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Incidence Among Elderly Patients is HIGH - PowerPoint PPT Presentation

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Incidence Among Elderly Patients is HIGH. 1/3 of patients presenting to ER 1/3 of inpatients aged 70+ on general med units Incidence ranges 5.1% to 52.2% after noncardiac surgery 15-53% of older patients post op Highest rates after hip fracture and aortic surgeries

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Incidence among elderly patients is high
Incidence Among Elderly Patients is HIGH

  • 1/3 of patients presenting to ER

  • 1/3 of inpatients aged 70+ on general med units

  • Incidence ranges 5.1% to 52.2% after noncardiac surgery

    • 15-53% of older patients post op

    • Highest rates after hip fracture and aortic surgeries

    • 70-87% of patients in the ICU

      Dasgupta M et al. J Am Geriatr Soc 2006;54:1578-89

Delirium increased mortality
Delirium: Increased Mortality

  • One-year mortality: 35-40%

  • Independent predictor of higher mortality up to 1 year after occurrence

  • Hazard Ratio between 2 and 3

    • Elderly medical inpatients: Adjusted for dementia, comorbidity, clinical severity, APACHE II score, admitting service (med vs. geri), demographic variables (McCusker J et al. Arch Intern Med. 2002; 162:457-463)

    • Mechanically ventilated MICU & CCU patients: Adjusted for coma, age, CharlsonComorbidity Index, APACHEII score, SOFA, admitting diagnosis of sepsis or ARDS, sedative and narcotic use

      Ely EW et al. JAMA. 2004; 291:1753-62

Delirium increased risk of
Delirium: Increased Risk of…

  • Functional decline

  • New nursing home placement

  • Persistent cognitive decline:

    • 18-22% of hospitalized elders with complete resolution 6-12 months after discharge

    • CAVEAT: Many subjects with preexisting cognitive impairment

      Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704

Delirium costs
Delirium: Costs

  • Complicates the hospital stays for >7.3 older pts

  • Diagnosis increases the hospital costs by $2,500 per patient

  • 6.9 billion (2004) of Medicare hospital expenditures

Diagnosis call it what it is
Diagnosis: Call it what it is…

  • DELIRIUM: ICD-9 code 780.09

  • “Δ MS” or “mental status change”:

    • No ICD-9 code

Why is diagnosis not made
Why is diagnosis not made?

  • Fluctuating course

  • Overlap with dementia

  • Lack of formal cognitive assessment

  • Under appreciation of consequences

  • Failure to consider it important

Diagnosis confusion assessment method cam
Diagnosis: Confusion Assessment Method (CAM)

  • Acute change in mental status with a fluctuating course

  • Inattention


3. Disorganized thinking


4. Altered level of consciousness

Sensitivity: 94-100%; Specificity: 90-95%

Inouye SK et al. Ann Intern Med. 1990; 113: 941-948

How to distinguish delirium from dementia
How to Distinguish Delirium from Dementia

  • Features seen in both:

    • Disorientation

    • Memory impairment

    • Paranoia

    • Hallucinations

    • Emotional lability

    • Sleep-wake cycle reversal

  • Key features of delirium:

    • Acute onset

    • Impaired attention

    • Altered level of consciousness

Assume it is delirium until proven otherwise
Assume it is Delirium until Proven Otherwise

Delirium may be the only manifestation of life-threatening illness in the elderly patient.

A model of delirium
A Model of Delirium

A multifactorialsyndrome that arises from an interrelationship between:

  • Predisposing factors a patient’s underlying vulnerability


  • Precipitating factors noxious insults

Predisposing factors i e baseline underlying vulnerability
Predisposing Factors Factors (insults)i.e. baseline underlying vulnerability

  • Baseline cognitive impairment

    • 2.5 fold increased risk of delirium in dementia patients

    • 25-31% of delirious patients have underlying dementia

  • Medical comorbidities:

    • Any medical illness

  • Visual impairment

  • Hearing impairment

  • Functional impairment

  • Depression

  • Advanced age

  • History of ETOH abuse

  • Male gender

Precipitating factors i e noxious insults
Precipitating Factors Factors (insults)i.e. noxious insults

  • Medications

  • Bed rest

  • Indwelling bladder catheters

  • Physical restraints

  • Iatrogenic events

  • Uncontrolled pain

  • Fluid/electrolyte abnormalities

  • Infections

  • Medical illnesses

  • Urinary retention and fecal impaction

  • ETOH/drug withdrawal

  • Environmental influences

Some drug classes associated with delirium
Some Drug Classes Associated with Delirium Factors (insults)

  • Medications with psychoactive effects:

    • 3.9-fold increased risk

    • 2 or more meds: 4.5-fold

  • Sedative-hypnotics: 3.0 to 11.7-fold

  • Narcotics: 2.5 to 2.7-fold

  • Anticholinergic drugs: 4.5 to 11.7-fold

  • Risk of delirium increases as number of meds prescribed rises

Prevention of delirium it can be done
Prevention of Delirium: Factors (insults)It can be done!

Find patients with 1 to 4 of the following predisposing characteristics:

  • Visual impairment (worse than 20/70 corrected)

  • Severe illness

  • Cognitive impairment (MMSE<24/30)

  • High BUN/Cr ratio (>18)

    Inouye SK et al. Ann Intern Med. 1993; 119:474-481

Prevention good hospital care for the elderly patient
Prevention = Good Hospital Care for the Elderly Patient Factors (insults)

Inouye SK et al. NEJM. 1999;340:669-76

A multicomponent intervention to prevent delirium
A Factors (insults)Multicomponent Intervention to Prevent Delirium

Inouye SK et al. NEJM. 1999;340:669-76

Keys to effective management
Keys to Effective Management Factors (insults)

Find and treat the underlying disease(s) and contributing factors

  • Comprehensive history and physical

  • Including neurological and mental status exams

  • Choose lab tests and imaging studies based on the above

  • Review medication list

Always try nonpharmacologic measures first
Always Try Factors (insults)Nonpharmacologic Measures First

  • Presence of family members

  • Interpersonal contact and reorientation

  • Provide visual and hearing aids

  • Remove indwelling devices: i.e. Foley catheters

  • Mobilize patient

  • A quiet environment with low-level lighting

  • Uninterrupted sleep

Management hyperactive agitated delirium
Management: Hyperactive, Agitated Delirium Factors (insults)

  • Use drugs only if absolutely necessary: harm, interruption of medical care

  • First line agent:haloperidol (IV, IM, or PO)

    • For mild delirium:

      • Oral dose: 0.25-0.5 mg

      • IV/IM dose: 0.125-0.25 mg

    • For severe delirium: 0.5-1 mg IV/IM repeated q30 min until calm

      • Patient will likely need 2-5 mg total as a loading dose

    • Maintenance dose: 50% of loading dose divided BID

  • May use olanzepine and risperidone

    Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD05594

What about ativan lorazepam
What about Factors (insults)Ativan (lorazepam)?

  • Second line agent

  • Reserve for:

    • Sedative and ETOH withdrawal

    • Parkinson’s Disease

    • Neuroleptic Malignant Syndrome

Delirium in the elderly take home points
Delirium in the Elderly: Factors (insults)Take Home Points


Delirium in the elderly take home points1
Delirium in the Elderly: Factors (insults)Take Home Points

  • A multifactorial syndrome: predisposing vulnerability and precipitating insults

  • Delirium can be diagnosed with high sensitivity and specificity using the CAM

  • Prevention should be our goal

  • If delirium occurs, treat the underlying causes

  • Always try nonpharmacologic approaches

  • Use low dose antipsychotics in severe cases