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Delirium in the Elderly. Kirsten M. Wilkins, MD Assistant Professor of Psychiatry Yale School of Medicine VA CT Healthcare System. Case 1:.

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Delirium in the elderly

Delirium in the Elderly

Kirsten M. Wilkins, MD

Assistant Professor of Psychiatry

Yale School of Medicine

VA CT Healthcare System


Case 1
Case 1:

A 79 year old man with dementia, DMII, CAD, COPD, and acute renal failure but no other psychiatric history was admitted for pneumonia. After a 3 week hospital course complicated by delirium, hyponatremia, and UTI, he has been less agitated, more cooperative and more oriented for 2 days in association with decreased wbc and lessened oxygen requirements. You are consulted for acute suicidal ideation.

What initial plan would be best?

a. Assign a sitter (1:1), evaluate patient for antidepressant, provide supportive psychotherapy to address prolonged hospitalization

b. Assign a sitter (1:1), check urinalysis, do a chest x-ray, begin SSRI

c. Transfer to psychiatry for further care

d. Evaluate for a sitter (1:1), check urinalysis, do a chest x-ray, discuss with primary team


Case 1 discussion
Case 1 - Discussion

  • Answer = D: Evaluate for a sitter (1:1), check urinalysis, do a chest x-ray, discuss with primary team

  • Delirium must be ruled out first in this case…it offers more morbidity than depression in this setting and this patient is at higher risk for having delirium. Suicidal ideation is common in delirium. Adding an antidepressant may worsen the picture—better to wait 2-3 days to rule out delirium, as that delay will not greatly impact treatment of depression; but, misdiagnosing as depression may result in failing to search for the cause of the delirium.


Delirium
Delirium

  • DSM-IV-TR Criteria

    • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.

    • A change in cognition (memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance (i.e. auditory or visual hallucinations) that is not better accounted for by a preexisting dementia.


Delirium1
Delirium

  • DSM-IV-TR Criteria, cont.

    • The disturbance develops over a short time (hours to days) and fluctuates during the day.

    • There is evidence that the disturbance is caused by the direct physiological consequences of a general medical condition or substance.


Delirium2
Delirium

DELIRIUM IS ALSO KNOWN AS….

acute confusional state

acute mental status change

altered mental status

brain failure

hepatic encephalopathy

organic brain syndrome

toxic or metabolic encephalopathy


Delirium epidemiology
Delirium: Epidemiology

  • Prevalence depends on population

    • Greater in med/surg population

  • Community 0.4 - 2%

  • General hospital admissions ~20%

  • On admission 10 – 15% elders

    • During hospitalization up to 40%

  • At end of life up to 83%

    Trzepacz and Meagher 2005

    Saxena and Lawley 2009

    Fong et al 2009


Delirium epidemiology1
Delirium: Epidemiology

  • Higher rates seen with…

    • Post-op (ortho, cardiothoracic, vascular)

    • ICU admission

  • Poor functional recovery

  • Increased hospital lengths of stay

  • Increased likelihood of NH placement

    • Up to 60% NH pts have delirium

      Trzepacz and Meagher 2005

      Mittal et al 2011


Delirium impact
Delirium - Impact

  • Increased morbidity

    • Poorer recovery from medical illness

    • Increased need for walking devices

    • 6x increased risk of decubitus ulcers or aspiration pneumonia

  • Increased risk of future cognitive decline

  • 10-33% mortality rate in hospital

  • Increased risk of mortality even months after d/cFong et al 2009

    Siddiqi et al 2006


Case 2
Case 2:

  • Consult requested for 85 yo female with h/o dementia recently admitted to SNF, following hospitalization for hip fracture/repair , complicated by post-op infection. Pt noted by staff to be disoriented, “sundowning,” and resistant to care and PT. Per staff, family concerned that her dementia is “much worse” than before her surgery despite apparently successful surgery and resolution of her infection. Which of the following may explain her symptoms?

