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CHAMP Delirium Part 2: Evaluation & Management. Andrea Bial, M.D. University of Chicago. Goals. Develop a plan for teaching a Systematic Approach to the Evaluation of hospitalized older patient with delirium.

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champ delirium part 2 evaluation management

CHAMPDelirium Part 2:Evaluation & Management

Andrea Bial, M.D.

University of Chicago

goals
Goals
  • Develop a plan for teaching a Systematic Approach to the Evaluation of hospitalized older patient with delirium.
  • Develop a plan for teaching an appropriate Treatment Plan for the hospitalized older patient with delirium
overnight events morning rounds at the bedside
Overnight Events: Morning Rounds at the Bedside
  • 75yo W admit 2d ago w/ COPD, bronchitis
  • Intern reports: o/n she pulled out her IV, thought she was at home
  • X-cover ordered Prosom 1mg & po abx
overnight cont d
Overnight, cont’d
  • Currently, pt w/o c/o. Doesn’t recall events of previous night.
  • PE: sleepy, arouseable

37.6 148/62 88 20 93%2L

Lungs w/ faint wheeze bilat

Rest w/o change

Labs WBC 13.2, diff P; H/H stable

Na 133, BUN 26, Cr 1.2

overnight cont d5
Overnight, cont’d
  • A/P #1) COPD—cont nebs, steroids, po abx

#2) HTN—stable on meds

#3) Confusion—add risperdal 1mg QHS prn

#4) Disp—await PT/OT

systematic approach to the evaluation of delirium
Systematic Approach to the Evaluation of Delirium
  • No one “gold standard” approach
  • Multiple Mnemonics (e.g., Delirium) & algorithms
  • Need individualized, systematic approach to avoid missing potential causes
  • Few studies exist specifically looking at causes
evaluation of delirium causes
Evaluation of Delirium: Causes
  • Francis (1990)
    • Large teaching hospital
    • General medicine patients (n=229)
    • Delirium developed in 22% (n=50)
    • Determined cause(s) as: definite, probable, or possible
      • 18 (36%) w/ one definite cause

(Drug toxicity, then infection=fluid/lyte imbalance)

      • 10 (20%) w/ one probable cause
      • 22 (44%) w/ >1 cause; 62 possible etiologies (2.8/pt)
evaluation dementia teaching points
Evaluation: Dementia Teaching Points
  • Hx of dementia?
  • Hx of sundowning?
  • Agitated dementia ≠ delirium

4. Importance of considering dx:

DEMENTIA DELIRIUM

evaluation physical exam
Evaluation: Physical Exam
  • Head to toe:
    • Vitals (temp, HR, RR, BP, pulse ox, pain)
    • Head (CVA, bleed, meningitis, sz, blind, deaf)
    • Lung (pneumonia, PE, CHF)
    • Chest (ischemia, CHF, arrhythmia)
    • Abd (ischemia, impaction, bleed)
    • GU (UTI, retention)
    • Extrem (pain, volume status, CVA)
    • Skin (pressure ulcer, volume status)
evaluation head ct
Evaluation: Head CT?
  • No evidence to support routine ordering
  • Order if:
    • new focal finding(s) on exam
    • head trauma
    • suspicion of encephalitis
    • no other identifiable causes found
evaluation medication review
Evaluation: Medication Review
  • Too little (alcohol or other drug w/d)
    • Francis (1990) 1/50pts (2%)
    • Lawlor (2000) 4/71pts (6%)
  • Too much
    • narcotics, neuroleptics, anticholinergics, antiemetics

Francis 1990, Schor 1992, Lawlor 2000

evaluation medication list
Evaluation: Medication List
  • Antibiotics (aminogly, PCN, ceph, sulfa)
  • Benadryl
  • Benzodiazepines (triazolam, alprazolam, diazepam)
  • Digoxin
  • GI (Reglan, Bentyl)
  • Lithium
  • Narcotics
  • Neuroleptics
  • Steroids
  • NSAIDs (Indocin)
  • H2 Blockers (Cimetidine,…)
  • Parkinsons drugs (Levodopa, Benztropine, Amantadine)
  • Tricyclics
evaluation medication list15
Evaluation: Medication List
  • Antibiotics (aminogly, PCN, ceph, sulfa)
  • Benadryl
  • Benzodiazepines (triazolam, alprazolam, diazepam)
  • Digoxin
  • GI (Reglan, Bentyl)
  • Lithium
  • Narcotics
  • Neuroleptics
  • Steroids
  • NSAIDs (Indocin)
  • H2 Blockers (Cimetidine,…)
  • Parkinsons drugs (Levodopa, Benztropine, Amantadine)
  • Tricyclics
evaluation medications cont d
Evaluation: Medications, cont’d

Anticholinergic properties frequently overlooked:

Elavil (amitriptyline) Flexeril (cyclobenzaprine)

Cogentin (benztropine) Atarax/Vistaril(hydroxyzine)

Bentyl (dicyclomine) Welbutrin/Zyban (bupropion)

Ditropan (oxybutynin) Antivert (meclizine)

Detrol (tolterodine) Ipratropium (atrovent)

Benadryl (diphenhydramine) Phenergan (promethazine)

