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Delirium: An Update

Delirium: An Update. Prof. Brian Kelly John Hunter Hospital School of Medicine and Public Health University of Newcastle. Objectives. Undertake a clinical assessment focussing on history and mental state signs of delirium Undertake assessment of cognitive function

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Delirium: An Update

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  1. Delirium: An Update Prof. Brian Kelly John Hunter Hospital School of Medicine and Public Health University of Newcastle

  2. Objectives Undertake a clinical assessment focussing on history and mental state signs of delirium Undertake assessment of cognitive function Be able to differentiate delirium from other common clinical syndromes Formulate a management plan that includes - risk factors to delirium - appropriate investigations - behavioural interventions - pharmacologic treatments

  3. MR ES • 78 year old man • Wandering his home and neighbourhood at night • Believes home is being “bugged” and suspicious that wife wants to harm him • Brought to ED by ambulance

  4. Past history • Chronic Obstructive Pulmonary Disease • Ischaemic Heart Disease • Recent prostatectomy for BPH • Depression

  5. Which of the following clinical features would be most likely to indicate the presence of delirium • Sleep disturbance • Irritability and restlessness • Rapid onset of symptoms • Poor memory

  6. What is “Delirium”

  7. Delirium • A “syndrome of cerebral insufficiency” (Engel & Romano) • ‘Acute Brain Failure’ (Lipowski) • Acute confusional state/ Acute Organic Brain Syndrome

  8. Delirium: Current Concepts • Pathophysiologicmechanisms • reduction in cerebral metabolism • altered function of neurotransmitters • Acetylcholine, DA, GABA, NA, 5-HT • false neurotransmitters (eg hepatic failure) • pro-inflammatory agents (eg cytokines)

  9. Delirium: Clinical Features • A transient organic brain syndrome • acute onset and fluctuating course • altered level of consciousness • reduced attention and concentration • global impairment of cognitive function

  10. Subtypes • Hyperactive • Agitation, irritability • Restlessness • Distractibility • “hyperarousal” • Hypoalert/hypoactive • reduced reactivity • motor and speech slowing • withdrawal • Mixed states (most common) (>70%) De Rooij et al, In J Geriatr Psychiatry, 2005; 20: 609-15 Caraceni & Simonetti, Lancet Oncology, 2009, 164-172

  11. Which of the following is the best indicator of the presence of delirium? • Hallucinations • Agitation and irritability • Restlessness • Poor concentration • Definable organic cause

  12. Signs Cognitive signs • Attention 97% * • Memory 89% • Orientation 76% • Language 57% Non-cognitive • Sleep-wake cycle disturbance 97% * • Psychomotor changes 62% Psychotic Symptoms • Delusions 30% • Hallucinations 50% Meagher et al, Br J Psychiatry, 2007, 190, 135-141

  13. Best indicators of severity • Signs • Cognitive signs • Attention 97% * • Memory 89% • Orientation 76% • Language 57% • C’hension 39% * • Non-cognitive • Sleep-wake cycle disturbance 97% * • Psychomotor changes 62% • Psychotic Symptoms • Delusions 30% • Hallucinations 50% Meagher et al, Br J Psychiatry, 2007, 190, 135-141

  14. Other Clinical Presentations • “non-compliance” and denial • anxiety and panic • “crescendo pain” • “adjustment problems” • suicidal ideation and actions • depression • staff and family conflict Breitbart & Alici, 2010; Akechiet al,1999; Farrell & Ganzini,1995

  15. Screening and Diagnosis 1. Screening Instruments Confusion Rating Scale Clinical Assessment of Confusion Nursing Delirium Screening Scale (Mini-Mental State Examination) 2. Diagnostic Instruments Confusion Assessment Method Delirium Symptom Interview 3. Delirium Severity Rating Scales Delirium Rating Scale Memorial Delirium Assessment Scale

  16. Acute onset and fluctuating course AND Inattention + either Disorganised thinking Altered level of conciousness

  17. Table 1 Differentiating features of conditions that mimic delirium Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatmentNat Rev Neurol doi:10.1038/nrneurol.2009.24

  18. Prevalence • 10-30% of hospitalized medically ill patients • 25% hospitalized cancer patients • 30-40% hospitalized patients with AIDS • 80% of patients with terminal illness

  19. Delirium • higher risk groups: • hip fracture • surgery • CNS lesion • burns • dialysis • dementia

  20. Delirium • Etiologic Factors • primary cerebral disease • systemic disease with secondary affect on brain function (eg hypoxia, hyponatraemia, infection) • exogenous substance • substance withdrawal

  21. Predisposing factors • Sleep Deprivation • Immobility • Visual and/or hearing impairment • Dehydration • Malnutrition • Hypoxia • Poor functional status • Cognitive impairment Caraceni & Simonetti, Lancet Oncology, 2009, 164-172

  22. Caraceni &Simonetti, Lancet Oncol, 2009; 10:164-72

  23. Figure 1 Relationships between various etiological factors in delirium Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatmentNat Rev Neurol doi:10.1038/nrneurol.2009.24