  • A) Opioid pain medications

  • B) Ongoing symptoms of delirium

  • C) New cognitive “baseline”

  • D) Old age

  • E) A, B, and C


Delirium risk factors
Delirium Risk Factors

  • Age

  • Preexisting dementia

  • Recent surgery

  • Bone fractures

  • Infections

  • Hypoalbuminemia

  • Preexisting CNS structural abnormalities


Delirium risk factors1
Delirium Risk Factors

  • Abnormal sodium

  • Severe illness

    • AIDS, Cancer

  • Polypharmacy

  • Dehydration

  • Visual/hearing impairment


Delirium risk factors2
Delirium Risk Factors

  • Substance Abuse

    • Alcohol

    • Prescription drugs

    • Illicit drugs

  • You must ask!

    • Collateral informant


Delirium presentation
Delirium: Presentation

Three types

Hyperactive

Better recognized

More attention to treatment

Associated with improved outcome

Hypoactive

Little recognized

Depression is primary differential

Associated with poor outcomes

Mixed


Delirium presentation1
Delirium: Presentation

  • Cognitive Symptoms

    • Inattention

    • Memory impairment

    • Disorientation

  • Behavioral Symptoms

    • Agitation or hypoactivity

    • Resistance to care

    • Sleep-wake disturbance

  • Psychiatric Symptoms

    • Paranoia, delusions

    • Hallucinations (often visual), illusions

    • Affective lability


Disrupted sleep wake cycle
Disrupted Sleep-wake Cycle

  • Insomnia

  • Napping

  • Being awake at night, limited light and external cues leads to disorientation and paranoia which may cause agitation

  • Caution with sedative medications due to concerns of worsening delirium


Affective lability
Affective Lability

  • Mood may fluctuate widely in a very short period of time (minutes/hours)

  • Anxiety/panic/fear/anger

  • Apathy/sadness - commonly mistaken for depression

  • Euphoria (esp. if steroid-induced)


Delirium differential diagnosis
Delirium:Differential Diagnosis

  • Dementia with Behavioral Disturbance

  • Psychotic Disorder (Schizophrenia)

  • Mood Disorder (Depression, Mania)

  • Catatonia

  • Others


Delirium versus dementia
Delirium versus Dementia

DELIRIUM

impaired memory +++

impaired thinking +++

clouding of consciousness +++

major attention deficit +++

fluctuation of course/day +++

disorientation +++

vivid perceptual disturbance ++

incoherent speech ++

disrupt sleep/wake cycle ++

nocturnal exacerbation ++

lack of insight ++

acute or sub acute onset ++

impaired judgment +++

DEMENTIA

+++

+++

-

+

+

++

+

+

+

+

+

-

+++


Delirium3
Delirium

Generally divided into 4 major types:

Delirium secondary to general medical condition

Delirium secondary to substance intoxication

Delirium secondary to substance withdrawal

Delirium secondary to multiple etiologies


Delirium4
Delirium

“Rarely is delirium caused by a single factor; rather, it is a multifactorial syndrome, resulting from the interaction of the vulnerability on the part of the patient (ie, predisposing conditions—cognitive impairment, severe illness, visual impairment) and hospital-related insults (ie, medications and procedures).” –Inouye et al 2007



Case 21
Case 2:

  • Consult requested for 85 yo female with h/o dementia recently admitted to the SNF, following hospitalization for hip fracture/repair , complicated by post-op infection. Pt noted by staff to be disoriented, “sundowning,” and resistant to care and PT. Per staff, family concerned that her dementia is “much worse” than before her surgery despite apparently successful surgery and resolution of her infection.

  • What initial plan would be best?

    • A) Send her to the ER

    • B) Review chart including medication list, talk to staff/family, physical and mental status exams

    • C) Begin routine haloperidol 0.5 mg TID for agitation

    • D) Begin lorazepam 1 mg with dinner for sundowning behaviors


Etiologies of delirium
Etiologies of Delirium

  • Urgent recognition

    • Wernicke’s

    • Hypoxia

    • Hypoglycemia

    • Hypertensive encephalopathy

    • Intracerebral hemorrhage

    • Meningitis/encephalitis

    • Poisoning/medications


Etiologies i watch death

I = Infection

W = Withdrawal

A = Acute Metabolic

T = Trauma

C = CNS Pathology

H = Hypoxia

D = Deficiencies (especially vitamin)

