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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

AND

3. Disorganized thinking

or

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

AND

  • Precipitating factors noxious insults
predisposing factors i e baseline underlying vulnerability
Predisposing Factorsi.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 Factorsi.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
  • 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: 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

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

a multicomponent intervention to prevent delirium
A Multicomponent Intervention to Prevent Delirium

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

keys to effective management
Keys to Effective Management

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 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
  • 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 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: Take Home Points

AVOID RESTRAINTS AT ALL COSTS:Measure of LAST(!!!) resort

delirium in the elderly take home points1
Delirium in the Elderly: 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
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