Delirium

1. Delirium Karin Neufeld MD MPH Director of General Hospital Psychiatry Johns Hopkins University School of Medicine

2. Objectives • Define and describe the features • Describe associated outcomes • Identify risk factors • Review approach to treatment • Review prevention strategies

3. Objectives • Define and describe the features

4. Delirium: de lira = “off the path”

5. Definition of Delirium • Disturbance in consciousness • Global cognitive disturbance (esp. attention) • Of relatively abrupt onset and fluctuating • Due to underlying physiological disturbances • Other features often include: • Sleep-wake cycle reversal • Emotional lability or irritablity • Hallucinations (oneroid), illusions and delusional beliefs • Motor changes: agitation/or lethargy APA, Diagnostic and Statistical Manual – IV edition

6. Delirium is Called Many Things • Acute mental status change • Δ MS • Subacute befuddlement • Encephalopathy • ICU Delirium • Sundowning

7. Delirium Subtypes Ely, EW, et al. JAMA 2001; 286, 2703-2710; McNicoll L, JAGS 2003;51:591-98;

8. Clinical Findings • History • Acute change from a previous baseline (collateral information) • Mental State Exam • Motor changes (lethargy or agitation) • Changes in level of arousal (fluctuating level of consciousness) • Disorientation • Difficulty sustaining attention (days of the week backwards, serial 7’s or “world” backwards) • Difficulty learning new information (decreased short term recall) • Laboratory Investigations • EEG - “generalized dysfunction” • Further history, physical exam and investigation • To identify etiology of the delirium

9. Why A Lecture on Delirium? • Clinical diagnosis requiring exam of the mental state • Psychiatrist are often involved in detection however… • Delirium belongs to every specialty in medicine • Many patients missed • Physicians miss 75% percent of delirious patients in ED • Most of these remained undetected on inpatient units after admission • Need to improve detection

10. Objectives • Define and describe the features • Describe associated outcomes

11. Why care about delirium?

12. Delirium is Common • ICU Ventilated Population • 60-85% • General Medical Inpatient Units • 10-40% • Medical Oncology Units • 20-70% • Orthopedic Surgery: Hip fracture repair • > 40% • Emergency Room by 65+ year olds • 10-20%

13. Delirium: Increased Mortality • Higher mortality for 1 year after occurrence • Hazard ratio = 2-3 (Mortality Delirium + vs Delirium -) • Adjusting for age, illness severity, comorbid conditions, dementia, use of sedatives or analgesic meds • Demonstrated in critical care settings, and routine inpatient settings Salluh JI et al Crit Care 2010, 14:R210.

14. Delirium: A Red Flag • Nonspecific warning sign • Like fever or hypotension • Something is wrong and requires further investigation • 39% of in-patients with delirium die within one year • Don’t ignore this red flag

15. Delirium: Increased Risk of… • Functional decline • New nursing home placement • Persistent cognitive decline: • 18-22% of hospitalized elders had complete resolution of delirium 6-12 mo after discharge • Many had preexisting cognitive impairment • Significant proportion develop dementia in 2 years of f/u Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704)

16. Delirium: Psychological Impact For Patients: • Often have terrifying experiences during delirium • More prone to developing anxiety disorders (PTSD, phobias) For Family Members and Loved Ones: • Very frightening • Need reassurance and teaching in order to understand

17. Objectives • Define and describe the features • Describe associated outcomes • Identify risk factors

18. A Model of Delirium A multifactorial syndrome that arises from: • Predisposing factors underlying vulnerability AND • Precipitating factors noxious insults Delirium arises when noxious insults act in combination with a patient’s predisposing factors.