Zyprexa (olanzapine) Atropine

Levsin (hyoscyamine) Quinidine

evaluation additional tests
Evaluation: Additional tests
  • Labs
    • CBC, lytes, liver, renal
    • Consider TSH, B12, cortisol, ammonia, abg
  • Drug levels (digoxin, etc)
  • Urine tox, UA
  • CXR
  • EKG
  • EEG
evaluation eeg
Evaluation: EEG
  • Since 1950’s, recommendations for EEGs
  • Usually: generalized slowing
  • Sensitivity 75%
management non pharmacologic
Management: Non-Pharmacologic
  • Cognition: orientation board (carry pen!) & open drapes during day
  • Sleep: minimize deprivation (no 2am labs, no o/n BS/vitals if able, give meds when awake)
  • Mobility: OOBchair asap, PT/OT, no foley/restraints
  • Vision: glasses
  • HOH: get aids; adapt environment; stethoscope trick
  • Dehydration: po fluids; observe at mealtime; avoid “Boost at nightstand”
  • Observation: Involve family (rotate members) or get sitter; move pt to room close to RN station
management non pharmacologic restraint use
Management: Non-Pharmacologic Restraint Use
  • Avoid whenever possible
  • Increase risk of falls, injury, & delirium
  • Use only in emergency, for as short a duration as possible with frequent re-evaluations, and d/c asap
  • Absolutely no “sheeting”
management pharmacologic
Management: Pharmacologic
  • No RCT of treating delirium in hosp pt
  • Extrapolation from other populations studied (AIDS, NHs, outpatient AD, …)
  • See Table in handout
management pharmacologic antipsychotics
Management: Pharmacologic Antipsychotics

Typical: Haldol, (Chlorpromazine)

Advantages:min sedating

less ↓BP

Disadvantages: ↑ sz risk

more EPS side effects

↑ QT

↑ risk of Torsades

Dose: 0.25-0.5mg po, IM, IV

can repeat 30 mins x1, then q4h

t1/2=21h (10-38); peak 4-6h

(IV not FDA-approved; short duration of action)APA 1999

management pharmacologic antipsychotics cont d
Management: Pharmacologic Antipsychotics, cont’d

Atypical Antipsychotics

Advantages: less EPS

+/- sedation

Disadvantages: ↓ BP

weight gain

↑ BS

no evidence: short-term

↑mx (infection, CVS)

management pharmacologic antipsychotics cont d24
Management: Pharmacologic Antipsychotics, cont’d

Atypical Antipsychotic Doses:

Risperidone: 0.25-0.5mg po bid t1/2=20-30h

Olanzapine/Zyprexa: 2.5-5mg po qd t1/2=30 (21-54h)

Quetiapine/Seroquel: 25mg po bid t1/2=6h

(better in PD pts)

management pharmacologic benzodiazepines
Management: Pharmacologic Benzodiazepines

Used best in w/d of EtOH or benzo’s

(also consider use in PD, NMS)

Lorazepam 0.5-1mg po, IM, IV q4-6

t1/2=12h

(no adjustment needed for liver or renal dz)

management pharmacologic bottom line
Management: Pharmacologic Bottom Line
  • Try to avoid meds, but if needed:
    • Use Haldol in acute settings
    • Use risperidone for regular use (unless PD: quetiapine)
    • Use lorazepam for w/d
back to case
Back to case!
  • 75yo W admit 2d ago w/ COPD, bronchitis
  • Intern reports: o/n she pulled out her IV, thought she was a home
  • X-cover ordered Prosom 1mg & po abx
  • Currently, pt w/o c/o. Doesn’t recall events of previous night.
  • PE: sleepy, arouseable

37.6 148/62 88 20 93%2L

Lungs w/ faint wheeze bilat

Rest w/o change

Labs WBC 13.2, diff P; H/H stable

Na 133, BUN 26, Cr 1.2

  • A/P #1) COPD—cont nebs, steroids, po abx

#2) HTN—stable on meds

#3) Confusion—add risperdal 1mg QHS prn

#3) Disp—await PT/OT

teaching points
Teaching Points
  • Ask: What do you think caused last night’s events?
    • Was a h/o dementia missed?

(dementia/delirium relationship; role of MMSE;

further family hx)

    • Was her PE different at the time x-cover was called?

(systematic evaluation/head-to-toe)

    • Did we start or alter dose of any medications?

(nebs, steroids, abx)

teaching points cont d
Teaching Points, cont’d
  • Ask: Is she delirious now?
    • Discuss use of CAM

(comfort of tool; dx of delirium in chart)

    • Discuss outcomes of delirium

(increases: LOS, healthcare costs, mx, d/c to LTCF)

    • Discuss use of Prosom (and other benzo’s) in delirium
teaching points cont d30
Teaching Points, cont’d
  • Ask: Is there anything we should do today to follow-up on her confusion?
    • Discuss further studies that may or may not be needed

(CXR? UA? Repeat Na?)

    • Discuss the non-pharmacologic measures that should be put into place

(orient board, fluids, mobility, drapes, HS nebs & labs)

    • Discuss use of risperidone (and other antipsychotics) in delirium
recommended reading
Recommended Reading
  • Inouye SK. Delirium in older persons. NEJM 2006;354:1157-65
  • Schneider LS et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. NEJM 2006;355:1525-38.
  • Sink KM et al. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA 2005;293:596-608.
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