E = Endocrinopathies

A = Acute Vascular

T = Toxins

H = Heavy metals

Etiologies -“ I WATCH DEATH “


Etiologies of delirium1
Etiologies of Delirium

General Medical Conditions

HIV/AIDS

Orthopedic procedures (50%)

Infectious (UTI, Pneumonia, Sepsis)

Metabolic derangement

Cancer (PLE, brain mets—L, B, M)

Impaction, constipation, dehydration, many, many others…


Etiologies of delirium2
Etiologies of Delirium

  • Iatrogenic and polypharmacy

    • Anticholinergic medications

    • Opioids

    • Benzodiazepines

    • Steroids

    • Antihistamines

    • Antibiotics

    • Many, many others…


Delirium neurobiology
Delirium: Neurobiology

  • Best established neurotransmitter dysfunction: reduced cholinergic activity

  • Increased dopamine may also play a role

  • Low and excessive serotonin

  • Low and excessive GABA

    Trzepacz and Meagher 2005


Delirium neurobiology1
Delirium: Neurobiology

  • Direct injury to the neurons

    • Metabolic

    • Ischemic

    • Alters synthesis/release of neurotransmitters

  • Stress response

    • Trauma, surgery, infection  release of proinflammatory cytokines, elevated cortisol

    • Direct neurotoxic effects

    • Alters neurotransmitter levels

      Mittal et al 2011


Diagnosis of delirium
Diagnosis of Delirium

  • Delirium is a clinical diagnosis

  • History and physical examination (attention to VS)

  • Mental Status Exam

  • Rating Scales-consider on admission

    • Confusion Assessment Method

    • Delirium Rating Scale

    • MMSE/Clock


Diagnosis of delirium1
Diagnosis of Delirium

  • Lab tests cannot diagnose delirium but may support dx

    • CBC, CMP, UA, urine tox, TSH, B12, ammonia

    • CXR, EKG, LP if indicated

    • Neuroimaging

  • EEG

    • Generalized slowing in delirium, nonspecific

    • Triphasic waves in hepatic encephalopathy

    • Low voltage fast activity in EtOH or BZD w/d


Delirium management
Delirium: Management

  • Identification and reversal of cause is the definitive treatment

  • The search must be thorough, as in the diagnosis and treatment of any other organ system failure.

    • Delirium is brain failure!


Delirium management1
Delirium: Management

  • Monitor VS and I/O

  • Ensure good oxygenation

  • D/C nonessential medications

    • Minimize opioids, benzos, etc

  • Repeat PE, further lab, radiologic studies if cause not yet identified


Delirium management2
Delirium: Management

  • Behavioral/Environmental Strategies

    • Reorientation, calendars, clocks

    • Room near nursing station

    • Lights on/off during day/night

    • Windows

    • Family/familiarity

    • Hearing aids, glasses

    • Avoid restraints


Delirium management3
Delirium: Management

  • Pharmacological Therapy

    • Nothing FDA-approved

    • Antipsychotics are treatment of choice for agitation compromising care or safety

    • Haloperidol best studied, widely used

      • Virtually no anticholinergic effects

      • Virtually no hypotensive effects

      • Risk of EPS (akathisia), rare with IV route


Delirium management4
Delirium: Management

  • Pharmacological Therapy

    • Haloperidol

      • EPS rare when IV route used, however, IV route carries risk of QTc prolongationrisk of TdP

      • Risk greatest with higher doses over shorter periods of time, in pts with QTc >450

      • Monitor EKG and electrolytes (K, Mg)

      • Monitor for akathisia


Delirium management5
Delirium: Management

  • Antipsychotic Dosing in Elderly

    • Use clinical judgment depending on severity of symptoms for starting dose:

      • Haloperidol

        • 0.5mg mild

        • 1mg moderate

        • 2mg severe

    • Assess response to initial dose and repeat as needed, monitoring for effectiveness and adverse effects

    • Day one: order prn

    • Day two and beyond: assess total drug needed previous day and schedule that amount over the next day. Reassess daily continuing process until delirium resolves.

