Delirium

1. Delirium Susan Cox, DO Chief Resident July 2014

2. Goals • Understand the different presentations of delirium • Know the most common causes of delirium in the hospital • Learn a diagnostic approach to the delirious patient • Obtain skills to minimize and manage delirium in your patients

3. Case 1 • Any elderly woman is admitted for sepsis secondary to UTI. At baseline she has mild dementia, but is pleasant and functional. Yesterday she was doing well. Today, hospital day #4, she is talking to herself, and it is difficult to understand what she is saying. She is anxious, yelling at you, and repeatedly pulling at her clothes. She argues with the nursing staff and refuses blood draws.

4. What is this patient displaying? • Delirium • Psychosis • Dementia • Depression with psychotic features

5. What is this patient displaying? • Delirium • Psychosis • Dementia • Depression with psychotic features

6. Delirium: DSM 5 • Disturbance in attention or cognition • Acute onset • Change from baseline • Fluctuating severity • Not fully explainable by chronic psychiatric disorder • Level of impairment does not occur in the context of coma

7. Delirium: Confusion Assessment Method (CAM) 1. Acute Onset and Fluctuating Course 2.  Inattention 3.  Disorganized thinking 4. Altered Level of consciousness To diagnose delirium by CAM you need 1 and2 with either 3 or 4.

8. Epidemiology • Delirium complicates at least 25% of all hospitalizations in the elderly Prevalence of delirium Fong et al 2009

9. Consequences • In ONE THIRD of patients, it will take >8 weeks for delirium to completely resolve • Delirium can initiate a cascade of events that lead to functional decline, loss of independence and death 12 month mortality post-discharge Hospital length of stay (days) McCusker et al 2003 McCusker et al 2002

10. Case 2 • An elderly man is on your team for a hip fracture. Previously he was independent and active. He is POD #1 s/p ORIF and you have not heard any calls from the RN overnight. On your morning rounds, he is sleepy and falls asleep as you talk to him. You return to his room at 2:00 PM and he is napping again. He missed his breakfast and lunch because he was asleep. He has not used any of his prn medications.

11. What is this patient displaying? • Depression • Status epilepticus • Delirium • He’s just tired

12. What is this patient displaying? • Depression • Status epilepticus • Delirium • He’s just tired

13. Types of delirium • More than half of elderly patients with delirium present with hypoactive or mixed type • Which ones do you get called about? Fong et al

14. It’s up to you! • You must have a high index of suspicion for delirium in your elderly patients • Remember, 25-80% of your patients will suffer from this depending on your location in the hospital • Most of the time they will just appear sleepy and the RN won’t call you about it • Do not normalize lethargy • Delirium predicts your patient’s mortality

15. Delirium is a SYMPTOM • That means you must recognize it and decide what is causing it – NOT just treat it • What are some of the causes of delirium in the hospital?

16. Causes of delirium • Your patient brings along his/her own non-modifiable risk factors • Add an acute illness • Add the stressful hospital environment • Add medication side effects

17. Patient risk factors

18. Case 3 – What’s going on? • An 86 year old man presents to the ER brought in by his son because he is not responding appropriately for the last day. He is inattentive and won’t follow commands. He keeps asking for his wife; she died 15 years ago. • On exam he appears frail and he has a hearing aid. • His son doesn’t know his medications, but knows he takes 15 pills daily. • You don’t have any labs back yet.

19. What is the cause of his delirium? • WBC 15, Hgb 19, Plt 300k. 80% N, 10% Bands • Sodium 153, K 4.3, Cl 105, CO2 15, BUN 30, Crt 1.9 • LFTs and coags normal • Lactate 6 • UA 1.022 pH 5, 30WBC +nitrite +LE

20. Delirium in this patient • Elderly • Frail • Polypharmacy • Hypernatremia • Severe sepsis secondary to UTI

21. Case 4 – What’s going on? • You are the medicine inpatient consultant for the surgical teams • You receive a consult from orthopedics for “∆MS” – a 70 year old female admitted for ankle fracture, POD #2 s/p ORIF is now disoriented, climbing out of bed and pulling off her splint.

22. What is the cause of her delirium? • Her medications are: • Metoprolol 25mg PO BID • Lisinopril 10mg PO Qday • Lasix 10mg PO daily • Oxybutynin 5mg PO daily • Ativan 0.5mg IVP Q2 prn agitation • Benadryl 25mg PO QHS prninsomina You see this on physical exam

23. Delirium in this patient • >65 years old • Post-op • Polypharmacy • Anticholinergic drugs • Benadryl • Scopolamine patch • Oxybutynin • Sedative hypnotics • Ativan

24. Causes of delirium - organizing • Categories • Acronym

25. Causes of delirium

26. Causes of delirium

27. Causes of delirium

28. Causes of delirium • D Drugs • E Eyes, ears • L Low oxygen states (hypoxia, MI, stroke) • I Infection • R Retention of urine or stool • IIctal • UUnderhydration, undernutrition (hypoglycemia, thiamine deficiency) • M Metabolic

29. Uncovering the responsible illness • There are dozens of causes of delirium! • How do you approach a patient with delirium? • Recognize/identify it • Find the etiology • Treat the central cause • Manage patient symptoms

30. Case 5 • You are the medicine night float. It is 3:00 AM. You are covering 60 patients tonight. You get a page from the med/surg RN. She says, “Doctor, Mr. Johnson is getting agitated again. He’s trying to pull out his foley. Can we get a prnativan?” • What do you do?

