Champ delirium part 2 evaluation management l.jpg
This presentation is the property of its rightful owner.
Sponsored Links
1 / 31

CHAMP Delirium Part 2: Evaluation & Management PowerPoint PPT Presentation


  • 119 Views
  • Uploaded on
  • Presentation posted in: General

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.

Download Presentation

CHAMP Delirium Part 2: Evaluation & Management

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript


Champ delirium part 2 evaluation management l.jpg

CHAMPDelirium Part 2:Evaluation & Management

Andrea Bial, M.D.

University of Chicago


Goals l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Evaluation:Dementia Teaching Points

  • Hx of dementia?

  • Hx of sundowning?

  • Agitated dementia ≠ delirium

    4. Importance of considering dx:

    DEMENTIA DELIRIUM


Evaluation physical exam l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Evaluation: EEG

  • Since 1950’s, recommendations for EEGs

  • Usually: generalized slowing

  • Sensitivity 75%


Management non pharmacologic l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Management: PharmacologicAntipsychotics

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 l.jpg

Management: PharmacologicAntipsychotics, 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 l.jpg

Management: PharmacologicAntipsychotics, 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 l.jpg

Management: PharmacologicBenzodiazepines

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 l.jpg

Management: PharmacologicBottom 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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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.


  • Login