19. Delirium Risk Model Incidence of Delirium (per day) Baseline Predisposing Risk Precipitating Factor Group Inouye & Charpentier; JAMA. 1996 20;275:852-7

20. Predisposing Factors: Age “Pushing sixty isn’t the problem--it’s pulling fifty-nine.”

21. Predisposing Factors • Visual impairment • Hearing impairment • Functional impairment • History of ETOH abuse • Increased age • Baseline cognitive impairment • 2.5 X risk if Demented • 25-31% of delirious patients have underlying dementia • Medical comorbidities: • Any medical illness

22. Delirium: Predisposing Risk The more predisposing risk factors present… • The more likely delirium will develop • Target high risk patients • More to follow with prevention discussion

23. Precipitating Risk Factors (Insults) • Urinary retention • Fecal impaction • Immobility • Environmental influences • Physical restraints • Indwelling catheters • Uncontrolled pain • Medications • New medical illnesses • Infections • ETOH/drug withdrawal • Fluid/electrolyte abnormalities

24. Medications Drug Withdrawal Neurotransmitter Imbalance (Especially cholinergic deficiency and dopaminergic excess) Direct Ischemic Damage Cytokine Imbalance Hypoxia Hypoperfusion Systemic Inflammation DELIRIUM Cortisol Excess Acute Stress Response Glucocorticoids Cushing’s Syndrome Pathophysiologic Mechanisms • Neufeld, K, et al McGraw Hill, in press.

25. Drug Classes Associated with Delirium • Medications with psychoactive effects: • 3.9X increased risk of delirium • 2 or more psychoactive meds: 4.5X • Sedative hypnotics: 3.0 to 11.7X • Narcotics: 2.5 to 2.7X • Anticholinergic meds: 4.5 to 11.7-fold • Delirium  as overall # medications 

26. Delirium and Anticholinergics Lu & Tune, Am J Geriatr Psychiatry. 2003;11:458-61

27. Objectives • Define and describe the features • Describe associated outcomes • Identify risk factors • Review approach to treatment

28. Treatment of Delirium • Get history and examine first • Focus on time course of cognitive changes • Association with other symptoms or events • Neurologic and mental status examination • Vital signs, oxygen saturation • Medication review, including OTC drugs, alcohol, prn meds • General medical work-up Treat the Underlying Causes and Correct Insults

29. Management: General Principles • Requires interdisciplinary effort • MDs • Nurses and Aides • Physical Therapy and Occupational Therapy • Pharmacists • Family and loved ones • Multifactorial approach best because of multiple causes • Failure to diagnose and manage delirium is bad • Life-threatening complications, • Loss of function, • Costly

30. Nonpharmacologic Management • Facilitate constant presence of family members • Interpersonal contact and reorientation • Provide visual and hearing aids if needed • Remove indwelling devices (eg., Foley catheters) ASAP • Wrap IV lines in gauze (so patient can’t see them) • Mobilize patient as soon as possible • Encourage OT and cognitive exercises • Keep patient awake during the daytime • Provide uninterrupted sleep at night AVOID RESTRAINTS: Measure of Last Resort

31. Management: Hyperactive Delirium • If absolutely necessary, use antipsychotics to calm • Use LOW DOSE antipsychotic agents (not FDA approved) • Haloperidol • Quetiapine • Olanzepine • Antipsychotics have side effects (start low/go slow) • Anticholinergic • Orthostatic hypotension • Extrapyramidal side effects and acute dystonias • Can prolong the QT interval • Avoid sedative hypnotics (benzodiazepines) • Unless precipitating cause is alcohol/benzodiazepine withdrawal

32. Objectives • Define and describe the features • Describe associated outcomes • Identify risk factors • Review approach to treatment • Review prevention strategies

33. Can delirium be prevented?

34. Delirium: Prevention is Possible • 1/3 of delirium is preventable in the inpatient setting • With 1-4 of the following predisposing characteristics: • Visual impairment (worse than 20/70 corrected) • Severe illness • Cognitive impairment (MMSE<24/30) • Dehydration • Give them the following targeted interventions

35. Prevention: AKA “Good Hospital Care” Inouye SK et al. NEJM. 1999;340:669-76

36. Summary • Delirium is common and easy to miss • Associated with mortality and suffering • Predisposing and precipitating risk factors • Signals need for tx of underlying medical causes • Targeted strategies can prevent delirium