31. Uncovering the responsible illness • History: Evaluate for: recent febrile illness, organ failure, detailed medication list, alcohol or drug abuse

32. Case 5 • You review your signout • 80 year old male, diabetic, nursing home resident here for decompensated heart failure and AKI, diuresing. HD day #4. He has been NPO because of an ileus, not on any fluids because of volume overload. His last labs were drawn 48 hours ago. • Meds: Lasix 40mg IV BID, Coreg 6.25mg PO BID, Lisinopril 20mg PO daily, Lantus 10 units QHS, Heparin 5000units SQ BID • What are you thinking? • Now what?

33. Uncovering the responsible illness • History: Evaluate for: recent febrile illness, organ failure, detailed medication list, alcohol or drug abuse • Physical Exam: Vitals, volume status, infection, hyperventilation • Jaundice, breath (smell of alcohol, ketones), tongue biting, retinal hemorrhages, asterixis, myoclonus, nystagmus

34. Case 5 • 38C, HR 99, BP 105/70, RR 22, O2 90% RA • He is tachypneic, agitated, pulling at his foley • JVD to jaw • Crackles at bases • 2+ edema • He has only diuresed 2 L since admission despite aggressive lasix • What are you thinking? • Now what?

35. Case 5 • What is on your differential diagnosis? • Hypoxia • Hypoglycemia • Infection / sepsis • Uremia • Hyponatremia • Arrhythmias • Heart failure

36. Uncovering the responsible illness • Accucheck • ABG • CXR • CBC • CMP • UA, urine culture • Blood cultures • EKG / cardiac enzymes • Utox • Ammonia • Drug levels (lithium, digoxin) • Lumbar puncture • Head CT

37. Case 5 pH 7.37 pCO2 33 pO2 55 on 4L NC Blood glucose 122

38. Uncovering the responsible illness • THE KEY POINTS: • You must find out WHY the change occurred • You then can address the primary issueand manage symptoms • NUMBER ONE • Is the change in mental status acutely life threatening?

39. Life threatening causes UpToDate

40. Life threatening causes • Hypoxia & Hypoglycemia • Bedside testing • Reverse with treatment • Sepsis • May present with fever or hypothermia • Look for SIRS criteria • Hypertensive Encephalopathy • Diagnosis of exclusion • Reduce blood pressure appropriately

41. Life threatening causes • Wernicke’s Encephalopathy • Uncommon • Alcoholic or malnutritioned patients • Tx: empirically with Thiamine (high dose, more than what is inside a banana bag) • Drug overdose (opiates, benzos, etc.) • Remember ABC • Poison control or medical toxicology for help

42. Life threatening causes • Acute neurologic disorders • Meningitis and subarachnoid hemorrhage • Confusion, headache, or fever • Acute or delayed CNS trauma • Subdural hematoma • Seizures • Postictal state • Some seizures may present without convulsions and persistent confusion (status epilepticus)

43. Diagnostic approach DELIRIUM Adequate Oxygen and Blood Glucose YES NO Correct as needed Determine cause Fever or other signs of infections?

44. Diagnostic approach Fever or other signs of infection? YES NO Do history and physical exam suggest likely cause of altered behavior? Search for source YES NO Pursue likely cause Diagnosis Uncertain

45. Diagnostic approach Diagnosis Uncertain Basic Testing: CBC, Electrolytes, UA, ECG, CXR Advanced testing or consulting as need: ABG, EEG, head CT, tox screen, drug levels, consults

46. Case 5 • Doctor, Mr. Johnson is awaiting his ICU bed. He is still pulling at his foley. What do you want to order?

47. Preventing Complications • Protect Airway – prevent aspiration • If applicable, maintain volume with IVF if unable to take PO • Maintain nutrition • Prevent pressure sores with frequent mobilization • Minimize unnecessary IV’s, NG tubes, foley catheters, etc.

48. Management of delirium • Remember, you have to identify the cause • Non-pharmacologic therapies are the best • Bedside sitter • Family involvement • Normalize patient’s sleep/wake cycle – uninterrupted sleep at night • Music relaxation • Hearing/visual aids • Light during the day, dark at night (pull the blinds open!)

49. Management of delirium • Avoid the following as much as possible: • Physical restraints • Pharmacological agents given increased risk for: • Falls • Death

50. If nonpharmacologic methods fail… • Haldol: 0.5 – 1 mg PO • Prolongs QT • Extrapyramidal symptoms (>3mg/day) • IV has short duration – AVOID IV USE • Seroquel: 12.5mg – 25mg PO • Prolongs QT • Extrapyramidal symptoms • Don’t use benzos unless it is for alcohol or benzo withdrawal • Atypical and typical antipsychotics are not approved for dementia related psychosis due to increased risk of death (black box warning)