Management of Delirious States In The Elderly

1. Management of Delirious States In The Elderly George T. Grossberg, MD Samuel W. Fordyce Distinguished Professor Director, Geriatric Psychiatry Department of Neurology & Psychiatry Saint Louis University School of Medicine

2. Disclosure No relevant disclosures for this presentation.

3. Presentation Architecture • Defining delirium including screening, tools • Prevalence • Risk factors • Pathophysioloy • Treatment • Non-pharmacologic • Pharmacologic • Conclusions

4. Defining Delirium in the Elderly • Often called: acute confusion or acute cognitive/mental status change • Central features include: • Acute/dateable onset with fluctuating course • Disturbance of consciousness (drowsy for hyper-alert) • Inattention (problem focusing or maintaining/shifting focus) • Disturbance of sleep/wake cycle; perception; and thinking (disorganized, incoherent) • Reduced awareness of environment Ref: DSM – IV- TR- Am Psychiatry Association; 2000

5. Defining Delirium in the Elderly (cont.) • Acute onset (hours/ 1-2 days) vs. Subacute onset (days to weeks) • Delirium may be accompanied by psychosis (usually visual hallucinations) • Should always be assumed to be reversible until proven otherwise.

6. Prevalence of Delirium in Elderly • Varies according to population examined • In ICU – 70-87%1 • In hospital – 6-56% • Post-Op – 15-62% • Long-Term care – Up to 60% at some point during their stay2 Ref: 1. Fong TG, Tulebaev SR, Inouye SK.  Delirium in elderly adults:  diagnosis, prevention and treatment.  Nat Rev Neurol 2009. 2. Fann JR. The epidemiology of delirium. Seminars in Clinical Neuropsychiatry, 2000

7. Risk Factors for Delirium • Advanced Age • Pre-existing Cognitive Impairment • Increased number of medical co-morbidities • Increased medications Ref: Saxena S, Lawley D: Delirium in the elderly: a clinical review. Postgrad Med J 2009

8. Delirium Subtypes • Agitated / increased psychomotor activity – hyperalert – hallucinations – inappropriate behavior – 25-30% • Quiet/decreased psychomotor activity – apathetic, lethargic, withdrawn, often missed – 50-55% • Mixed delirium – fluctuates between agitation and quiet confusion • Normal psychomotor activity Ref: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

9. The CAM Features • Acute Onset and Fluctuating Course • Inattention • Disorganized thinking • Altered level of Consciousness Diagnosis requires presence of 1 and 2 and either 3 or 4 Ref: Inouye S, van Dyck C, Alessi C, et al. Clarifying confusion: the confusion assessment method.  Annals of Internal Medicine, 1990

10. Delirium in LTC – Assessment Pearls • CNA or housekeeping staff report that resident is not acting like her or himself (last 1-5 days) • Resident who was at least partly oriented is now acutely disoriented; distractible; disorganized in thinking/speech • Acute onset (1-5 days) of depression; or not eating; or of agitation • Sudden exacerbation of BPSD • Frequent napping, but arrousable • Inability to repeat 5 digit number – new onset Ref: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

11. Pathophysiology of Delirium • Not well understood • Reversible dysregulation of neuronal membrane function neurotransmitter alterations: • Acetylcholine deficiency • Dopamine increase • GABA/NE – less studied Ref: Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin, 2008.

12. Pathophysiology of Delirium (cont.) • Direct neuronal injury e.g. hypoxia, hypoglycemia • Inflammation – systemic • Stress response • Neuroanatomic changes – cortical atrophy, ventricular enlargement, white-matter lesions Ref: Mittal V, Muralee S, Williamson D, McEnerney N, Thomas J, Cash M, Tampi RR. Am J AlzheimersDis Other Demen. 2011 .

