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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

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

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


  • 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


  • Past history

    • Chronic Obstructive Pulmonary Disease

    • Ischaemic Heart Disease

    • Recent prostatectomy for BPH

    • Depression


  • 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


  • What is “Delirium”


Delirium

  • A “syndrome of cerebral insufficiency”

    (Engel & Romano)

  • ‘Acute Brain Failure’ (Lipowski)

  • Acute confusional state/ Acute Organic Brain Syndrome


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

  • A transient organic brain syndrome

    • acute onset and fluctuating course

    • altered level of consciousness

    • reduced attention and concentration

    • global impairment of cognitive function


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


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

    • Hallucinations

    • Agitation and irritability

    • Restlessness

    • Poor concentration

    • Definable organic cause


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


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

  • “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

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


Acute onset and fluctuating course

AND

Inattention

+

either

Disorganised thinking

Altered level of conciousness


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


  • Prevalence

    • 10-30% of hospitalized medically ill patients

    • 25% hospitalized cancer patients

    • 30-40% hospitalized patients with AIDS

    • 80% of patients with terminal illness


Delirium

  • higher risk groups:

    • hip fracture

    • surgery

    • CNS lesion

    • burns

    • dialysis

    • dementia


Delirium

  • Etiologic Factors

    • primary cerebral disease

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

    • exogenous substance

    • substance withdrawal


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


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


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


  • 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

  • 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


  • 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


  • What is the recommended 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

  • 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

√ 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


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


  • 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.


  • 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

  • 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

  • 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


  • 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

  • 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)


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.


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

  • 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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