A Confused Old Man

1. HKCEM College Tutorial A Confused Old Man Author Dr. E. Yuen Revised by Dr. wongcheunglunwilliam Oct, 2013

2. Triage note • 76 years old man • ‘Decrease GC?’ • BP 170/50 • HR 120 • RR 20, SaO2 97% on 2L O2 • GCS 14 (E4 V4 M6) • Temp 38°C

3. History • Brought in by Home helper • Notice ‘Not quite himself’ • Home helper left before attended by MO • No relative/ informant available • Pt talking nonsense & not answering questions Where else can you find more information about him?

4. History from CMS • COAD, DM & HT • Last admitted one month ago for pneumonia • Exercise Tolerance: 5 min level ground • Home Oxygen 1L/min • Drug History: • Adalat retard, Diamicron, Ventolin, Becloforte • Living alone • Meals-on-wheels from home help

5. What are the 3Ds for confusion in elders? Delirium (Toxins) Dementia (Degenerated brain) Depression (Psychiatric problems)

6. How do you evaluate the mental status ? • Appearance and behavior • Self caring ability • Mood and affect • Speech • Thought process • Delusion • Perception • Hallucination • Cognitive function • Orientation • Memory • Attention • Concentration • Insight What is the Mini-Mental State Exam?

7. Mini-mental state examination (MMSE) • Level of consciousness • Alert, Drowsy, Stupor, Coma, Fluctuating • Orientation • Time, Place, Person, Purpose • Memory • Short and Long term • Attention span and calculation • Serial 7 • Language ability • Dysnomia (name object) • Dysgraphia (writing) Most sensitive indicator of delirium • In Hong Kong (Chiu et al, 1994,1998) • Cut off 19/20 • illiterate: 18 or below • 1-2 years schooling: 20 or below • > 2 years schooling: 22 or below • In US & many western countries • 9+ education: MMSE≤23 : Cognitive impairment Cognitive impairment ≠ Dementia

8. Abbreviated Mental Test (AMT) • Consists of 10 simple questions • Age (±5 years) • Time (Nearest to hour, AM/noon/PM) • Address for recall at the end of test • Year (±1 year) • Place name • Recognition of two persons • Date of birth (day and month) • Date of mid-Autumn festival • Name of present Governor or Chinese leader • Count 20 -1 backwards • Cut off: 6, below 6 = cognitive impairment

9. Examination • Drowsy, Dehydrated, Urinary incontinence • NO sign of Head Injury or trauma • Temp: 38 oC • BP 170/50, HR 120, Normal Heart sound • Wheezy chest • Abdomen soft • No meningism • Unable to perform CNS exam

10. What are your Differential Diagnosis?

11. Cause of acute confusion – I WATCH DEATH Smith J, Seirafi J. Delirium and dementia. In: Marx JA III, Hockberger RS, Walls RM, eds. Rosen’s Emergency Medicine Concepts and Clinical Practices. 7th ed. Philadelphia, PA: Elsevier; 2010:1367–73.

12. Commonly prescribed drugs associated with delirium Agostini JV, Inouye SK. Delirium. In: Hazzard WR, Blass JP, Halter JB, et al, eds. Principles of Geriatric Medicine & Gerontology. 5th ed. New York, NY: McGraw-Hill; 2003:1503–15.

13. What tests would you perform?

14. Investigation • Hb 10.2, H’stix 16 • ECG: • Sinus Rhythm with RBBB • No ST segment change or new T wave abnormality • Urine multistix: • RBC 1+, WBC 4+, Protein -ve, Ketone 1+ • CXR: • Hyperinflated chest • No pneumothorax • No consolidation • Apical fibrosis

15. The likely diagnosis? • Delirium • Underlying urinary tract infection • Confused patient • Missed dose of DM/ HT drug • Not eating or drinking for 2 days

16. What is the immediate management? • Rehydration – Fluid resuscitation • Management of sepsis – Blood/Urine C/ST, Antibiotics • Relief bronchospasm – Inhale Ventolin • Admission for further stabilization

17. Acute Confusion in Elderly • Delirium (Toxic confusion) • Dementia (Organic confusion) • Depression (Psychiatric confusion)

18. Delirium “A disturbance of consciousness and a change in cognition that develops over a short period of time” American Psychiatric Association Acute onset or fluctuating course Transient cerebral dysfunction • Inattention • Altered level of consciousness • Disorganised thinking • Aggression, restless behaviour and hallucinations • Often worse at night Reversible decline in attention and cognition 3 Forms of Delirium Mixed Hypoactive Hyperactive

19. Delirium • Hyperactive form • Agitation, increased vigilance, hallucination • Hypoactive form • Lethargy and reduce psychomotor functioning • More common, underdiagnosed, poorer prognosis

