/behavioural symptoms • Sensory : Vision/hearing/communication • Nutrition/hydration • Bowel/bladder • Sleep pattern • Pain • Physical symptoms • Cardiac, respiratory, neurologic, abdominal, bladder, etc...... • Psychosocial history • Assess potential risk of harm

19. Delirium Inducing Drugs • Alcohol • Benzodiazepines, especially long ½ life • Antidepressants • Neuroleptics • Opiod analgesics • Hypoglycemics, insulin • NSAID • Antihistamines • Anticholinergics • Antispasmodics, antidepressants, antiparkinsons, muscle relaxants, antihistamine, antipuritic, urinary

20. What if any investigations do you order? • At home? • In office? • Consider a home visit? • Transfer to ED?

21. Basic Workup: Investigations • CBC, Na, K, Cl, urea, Creatinine, glucose • Ca, Mg, albumin, Liver function, TSH • serum drug levels (Lithium, tricyclics, seizure meds) • CXR • Urine culture – interpret with caution • ECG • O2 Sat • CT head – if localizing signs or hx of head trauma

22. Delirium and Urine Cultures • Asymptomatic Bacteruria in 15-50% >65 yrs • Higher in institutionalized persons • Risk of treatment • Resistive organisms, C Difficile • Miss other underlying cause of delirium • UTI symptoms • Suprapubic pain, dysuria, change in continence • Fever • Less reliable • Concentration, odour, sediment

23. Non Pharmacologic Management • Basic daily needs • Hydration, nutrition • comfort • Bowels, bladder • Mobilization, gait aids • Sensory Deficits • Hearing aids • Glasses • Familiar, safe environment • Educate and Support family/caregivers • Orientation – routine, reminders, calendars…. • Low glare surfaces, • Calm, consistent environment – minimize room change

24. Non pharmacologic • Appropriate stimulation • Music for auditory hallucinations • Avoid overstimulation • Monitor skin • Behaviour management • Familiar, safe environment, Least restraint • Warmth, calm, kind firmness • Do not confront if delusional, use distraction • Communicate • face to face • Clear consistent and repeated instructions

25. Pharmacologic Management • Treat underlying cause if identified • New medical illness • Gradual reduction of causal medications • Pain management • Bowel/bladder • Treat symptoms of delirium when • Distressful to patient • Risk of harm identified

26. Pharmacologic management of delirium symptoms • Use a SINGLE medication • Start with a low dose • Choose a drug with low anticholinergic activity. • Try to stop the medication as soon as possible once delirium clears. • Continue to use Non-Pharmacological Interventions.

27. Treatment of symptoms if distressing or potential harm • Atypical antipsychotic agents • Risperidone 0.25-1mg/day –divided dose • Olanzepine 2.5-10mg /day • Quetiapine 12.5-200mg/day • Haloperidol • 0.5mg– divided doses • Benzodiazepines • If alcohol or benzodiazepine withdrawal • Can worsen other causes of delirium

28. Mrs G’s Delirium • MULTIFACTORIAL • MCI • Post herpetic neuralgia - Pain • Change in medications • Bowel/bladder • nutrition/hydration • Sleep/fatigue

29. Mrs. G - course • Daughter increased support with meals, checking in • CCAC referral for personal care • Meals on wheels set up • Regular analgesics – acetaminophen • Amitriptyline and NSAID was tapered and stopped • Bowel management • Nutrition, hydration, milk of magnesia

30. Delirium prevention • Avoid medications that may contribute to delirium if possible • Identify high risk populations • Flag in family physician office • Pre-op screening • Education and involvement of staff, family and patients • Delirium protocols • RGP Ontario • RNAO • American Geriatric society

31. Delirium – Summary • A medical emergency!! • Common but under-recognized • Treatment • Address the underlying cause. • Non-Pharmacological approaches are essential. • Pharmacological mgt symptom based. • Prevention is the key to successful outcomes. • Acute Confusion is Delirium until proven otherwise

32. Delirium Resources • RNAO – best practice guideline ‘Screening for Delirium, Dementia, and Depression in Older Adults’ • www.rnao.org/bestpractices • Geriatrics InterorganizationInterprofessional Collaborative • www.giic.rgps.on.ca • CCSMH – National Guideline – Delirium • www.ccsmh.ca/en/projects/delirium.cfm • NICE pathway guidelines • http://pathways.nice.org.uk/pathways/delirium

33. ` • Questions?