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DELIRIUM INOLDER PERSONSRobert Schwartz, MDSeptember, 2009 AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.
Delirium in Older Persons Thanks for visiting, dear! Organic mental disorder characterized by the acute onset of altered level of consciousness, and fluctuatingcourse and disturbance in orientation, memory, attention, thought, and behavior
Delirium: Fast Facts (1 of 2) • The most frequent complication among hospitalized elderly • 10%15% prevalence on admission • Hospital prevalence 20%50% (ward; even higher in ICUs) • Patients with delirium are twice as likely to be re-hospitalized (30% vs. 13%)
Delirium: Fast Facts (2 of 2) • Higher mortality: in hospital, at 90 days, and at 1 and 2 years • Longer length of stay by 714 days • Increases the risk of institutionalization at 6 months: 43% vs. 8% • Often unrecognized: half of patients • There is a continuumamong depression, delirium, dementia
COGNITIVE OUTCOMESAFTER AN ICU STAY • Cognitive abnormalities occur in 100% of ARDS patients at hospital discharge and 80% at 1 year (chronic delirium) • Neuropsych abnormalities found in 50% at hospital discharge after mechanical ventilation • Patients who demonstrate in-hospital delirium are more likely to go on to develop dementia
Age Severe illness (eg, MI, PE) Infection (any) Abnormal electrolytes Fever Dementia/cog impairment Drugs—narcotics/sedatives Liver/renal dysfunction Hypoxia Hypoalbuminemia Alcoholism Pain (untreated) Sleep deprivation Immobility Visual impairment Hearing impairment Dehydration Surgery DELIRIUM: PREDISPOSING FACTORS
A Model of Delirium (1 of 2) A multifactorial syndrome that arises from: Predisposing factors patient’s underlying vulnerability AND Precipitating factors noxious insults Insufficient functional reserve capacity of the brain to compensate for stresses “BRAIN FAILURE”
A MODEL OF DELIRIUM (2 of 2) Predisposing Factors/Vulnerability Predisposing Factors/Insults High Vulnerability Noxious Insult Severe dementia Major surgery Severe illness ICU stay Major depression Psychoactive medications Sleep deprivation Strong social supports High self-efficacy Low Vulnerability Less Noxious Insult JAMA. 1996;275:851.
Evaluation OF DELIRIUM • Good H/P & labs to look for risk factors • Special attention to medications (30% of cases are due to drugs) • Anticholinergics (tricyclics & diphenhydramine) • Sedative-hypnotics, narcotics • Any drug can be implicated!
Drugs and Delirium Am J Psych. 1992;149:1393.
DiagnosticTools • MiniMental State Exam • Not reliable in distinguishing delirium from dementia • Some utility in serial assessment • Confusion Assessment Method (CAM) • CAM-ICU
Acute change in mental status with a fluctuating course AND (2) Inattention (3) Disorganized thinking OR (4) Altered level of consciousness DIAGNOSIS: CONFUSION ASSESSMENT METHOD (CAM) PLUS Sensitivity: 94%100%; Specificity: 90%95% Ann Intern Med. 1990;113: 941-948.
DIAGNOSIS: CAM-ICU Ely 2002
Preventing Delirium • Treat pain: pain pyramid • Judicious use of medication: avoid any unnecessary prescriptions • Correct metabolic abnormalities: Vol, Na, K, Glu, O2 • Bowel and bladder: discontinue catheter • Post-procedure complications: MI, PNA, PE, UTI, Hct • Other: mobility, sensory, orientation, sleep, food
A Multicomponent Intervention to Prevent Delirium N Engl J Med. 1999;340:669-676.
Effect of a Prevention Intervention N Engl J Med. 1999;340:669-676.
