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Delirious … You or the Patient?. Questions to ponder…. What risk factors are associated with delirium? What tools are available to assess delirium? What is the importance of diagnosing delirium? What is the appropriate workup?

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questions to ponder
Questions to ponder…
  • What risk factors are associated with delirium?
  • What tools are available to assess delirium?
  • What is the importance of diagnosing delirium?
  • What is the appropriate workup?
  • What medications are associated with confusion in the hospitalized older patient?
  • Can delirium be prevented?
  • Is delirium a marker for bad outcomes?
  • Once delirium occurs, can multitargeted strategies change the outcome?
  • Are medications useful for the management of patients with hyperactive or agitated delirium?
  • Is preventing delirium cost effective?
overview
Overview
  • Background and definition
  • Risk factors
  • Screening tools
  • Workup
  • Preventing delirium
  • Delirium as a marker of bad things to come
  • Treating delirium
    • Multitargeted strategies
    • Medications
definition and background
Definition and Background
  • DSM IV: reversible state of confusion with reduced level of consciousness manifest as inability to focus, sustain or shift attention
  • Acute confusional state
  • Acute onset, fluctuating course
  • Attention impairment
  • Up to 60% hospitalized elders
  • Often iatrogenic, often misdiagnosed
risk factors
Risk Factors
  • Advanced age
  • Underlying dementia/cognitive impairment
  • Acute medical illness
  • Alcohol abuse
  • Male gender
  • Depression
  • Malnutrition
  • Terminal illness
  • ICU stay (up to 80%)
iatrogenic risk factors
Iatrogenic Risk Factors
  • The things we do…
    • Physical restraints
    • Polypharmacy
    • Malnutrition
    • Other restraints…
      • Foley catheters
      • IV lines
      • Telemetry boxes
      • Oxygen tubing
screening or assessment tools
Screening or Assessment Tools
  • DSM IV definition
  • Serial MMSE
  • Confusion Assessment Method (CAM)
  • CAM-ICU
dsm iv definition
DSM –IV Definition
  • Acute confusional state associated with:
    • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
    • Change in cognition (memory impairment, disorientation, language deficits) or development of perceptual disturbance that is not due to underlying/established dementia
    • Development during hours/days with fluctuating course
slide9
MMSE
  • Pro: familiarity
  • Con: not specific (deficits may be due to underlying dementia, limitations due to low literacy level)
  • How to use: serial MMSE during hospital course; change in performance suggests delirium
confusion assessment method
Confusion Assessment Method
  • Quick and easy
  • Sensitivity 94–100%, specificity 90–95%
slide11
CAM
  • Acute onset and fluctuating course (history can beobtained from family/friends or staff)
  • Inattention (did the patient have difficulty keeping track of conversation?)
  • Disorganized thinking (was conversation rambling or incoherent, unclear, illogical or unpredictable?)
  • Altered level of consciousness (vigilant, lethargic, stupor, coma; anything other than “alert”)
disorganized thinking
Set A

Will a stone float on water?

Are there fish in the sea?

Does 1 lb weigh more than 2 lbs?

Can you use a hammer to pound a nail?

Set B

Will a leaf float on water?

Are there elephants in the sea?

Do 2 lbs weigh more than 1 lb?

Can you use a hammer to cut wood?

