Delirium

1. Delirium Ashley Duckett, MD Pamela Pride, MD Medical University of South Carolina 2012

2. CAM Definition of Delirium Acute onset or fluctuating course AND Inattention (decreased ability to focus, shift or sustain attention) PLUS EITHER Disorganized thinking (incoherent or illogical speech (questions – does a stone float on water, etc) OR Altered Level of Consiousness (anything other than alert and calm) – RASS other than 0 Confusion Assessment Method- Inouye, Ann Intern Med 1990

3. -INATTTENTION is the cardinal feature for diagnosis -Can use serial 7’s, WORLD, reciting days or months in reverse, etc; ICU uses letter test (SAVEAHAART) -SUBTYPES -Hyperactive – agitated, hyperalert -Hypoactive – calm and confused, lethargic -Mixed – features of both *no difference in etiology or outcomes among the subtypes *hypoactive pts commonly missed without formal screen

4. Mimickers-Know the 3 D’s

5. Why do we care? • VERY common (esp if older, had ICU stay) although underdetected • Increased morbidity and mortality • Higher risk for falls, decubs, pna • Higher risk of functional decline and institutional care • Longer LOS • Predictor of 12 mo mortality

6. Risk factors (far from an exhaustive list) • Age >70 • Dementia or underlying brain dysfunction • Alcohol abuse • Hearing or visual impairment • History of delirium Inouye et al, Multicomponent Intervention of Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76)

7. Modifiable risk factors • Medications • Polypharmacy (>3 new inpt meds) • Physical restraints and catheters • Sleep deprivation • Immobility • Uncontrolled pain • Medical illness (organ failure, electrolytes, etc)

8. Mnemonic for Meds that Cause Acute Change in Mental Status Antiparkinson drugs Corticosteroids UI drugs Theophylline Emptying drugs (motility drugs) Cardiovascular Drugs H2 blockers Antimicrobials NSAIDs Geropsychiatric drugs ENT drugs Insomnia drugs Narcotics Muscle relaxants Seizures Drugs Look to these medications if there is an ACUTE CHANGE IN MS http://www.geronurseonline.org; Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): 101-27.

9. Rapid Screen for Cognitive Impairment: Mini-Cog Mini-Cog Recall 0 Recall 1-2 Recall 3 Impaired Not Impaired Normal Clock Abnormal Clock Impaired Not Impaired Borson S et al. (2000), Int J Geriatr Psychiatry 15(11):1021-1027

10. Serial administration of a modified RASS for delirium screening Chester, JG et al. J Hosp Med 2012 May-June 7 (5) 450-3.

11. Evaluation • Vital signs, pulse ox, volume status • Focused exam including determining baseline cognition, urine output, last BM • Blood glucose • Review medications • Consider withdrawal as a cause • Testing – CBC, BMP, UA, CXR, EKG • Additional testing if clinically indicated

12. Management • Try to identify underlying cause • Prevent complications and provide supportive care • Avoid bed rest, catheters, mobilize patient • Sleep at night, awake during day • Monitor nutrition status and output • Consider aspiration precautions • Enlist the help of family

13. Management • Antipsychotics are drug of choice for treating agitation • Can consider treating hypoactive delirium to treat subjective stress (paranoia, hallucinations) • Haldol – cheap, can be given PO, IV, IM • CAN’T be used in Parkinson’s, Lewy body dementia, prolonged QT • DON’T USE BENZOs UNLESS YOU’RE TREATING WITHDRAWAL or NMS!!!

14. What’s the evidence? • Best drug? Haldol v Atypicals (Risperidone, Olanzipine, Quetipine) • Systematic reviews show similar efficacy, question of fewer side effects • NEED larger and better studies • 2005 FDA warning re risk of death • Use for shortest duration, with caution • NEED larger and better studies

15. Haldol and EKGs? • Concern for prolonged QTc and torsades or polymorphic VT • Review showed that most conduction disturbances involve heart disease and high doses (50mg/24 hrs) • More recent review – heart dz, >65, female, hypokalemia • Stop if QTc>500 • Don’t wait to give Haldol until after EKG Lawrence, Pharmacotherapy 1997; 17(3);531-537

16. Screening Inpatients • Delirium task force • Goal should be prevention; cutting back on physical restraints • Nurses will screen each shift with RASS • Delirium protocol - order set with suggested workup and drug dosing based on patient factors

17. References • DSM-IV TR, 2000 • Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76) • Borson S et al. (2000), The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 15(11):1021-1027 • Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): 101-27. • http://www.geronurseonline.org • Lawrence, Conduction Disturbances Associated with Administration of Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Pharmacotherapy 1997; 17(3);531-537 • Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Torsade de Pointes. DtschArzteblInt 2011; 108 (41): 687-93 • Delirium. Updates in Hospital Medicine 2012. Harvard Medical School • Antipsychotics for delirium. Cochrane review