Drug Trialsto Prevent Delirium • Pre-op and post-op use in high-risk patients • Donepezil: borderline effect in 1 study • Haloperidol: same incidence of delirium compared with placebo; shorter length of stay • New trials are ongoing
Delirium Evaluation Mnemonic • Drugs • Electrolyte imbalance • Lack of drugs (withdrawal) • Infection • Reduced sensory input • Intracranial process • Urinary retention • Myocardial infarction
Treatment of Delirium • Find and treat underlying cause • Non-pharmacologic management • Non-pharmacologic management • Non-pharmacologic management • Pharmacologic management (often a double-edged sword)
Non-pharmacologic Management(Always try first) • Avoid restraints (use sitters/family) • Mobilize if and however possible • Items from home (including family) • Glasses, hearing aids • Room with a view • Provide adequate nutrition/hydration • Attend to bowel and bladder function • Provide daytime clues, re-orientation • Promote appropriate sleep (less noise, lights, music, milk, no visitors at night) • Remove indwelling devices (eg, Foley catheters)
PharmacologicTreatment • Antipsychotics • Psychostimulants • Benzodiazepines
Risperidone (Risperdal) 3 prospective clinical trials (non-randomized) • All were small trials, 1028 patients • 80% effective • No difference compared with haloperidol J Am Med Dir Assoc. 2008;9:18-28.
Olanzapine (Zyprexa) Clinical trials • 2 included patients > 65 years • All had serious methodological problems • 50% improved; same as haloperidol (N = 22) • Olanzapine + haloperidol: significant improvement(N = 73)
Quetiapine (Seroquel) Clinical trials • 2 small trials (N < 22) • No randomization or control group
Conclusion: ANTIPSYCHOTIC Treatment of Delirium To date there are no randomized controlled trials clearly illustrating improvement in delirium symptoms with atypical antipsychotics American Psychiatric Association. Am J Psychiatry. 1999;156(5 suppl):1-20.
Atypical Antipsychotics:Class Concerns • Elevated glucose • 8-fold increase in CVD and death • Increased risk of stroke in elderly with dementia • Public health advisory by the FDA warned: Atypical antipsychotics increase mortality among patients with dementia • Risks may be similar with “typical” antipsychotics JAMA. 2005;294:1934-1943. N Engl J Med. 2005;353: 2235-2341.
Management: Hyperactive (Agitated) Delirium • Use drugs only if absolutely necessary: can do harm, interrupt medical care • First-line agent: haloperidol (IV, IM, or PO) • For mild delirium: 0.250.5 mg PO or 0.1250.25 mg IV/IM • For severe delirium: 0.51 mg IV/IM repeated q30min until calm • Evaluate for akathisia and extrapyramidal signs
Pharmacologic Treatment of Hypoactive Delirium Psychostimulants • Improve cognition and psychomotor activity • Methylphenidate 2.510 mg at 0700 and noon
What aboutlorazepam (ATIVAN)? • Second-line agent • Reserve for: • Sedation • Alcohol withdrawal • Parkinson’s disease; Lewy body dementia • Neuroleptic malignant syndrome • Dexmedetomidinesuperior in ICU? JAMA. 2009;301:489-499. JAMA. 2007;298:2644-2653.
Take-Home Points on Delirium: • A multifactorial syndrome: predisposing vulnerability and precipitating insults • Delirium can be diagnosed with high sensitivity and specificity using the CAM • Prevention is the goal • If delirium occurs, find and treat underlying causes • Always try nonpharmacologic approaches first • Use low-dose neuroleptics in severe cases • May be added to the list of “NEVER EVENTS”
Which of the following is the best way to diagnose delirium in the hospital? 1. DSM-IV-TR criteria 2. Mini-Mental State Exam 3. Clock-drawing test 4. CAM or CAM-ICU 5. Geriatric medicine consult 10
Which of the following has been shown in randomized controlled trials to reduce the incidence of delirium? • Proactive geriatric consultation • Haloperidol prophylaxis • Epidural vs. general anesthesia • Donepezil prophylaxis 10
Which of the following is unlikelyto be a risk factor for deliriumin a post-op patient? • Underlying dementia • Multiple chronic medical problems • Multiple prescriptions • Lorazepam for sleep • Urinary tract infection • Poorly treated pain • None of the above 10
Which of the following is nota common complicationassociated with delirium? • Higher 1-year mortality • Higher 30-day readmission rate • Hip fracture • Poor functional state at discharge • Decubitus ulcer • Hyponatremia • None of the above 10
Suggested Reading List • Inouye SK. Delirium in older persons. N Engl J Med. 2006;354:1157-1165. • Schneider LS, et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355:1525-1538. • Sink KM, et al. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA.2005;293:596-608.
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