  24. Majority of patients have 3 or more contributing factors • 50% or more have a reversible component • Metabolic • Infective • Drug-related Meagher et al, Br J Psychiatry, 2007, 190, 135-141 Caraceni &Simonetti, Lancet Oncol, 2009; 10:164-72

  25. Impact • Poorer patient outcomes • Mortality • Prolonged hospitalisation • Adverse events (inc safety, suicide) • Costs of care (↑ x 2.5) • Post-delirium psychological distress • Communication, decision-making, symptom management • “Mental awareness” • Family and staff • >70% report severe distress relating to delirium Leslie et al, Arch Int Med, 2008, 168: 27-32 Gagnon et al, J Pall Care, 2002, 18: 253-261 Steinhauser et al, JAMA, 2000; 284: 2476-2482

  26. Patients • 50-75% distressing recall of symptoms • both hypo- and hyper-active delirium • Family • Strongest mediator of caregiver anxiety • Conflict with clinicians Bruera et al, Cancer, 2009; 115: 2004-12 Buss et al, J Pall Med, 2007; 10: 1083-92 Breitbart et al,Psychosomatics,2002;43:183-94

  27. What is the recommended treatment?

  28. Treatment • Standardised assessment and monitoring • Improve recognition • Risk factors (eg prior cognitive impairment, alcohol use) • Early onset of delirium • Standardised management • identify and address underlying causes** • Prevent delirium related complications (incl safety) • Patient support and information • Family , carer and staff needs APA Practice Guidelines (1999) Meagher et al, BMJ, 322: 145-149

  29. Interventions • Research findings support: • Discontinuation of unnecessary psycho-active medication • attention to hydration • change of opioid or dose modification • use of antipsychotic drug if needed • Use of environmental interventions

  30. Drug treatments √ Antipsychotic agents • Haloperidol (0.5-2mg; 2-12 hr) • Olanzapine (2.5-5mg; 12-24hr) • Risperidone (0.25-1mg; 12-24hr) X Benzodiazepines** X Anticholinesterase inhibitors X Psychostimulants ** hepatic encephalopathy, benzodiazepine and alcohol withdrawal Overshott et al, Cochrane Database of Systematic Reviews, 2008:1 Lonergan et al, Cochrane Database of Systematic Reviews, 2007:2

  31. Table 3 Pharmacological therapy for delirium Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatmentNat Rev Neurol doi:10.1038/nrneurol.2009.24

  32. Antipsychotic treatments in delirium • Low dose haloperidol (<3mg per day) • Haloperidol = Atypical APDs (egolanzapine, risperidone) • High dose haloperidol (>4mg per day) • Haloperidol < Atypical APDs Lonergan et al, Cochrane Database of Systematic Reviews; 2007;2.

  33. Determinants of drug choice/dose • Route of administration • Symptom profile • Hyperactive - ?olanzapine • Hypoactive- ? Haloperidol • Adverse effects eg EPS • NB Staff factors Hui et al, JPSM, 2010, 39:186-196

  34. Caregivers • Note adverse impact on bereavement outcomes • Patient agitation and incoherence • Decision-making • Benefits of interventions with caregivers • Information, explanation, emotional support • Improved confidence • Lowering of distress • Improvement in decision-making Morita et al, JPSM, 2006 Gagnon et al, J Pall Med, 2002

  35. The patient’s experience of delirium • effect on adaptive and cognitive capacity • “Mental awareness” • Involvement in decisions • Understanding illness and “being prepared” • effect on communication of symptoms • effect on patient’s key relationships • distressing recall of delirium Steinhauser et al, JAMA, 2000; 284: 2476-2482 Breitbart et al, Psychosomatics, 2002;43:183-184

  36. Specific populations • Children and adolescents • Limited research • Focus on hyperactive delirium • Special considerations • Pre-existing chronic mental illness (eg schizophrenia) • Pre-existing cognitive impairment (eg dementia) Viron & Stern, Psychosomatics, 2010; 51: 458-65 Hatherill & Flisher, J Psychosom Res, 2010; 68:337-44

  37. Prevention • primary • identify risk groups • Age • Prior CNS disease • Substance use • enhance environment • modify causative factors (eg drug treatment practices) • Address sensory impairments (eg hearing, vision) • Maintain mobility • secondary • early identification through cognitive monitoring • early intervention - identify key early symptoms (eg sleep disturbance, agitation, irritability, somnolence) • Identify and address precipitants (eg hydration)

  38. Prevention • Studies in elderly peri-operative prevention • HPD 1.5 mg per day (1-3 days pre-; 3 days post-op) ↓Delirium incidence, severity and duration ↓ Duration admission Kalisvaart, J Am Geriatr Soc. 2005 Oct;53(10):1658-66.

  39. 400 pts > 65 yrs 5mg Olanzapine pre- and post op. ↓ Incidence No difference in severity/duration Larsen et al, Psychosomatics, 2010, 51: 409-18

  40. Conclusion • Delirium • common clinical syndrome • significant impact on patient, family and staff • interwoven with often complex clinical and ethical issues • Opportunities for prevention • Need for standardised assessment and monitoring • Patient and family support and information needed

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