Disorganized Thinking
workup delirium is a marker
Workup: Delirium is a Marker!
  • Medication review
  • Labs: Na, glucose, ca, creat/BUN
  • Infection (UTI, pneumonia)
  • Hypoxemia
  • Neuroimaging for subdural
  • EEG
  • Sleep apnea
  • Pain (skin, urinary retention)
  • Myocardial ischemia
  • Alcohol or benzo withdrawal
  • Consider LP (arboviral infections/encephalitis in elderly!)
  • Review for underlying dementia
medications associated with delirium first think drugs
Medications Associated with Delirium: First Think Drugs!
  • General: anticholinergics and benzodiazepines!
  • Opioids (especially meperidine)
  • Tricyclic antidepressants
  • Antihistamines (DO NOT USE BENADRYL FOR SLEEP!!!!)
  • Anti-Parkinsonian meds: levodopa/carbidopa, amantadine, bromocriptine)
  • H2 receptor blockers
  • Antibiotics (ciprofloxacin)
  • Anticonvulsants
  • Prednisone
  • Clonidine
perioperative delirium
Perioperative Delirium
  • Orthopedic and vascular surgeries: 40–50% incidence
  • Vascular surgeries: associated with underlying hyperlipidemia, amputation, age over 65, depression
cardiac surgery and delirium
Cardiac Surgery and Delirium
  • Associated with delirium and persistent memory impairment
  • Microembolism, hypoperfusion, inflammatory responses
  • Highest risk: history of cerebrovascular disease, PVD, diabetes, cardiomyopathy, urgent operation, long surgery time, high transfusion requirement
  • CABG with “beating heart/off pump” technique associated with less delirium
preventing delirium can it be done
Preventing Delirium, Can It Be Done?
  • Inouye NEJM 1999
    • Randomized trial of 852 patients
    • Multicomponent intervention plan
    • Delirium developed in 9.9% intervention group vs 15% usual care group
    • Total number days with delirium: 62 intervention group, 90 in control group
    • NO DIFFERENCE in severity or recurrence of delirium once it developed: KEY IS PREVENTION
preventing delirium
Preventing Delirium
  • Recognizing patients at risk (screening high risk patient)
  • Avoiding risky medications
  • Close observation for infection
  • Family/friend involvement
  • Decrease isolation: hearing aids, glasses
  • Decrease sleep disturbances
  • Environmental cues (opening blinds…)
  • Avoiding restraints
  • Avoiding “restraints” (foley catheters, oxygen, IV fluids, telemetry boxes) that are not needed
  • Vigilance for withdrawal syndromes (benzo, ETOH, SSRI)
delirium bad things to come
Delirium, Bad Things to Come?
  • Observational data suggests that delirium associated with adverse outcomes including loss of independence, need for placement, cognitive decline, increased mortality
  • Problem: confounding… (those at highest risk for delirium are also the oldest and the sickest)
prognostic significance of delirium
Prognostic Significance of Delirium…
  • Prospective studies do demonstrate delirium and dementia being associated with decline in cognitive and functional status, even up to 12 months after hospital stay
  • Highest decline in patients with both dementia and delirium
can multi targeted strategies change outcomes of patients with delirium
Can Multi-targeted Strategies Change Outcomes of Patients with Delirium?
  • Lack of data
  • Several studies have failed to demonstrate a difference in patients with delirium treated with various strategies compared to “usual care”
    • Problem: “Hawthorne Effect”
    • Studies randomized, but “usual care” group likely benefited from presence of study itself
antipsychotic use
Antipsychotic Use
  • Commonly used… maybe too commonly
  • Care to ensure not missing underlying pain, urinary retention, psychiatric disorder, withdrawal syndrome, infection!
  • If used, use atypicals in very, very low dose!
  • Remember, no great data to support this use… so use care
  • Avoid benzodiazepine use (unless for withdrawal)
typical antipychotics
Typical Antipychotics
  • Haloperidol
    • Try to avoid
    • High risk of tardive diskinesia and EPS with long term use (over 50% in elderly)
    • If used, use low dose (0.5 mg), and limit to 1–3 days
    • Newer routes of atypical agents (IV, sublingual, IM) should make use of haloperidol in this setting obsolete
general risks of antipyschotics
General Risks of Antipyschotics…
  • Much less risk of EPS and TD with atypicals
  • Orthostasis
  • Sedation
  • Cardiovascular effects (QT prolongation)
  • Weight gain
  • Edema
risperidone risperdal
Risperidone (Risperdal)
  • Begin 0.25 mg – 0.5 mg, 1–2 times/day
  • Effectiveness at low doses in elderly (max 1–3 mg/day)
olanzepine zyprexa
Olanzepine (zyprexa)
  • 2.5– 5 mg
  • Sedation (usually started at night) with more anticholinergic side effects
  • Routes: PO or rapidly dissolving tablet (Zydis)
  • Link with weight gain and diabetes
quetiapine seroquel
Quetiapine (seroquel)
  • Start at 25 mg
  • Can rapidly increase up
  • Sedating, use at night
  • More commonly used longer term for behavior problems with dementia (limited EPS and TD effects)
ziprasidone geodon
Ziprasidone (Geodon)
  • Restricted use at UNC
  • IV form
  • 20–80 mg
  • Contraindicated with acute CV disease (nondose dependent QT prolongation)
clozapine
Clozapine
  • Great with underlying Parkinsonian symptoms due to little risk of increasing tremor
  • Significant rate of agranulocytosis
  • Restricted use
antipsychotic use1
Antipsychotic Use
  • FDA Black Box warning
  • Increased association with stroke and sudden death
  • Do not improve delirium; may increase LOS; likely just makes your delirious patient a more sedated delirious patient
  • May benefit a subset of patients with psychotic symptoms or aggressive behavior patterns
  • Chemical restraints
anticholinesterase inhibitors
Anticholinesterase Inhibitors??
  • Agents such as donepezil being studied
  • Observational data suggest benefit with behavioral disturbances with dementia
take home points
Take Home Points
  • Delirium is very common and often missed in hospitalized older patients (15% on a general medical unit, up to 50% undergoing surgeries)
  • Think drugs, lines, sleep deprivation, pain, infection
  • Think prevention!
take home points1
Take Home Points:
  • Avoid drugs such as benadryl for sleep!
  • Avoid benzodiazepines!
  • When using narcotics, stay with one narcotic and try to avoid agents such as darvocet
  • Prevent
  • Treat WITHOUT ADDING MORE DRUGS
  • Avoid antipsychotics!