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Delirium: An Update. Prof. Brian Kelly John Hunter Hospital School of Medicine and Public Health University of Newcastle. Objectives. Undertake a clinical assessment focussing on history and mental state signs of delirium Undertake assessment of cognitive function

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Delirium an update

Delirium: An Update

Prof. Brian Kelly

John Hunter Hospital

School of Medicine and Public Health

University of Newcastle


Objectives

Objectives

Undertake a clinical assessment focussing on history and mental state signs of delirium

Undertake assessment of cognitive function

Be able to differentiate delirium from other common clinical syndromes

Formulate a management plan that includes

- risk factors to delirium

- appropriate investigations

- behavioural interventions

- pharmacologic treatments


Delirium an update

  • MR ES

    • 78 year old man

    • Wandering his home and neighbourhood at night

    • Believes home is being “bugged” and suspicious that wife wants to harm him

    • Brought to ED by ambulance


Delirium an update

  • Past history

    • Chronic Obstructive Pulmonary Disease

    • Ischaemic Heart Disease

    • Recent prostatectomy for BPH

    • Depression


Delirium an update

  • Which of the following clinical features would be most likely to indicate the presence of delirium

  • Sleep disturbance

  • Irritability and restlessness

  • Rapid onset of symptoms

  • Poor memory


Delirium an update

  • What is “Delirium”


Delirium

Delirium

  • A “syndrome of cerebral insufficiency”

    (Engel & Romano)

  • ‘Acute Brain Failure’ (Lipowski)

  • Acute confusional state/ Acute Organic Brain Syndrome


Delirium current concepts

Delirium: Current Concepts

  • Pathophysiologicmechanisms

    • reduction in cerebral metabolism

    • altered function of neurotransmitters

      • Acetylcholine, DA, GABA, NA, 5-HT

    • false neurotransmitters (eg hepatic failure)

    • pro-inflammatory agents (eg cytokines)


Delirium clinical features

Delirium: Clinical Features

  • A transient organic brain syndrome

    • acute onset and fluctuating course

    • altered level of consciousness

    • reduced attention and concentration

    • global impairment of cognitive function


Subtypes

Subtypes

  • Hyperactive

    • Agitation, irritability

    • Restlessness

    • Distractibility

    • “hyperarousal”

  • Hypoalert/hypoactive

    • reduced reactivity

    • motor and speech slowing

    • withdrawal

  • Mixed states (most common) (>70%)

    De Rooij et al, In J Geriatr Psychiatry, 2005; 20: 609-15

    Caraceni & Simonetti, Lancet Oncology, 2009, 164-172


Delirium an update

  • Which of the following is the best indicator of the presence of delirium?

    • Hallucinations

    • Agitation and irritability

    • Restlessness

    • Poor concentration

    • Definable organic cause


Signs

Signs

Cognitive signs

  • Attention97% *

  • Memory89%

  • Orientation76%

  • Language57%

    Non-cognitive

  • Sleep-wake cycle disturbance97% *

  • Psychomotor changes62%

    Psychotic Symptoms

  • Delusions30%

  • Hallucinations50%

    Meagher et al, Br J Psychiatry, 2007, 190, 135-141


Delirium an update

Best indicators of severity

  • Signs

    • Cognitive signs

      • Attention97% *

      • Memory89%

      • Orientation76%

      • Language57%

      • C’hension39% *

    • Non-cognitive

      • Sleep-wake cycle disturbance97% *

      • Psychomotor changes62%

    • Psychotic Symptoms

      • Delusions30%

      • Hallucinations50%

        Meagher et al, Br J Psychiatry, 2007, 190, 135-141


Other clinical presentations

Other Clinical Presentations

  • “non-compliance” and denial

  • anxiety and panic

  • “crescendo pain”

  • “adjustment problems”