20. Confusion Assessment Method (CAM) Diagnosis of delirium: 1 AND 2 plus either 3 OR 4

21. Management of Delirium • Admission usually required • Unless the cause is easily reversible • or the delirium abates in ED • Identifyand treat the precipitating cause(s) • Simple measures (frequently overlook) • Adequate lighting • Close monitoring with one-to-one support • ideally a family member or caregiver • A quiet environment to decrease sensory overload • Use of hearing aids/glassess

22. Management of Delirium • Elderly with hyperactive delirium • Chemical restrain may be required to complete the examination • Haloperiodol (0.5-1mg intramuscular) may be effective • Beware of QTc prolongation, elderly with ACS, decompensated CHF • Acute dystonic reaction • Lorazepam (1mg intramuscular/intravenously) • A prospective study revealed combination of both lorazepam and haloperidol appeared to be more effective during 1st hour of treatment • Beware of respiratory suppression (Flumazenil may be needed) • May cause further confusion, reduce attentiveness and impair orientation • Minimize the use of sedative medications • Risperidone (0.25 – 0.5mg oral) • Effective, with fewer extrapyramidal side effect

23. Dementia “A decline in intellectual function affecting memory and other cognitive functions which occurs in clear consciousness” • Prevalence • 5-10% above 65 years old, 20% above 80 years old • Increases with age, very rare below 55 • Mini-mental examination helpful • Disorder of cognitive function • Memory loss – Salient feature • Memory loss for recent events more severe than remote events • Confabulation may be present • Loss of intellect and Loss of insight but clear consciousness • Judgment and general knowledge impaired • Disorientation in time, place and person

24. Dementia • Language Problem • Word finding difficulties initially • May talk nonsense or incoherent, mute at late stage • Delusion and hallucination • May have paranoid ideas, delusion of theft • Behavior changes • Inappropriate behavior, distractibility, restlessness • Change in personality • Mood changes • Sleep and appetite disturbance • Impaired function • Physical and functional ADL

25. Dementia Causes • Alzheimer’s disease • The most commonest cause • Senile plaques and neurofibrillary tangles in the cortex • Subcortical reduction in neurotransmitters • Insidious in onset, with slow deterioration • Mean survival of 5 - 7 years • Multi-infarct dementia • 25% of cases • Multiple small strokes, sudden onset with stepwise deterioration

26. Dementia Causes • Other causes • Dementia with Lewy bodies • Chronic alcohol abuse • Jakob-Creutzfeldt disease • HIV infection • Anoxia - CO poisoning, post-cardiac arrest • Potentially reversible cause (10-15%) • Hypothyroidism • Syphilis • Deficiencies of thiamine, B12 and folate • Subdural Haematoma (SDH) • Normal pressure hydrocephalus

27. Management of Dementia • Admission for sudden deterioration in known demented patient • Inability to report somatic symptoms • Manifestation of disease may be atypical • Often suffered from multiple co-morbidity • Prevention of complications (infection/malnutrition/incontinence/delirium) • Definite new diagnosis of dementia • Seldom made in A&E • Frequently required admission for workup • Need to rule out reversible causes

28. Depression • May presented up to one third of older ED patients • Interfere the clinical presentation of acute medical disorders • May manifest with demanding & withdrawn behavior; hypochondria, difficulty to sleep and a loss of self interest. • Consider admission for those living alone, physically incapacitated, previous suicidal attempts

29. 3 Item Emergency Department Depression Screening Instrument(ED-DSI)

30. In general… History • Need reliable source of history e.g. family member • Baseline functional and cognitive • Temporal course of symptoms and signs • History of fall and head injury • New-onset of incontinence is a common presentation of delirium • Drug history • Medication is the single most commonest reversible cause of delirium • Past medical history

31. Examination • Evidence of trauma, dehydration • Autonomic instability • e.g. diaphoresis, tachycardia, fever …etc • Focal neurological signs • Mental status examination • Level of consciousness (AVPU, GCS, Fluctuating conscious level) • Orientation in time, place, person • Attention span • Memory, Speech • Thought content and process

32. Investigations • Blood glucose • CXR (for Pneumonia) • ECG (for ACS) • SpO2 • Renal function test • Dehydration and electrolyte disturbance • CT scan for focal CNS pathologies

33. Discharge an elderly only if • Go home safely • Cope with their daily living • e.g. cooking, shopping and dressing up • Medication • Understand existing and new medications • Caring issue • Their relatives and friends can cope with looking after them

34. If Not • Discharge is risky • Seek help from medical social workers • ‘Meals on wheels’, Emergency accommodations • Community nurses (CNS) • Services such as change of dressings and urinary catheters

35. Learning points • Remember the three categories of Confusion • Screening tools for Delirium, Dementia, Depression • History is especially important to ascertain the previous mental state • Rapidly identifiable causes include infection, drug effect and, metabolic causes • Must rule out Head Injury • Consider home & social condition before discharging

36. The end