13. Treatment of Delirium Is Identifying the Cause: Treating It • Dehydration • Electrolyte imbalance; Endocrine; End-organ failure; ETOH; Electrical (Brain + Heart) • Lack of oxygen to brain – TIA/CVA, MI, PE, AF, COPD • Injury (hip fx; subdural); Impaction; Intestinal obstruction • Rule our other psychiatric disorders: mania, depression, psychosis, PTSD • Infection (urinary, pulmonary, cellulitis) • Urinary retention; unfamiliar environment • Medication – anticholinergics; benzos (intoxications withdrawal; Opiates; Malignancy) Adapted from Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

14. Treatment/Identifying Cause(s) of Delirium • Review of systems/ Head to Toe Approach • Ask: What has gone wrong acutely in this 85 y/o to upset the delicate cognitive equilibrium she/he was having • Always start with medication review including OTC, herbs, supplements. Focus on what has been recently started or dose increased • Always consider a UTI-early

15. Untreated Delirium In The Elderly • Increased mortality – 10-65% in hospital and 30% over 6 months in ER1 • In LTC- associated with increased mortality, hospitalization, risk of falls, increases caregiver burden, accelerated cognitive decline2 Ref: 1. Kakuma R, du Fort GG, Arsenault L et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 2003; 2. Gleason OC. Delirium. American Family Physician. 2003

16. Treatment of Delirium –Non-pharmacologic • Psycho-social environmental interventions are primary and include: • Bright light; massage/aromatherapy; soothing music (Snoezelen room); one-on-one monitoring, presence of family members; orientation via clocks/calendars; minimize physical restraints; address hearing/vision/sensory impairments; a quiet environment. Ref: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

17. Pharmacologic Treatment of Delirium • No FDA-Approved treatments • Mandatory if safety of patients or staff/family is an issue • Antipsychotics (PO or IM) are first line • Haloperidol (oral tablet/liquid, IM, IV) • 0.25 – 0.5 mg and 30 minutes to achieve sedation • Beware of EPS and akathisia • Risperidone (liquid/tablet) • 0.125 – o.25 mg and 30 minutes to achieve sedation Ref:1) Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment of delirium: a sys- tematic review. J Clin Psychiatry. 2007. 2)Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

18. Pharmacologic Treatment of Delirium (cont.) • Quetiapine (po) 12.5-25 mg qid –up to 200 mg/ day • Beware of sedation and orthostatis • Ziprasidone (IM) – 10-20 mg up to 80 mg /day • Beware QT prologation • Aripiprazole (IM) – 5-10 mg up to qid • Beware akathisia • Olanzapine (IM) 5-10 mg up to qid • Beware sedation With all antipsychotics “Black-Box Warning” in patients with dementia Ref:1. Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment of delirium: a sys- thematic review. J Clin Psychiatry. 2007. 2. Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

19. Outcomes of Delirium • Complete resolution (days to weeks) – usually in patients who are cognitively intact at baseline • Persistent delirium (weeks to months) – in those with cerebrovascular disease or end-organ failure; pre-existing cognitive impairment. • Delirium followed by progressive dementia – patient had subtle, undiagnosed, pre-existing dementia • Delirium causing dementia – controversial • Accelerated cognitive decline with pre-existing dementia Ref:1. Inouye SK. Delirium in older persons. NEJM 2006. 2. Inouye SK, Ferrucci L.  Elucidating the pathophysiology of delirium and the inter-relationship of delirium and dementia.  J Gerontol Med Sci. 2006.

20. Strategies To Reduce Risk of Delirium In LTC • Obtain pro-active geriatric consultation (Gero Psych, Geromed) for residents admitted for rehab from hospital or high-risk (cognitively impaired) patients • Decrease anti-cholinergic drugs • Decrease unnecessary meds • Monitor for UTI • Reduce indwelling catheters and restraints • Use interventions to prevent infections e.g. vaccines • Diagnose/treat dementias in their early stages • Reduce inactivity/immobility (walk 1-3x/day) • Treat depression and pain optimally Adapted from: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

21. Strategies To Reduce Risk of Delirium In LTC (cont.) • Institute sleep enhancing strategies/avoid sleep deprivation • Treat hearing/vision impairment • Improve hydration/nutritional status • Daily cognitive stimulation • Provide written daily schedule/orientation strategies • Continuous activity programming – prevent boredom • Encourage residents to stay out of bed and encourage self-care Adapted from: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

22. Conclusions • Delirium is common in the elderly and is associated with increased morbidity and mortality • Prompt diagnosis, through evaluation and appropriate treatment of delirium is crucial • Prevention strategies may be useful