    • Once symptoms have remitted, continue effective dose for 48 hours, then slowly taper and discontinue over 1-5 days, depending on severity and duration of delirium up to that point. Avoid abrupt discontinuation after first day or two of mental clarity to avoid risk of rebound symptoms


Delirium management6
Delirium: Management

Atypical Antipsychotics

  • Risperidone 0.25-0.5 po bid prn

    • ODT available

  • Olanzapine 2.5 mg qhs

    • IM/ODT available

    • Caution: sedating, anticholinergic

  • Quetiapine 25 mg po bid prn

  • Limited data on aripiprazole, ziprasidone (concern for QTc prolongation)


Delirium management7
Delirium: Management

  • Cochrane Review 2007

  • Meta-analysis compared efficacy and adverse effects (3 trials included)

    • No difference in efficacy or adverse effects between low dose haloperidol and risperidone and olanzapine

    • High dose haloperidol (>4.5 mg/d) greater incidence of SE, mainly EPS

      Lonergan 2007


Delirium management8
Delirium: Management

  • Antipsychotics

    • Black box warning

    • Increased risk of death/CVAE’s in pts with dementia

    • Use judiciously, continue to reassess R/B ratio, taper when appropriate


Case 3
Case 3:

  • 70 yo male with no reported psychiatric history admitted for elective surgery. Doing well post-op until development of acute confusion, agitation, paranoia, trying to pull out lines and demanding to leave AMA. Exam reveals a diaphoretic, tremulous man with tachycardia and elevated BP. Which are part of the initial treatment plan?

    • A) Begin olanzapine 5 mg q4h routine for agitation

    • B) Transfer directly to psychiatry

    • C) Ensure safety of patient/staff

    • D) Obtain collateral information and history from family, review chart/meds, complete physical and mental status examinations

    • E) Initiate alcohol detox protocol with lorazepam

    • F) Check CMP, CBC, UA, urine tox, ammonia


Delirium management9
Delirium: Management

  • Pharmacological Therapy

    • Benzodiazepines

      • Primarily indicated in EtOH or benzodiazepine withdrawal delirium

      • Adjunct to neuroleptics in treatment of severe agitation

      • Lorazepam preferred given its reliable absorption from po/IM/IV routes

      • Generally avoided as may WORSEN delirium--especially hepatic encephalopathy


Prognosis
Prognosis

  • Variable

    • Full recovery (unlikely at time of hospital d/c in the elderly, may take several weeks)

    • Persistent cognitive deficits (new “baseline”)

    • Stupor, coma, death (the presence of delirium indicates a more serious medical illness, affecting the central nervous system)


Prevention
Prevention

  • 30-40% cases preventable

  • Risk factor intervention (Inouye 1999)

    • Standardized protocols for 6 risk factors:

      • Reduced incidence of delirium

      • Decreased total # of days and # of episodes

    • No difference in:

      • Severity of delirium

      • Recurrence of delirium

        Fong 2009

        Inouye et al1999


Conclusion
Conclusion

  • Delirium is common in the geriatric population

  • Dementia is a risk factor for delirium – patients frequently have both

  • Recognizing delirium, and distinguishing the syndrome from primary psychiatric conditions is critical

  • Delirium can present in a variety of ways and can be a result of a number of etiologies

  • Awareness of the hypoactive subtype of delirium is important – avoid confusing it with depression

  • Antipsychotic medications are useful in the management of symptoms of delirium; benzodiazepines are useful in cases of alcohol or benzodiazepine withdrawal, only.


References
References

Trzepacz PT, Meagher DJ. Delirium. In: Levenson JL, ed. Textbook of Psychosomatic Medicine. Arlington, VA: American Psychiatric Publishing, 2005:91-130.

Saxena S, Lawley D. Delirium in the Elderly: a clinical review. Postgrad Med J. 2009;85(1006):405-413.

Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5(4):210-220.

Mittal V, Muralee S, Williamson D, et al. Delirium in the elderly: a comprehensive review. Am J Alzheimer’s Dis Other Dement. 2011 Mar;26(2):97-109.

Siddiqui N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35(4):350-364.

Lonergan E, Britton AM, Luxenberg J. Antipsychotics for delirium. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005594. DOI: 10.1002/14651858.CD005594.pub2

Inouye SK, Bogardus ST Jt, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med. 1999;340(9):669-676.