  • suicidal ideation and actions

  • depression

  • staff and family conflict

    Breitbart & Alici, 2010; Akechiet al,1999; Farrell & Ganzini,1995


Screening and diagnosis

Screening and Diagnosis

1. Screening Instruments

Confusion Rating Scale

Clinical Assessment of Confusion

Nursing Delirium Screening Scale

(Mini-Mental State Examination)

2. Diagnostic Instruments

Confusion Assessment Method

Delirium Symptom Interview

3. Delirium Severity Rating Scales

Delirium Rating Scale

Memorial Delirium Assessment Scale


Delirium an update

Acute onset and fluctuating course

AND

Inattention

+

either

Disorganised thinking

Altered level of conciousness


Delirium an update

Table 1 Differentiating features of conditions that mimic delirium

Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatmentNat Rev Neurol doi:10.1038/nrneurol.2009.24


Delirium an update

  • Prevalence

    • 10-30% of hospitalized medically ill patients

    • 25% hospitalized cancer patients

    • 30-40% hospitalized patients with AIDS

    • 80% of patients with terminal illness


Delirium1

Delirium

  • higher risk groups:

    • hip fracture

    • surgery

    • CNS lesion

    • burns

    • dialysis

    • dementia


Delirium2

Delirium

  • Etiologic Factors

    • primary cerebral disease

    • systemic disease with secondary affect on brain function (eg hypoxia, hyponatraemia, infection)

    • exogenous substance

    • substance withdrawal


Predisposing factors

Predisposing factors

  • Sleep Deprivation

  • Immobility

  • Visual and/or hearing impairment

  • Dehydration

  • Malnutrition

  • Hypoxia

  • Poor functional status

  • Cognitive impairment

    Caraceni & Simonetti, Lancet Oncology, 2009, 164-172


Delirium an update

Caraceni &Simonetti, Lancet Oncol, 2009; 10:164-72


Delirium an update

Figure 1 Relationships between various etiological factors in delirium

Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatmentNat Rev Neurol doi:10.1038/nrneurol.2009.24


Delirium an update

  • Majority of patients have 3 or more contributing factors

  • 50% or more have a reversible component

    • Metabolic

    • Infective

    • Drug-related

      Meagher et al, Br J Psychiatry, 2007, 190, 135-141

      Caraceni &Simonetti, Lancet Oncol, 2009; 10:164-72


Impact

Impact

  • Poorer patient outcomes

    • Mortality

    • Prolonged hospitalisation

    • Adverse events (inc safety, suicide)

    • Costs of care (↑ x 2.5)

    • Post-delirium psychological distress

    • Communication, decision-making, symptom management

    • “Mental awareness”

  • Family and staff

    • >70% report severe distress relating to delirium

      Leslie et al, Arch Int Med, 2008, 168: 27-32

      Gagnon et al, J Pall Care, 2002, 18: 253-261

      Steinhauser et al, JAMA, 2000; 284: 2476-2482


Delirium an update

  • Patients

    • 50-75% distressing recall of symptoms

      • both hypo- and hyper-active delirium

  • Family

    • Strongest mediator of caregiver anxiety

    • Conflict with clinicians

      Bruera et al, Cancer, 2009; 115: 2004-12

      Buss et al, J Pall Med, 2007; 10: 1083-92

      Breitbart et al,Psychosomatics,2002;43:183-94


Delirium an update

  • What is the recommended treatment?


Treatment

Treatment

  • Standardised assessment and monitoring

    • Improve recognition

      • Risk factors (eg prior cognitive impairment, alcohol use)

      • Early onset of delirium

  • Standardised management

    • identify and address underlying causes**

    • Prevent delirium related complications (incl safety)

    • Patient support and information

    • Family , carer and staff needs

      APA Practice Guidelines (1999)

      Meagher et al, BMJ, 322: 145-149


Interventions

Interventions

  • Research findings support:

    • Discontinuation of unnecessary psycho-active medication

    • attention to hydration

    • change of opioid or dose modification

    • use of antipsychotic drug if needed

    • Use of environmental interventions


Drug treatments

Drug treatments

√ Antipsychotic agents

  • Haloperidol (0.5-2mg; 2-12 hr)

  • Olanzapine (2.5-5mg; 12-24hr)

  • Risperidone (0.25-1mg; 12-24hr)

    X Benzodiazepines**

    X Anticholinesterase inhibitors

    X Psychostimulants

    ** hepatic encephalopathy, benzodiazepine and alcohol withdrawal

Overshott et al, Cochrane Database of Systematic Reviews, 2008:1

Lonergan et al, Cochrane Database of Systematic Reviews, 2007:2


Delirium an update

Table 3 Pharmacological therapy for delirium

Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatmentNat Rev Neurol doi:10.1038/nrneurol.2009.24


Delirium an update

  • Antipsychotic treatments in delirium

    • Low dose haloperidol (<3mg per day)

      • Haloperidol = Atypical APDs (egolanzapine, risperidone)

    • High dose haloperidol (>4mg per day)

      • Haloperidol < Atypical APDs

        Lonergan et al, Cochrane Database of Systematic Reviews; 2007;2.


Delirium an update

  • Determinants of drug choice/dose

    • Route of administration

    • Symptom profile

      • Hyperactive - ?olanzapine

      • Hypoactive- ? Haloperidol

    • Adverse effects eg EPS

    • NB Staff factors

      Hui et al, JPSM, 2010, 39:186-196


Caregivers

Caregivers

  • Note adverse impact on bereavement outcomes

    • Patient agitation and incoherence

    • Decision-making

  • Benefits of interventions with caregivers

    • Information, explanation, emotional support

      • Improved confidence

      • Lowering of distress

      • Improvement in decision-making

        Morita et al, JPSM, 2006

        Gagnon et al, J Pall Med, 2002


The patient s experience of delirium

The patient’s experience of delirium

  • effect on adaptive and cognitive capacity

    • “Mental awareness”

    • Involvement in decisions

    • Understanding illness and “being prepared”

  • effect on communication of symptoms

  • effect on patient’s key relationships

  • distressing recall of delirium

    Steinhauser et al, JAMA, 2000; 284: 2476-2482

    Breitbart et al, Psychosomatics, 2002;43:183-184


Delirium an update

  • Specific populations

    • Children and adolescents

      • Limited research

      • Focus on hyperactive delirium

      • Special considerations

    • Pre-existing chronic mental illness (eg schizophrenia)

    • Pre-existing cognitive impairment (eg dementia)

      Viron & Stern, Psychosomatics, 2010; 51: 458-65

      Hatherill & Flisher, J Psychosom Res, 2010; 68:337-44


Prevention

Prevention

  • primary

    • identify risk groups

      • Age

      • Prior CNS disease

      • Substance use

    • enhance environment

    • modify causative factors (eg drug treatment practices)

    • Address sensory impairments (eg hearing, vision)

    • Maintain mobility

  • secondary

    • early identification through cognitive monitoring

    • early intervention - identify key early symptoms (eg sleep disturbance, agitation, irritability, somnolence)

    • Identify and address precipitants (eg hydration)


Prevention1

Prevention

  • Studies in elderly peri-operative prevention

    • HPD 1.5 mg per day (1-3 days pre-; 3 days post-op)

      ↓Delirium incidence, severity and duration

      ↓ Duration admission

Kalisvaart, J Am Geriatr Soc. 2005 Oct;53(10):1658-66.


Delirium an update

400 pts > 65 yrs

5mg Olanzapine

pre- and post op.

↓ Incidence

No difference in severity/duration

Larsen et al, Psychosomatics, 2010, 51: 409-18


Conclusion

Conclusion

  • Delirium

    • common clinical syndrome

    • significant impact on patient, family and staff

    • interwoven with often complex clinical and ethical issues

    • Opportunities for prevention

    • Need for standardised assessment and monitoring

    • Patient and family support and information needed


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