DELIRIUM: Acute Confusion in the Elderly

1. DELIRIUM:Acute Confusion in the Elderly Donald R. Noll DO FACOI/ edited by Edward Warren, MD, Chair Geriatrics Carolinas Campus January 2012

2. Define delirium, diagnostic criteria, and its differential. List the manifestations and causes of delirium. Explain the concept of “brain failure” vis a visdeliriuim. Discuss the frequency and seriousness of delirium to patients. Recognize and diagnose delirium clinically. Prevent and treat delirium. Learning Objectives

3. There are many varied presentations and causes of delirium. The following slides cover a number of different common presentations. Delirium – many Presentations

4. An 85 year old woman comes to your office with vertigo. You diagnose benign positional vertigo and start meclizine. In the next 48 hours she develops progressive memory loss, confusion, hallucinations and can no longer take care of herself at home. Acute delirium 2° to medication Presentation 1

5. A 78 year old man with a history of hypertension and anxiety has a TURP done. He stays overnight because of somnolence after the anesthetic, so you hold the lorazepam. The next day, you are called to bedside because of acute shaking, agitation, fast pulse, and an elevated BP. Delirium 2° to lorazepam withdrawal Presentation 2

6. A 65 year old man with moderate dementia lives with his daughter. She leaves on a vacation, and he goes to stay with his son. During the first night, he has worsening of memory and increased confusion with agitation. Delirium 2° the stress of a new place Presentation 3

7. A 76 year old nursing home patient, debilitated from prior strokes, becomes anorexic, stops talking, and becomes lethargic. Work-up finds she has many bacteria and white blood cells in the urine and some supra-pubic pain. Delirium 2° to a UTI Presentation 4

8. A 70 year old man with no medical problems rushes out to shovel the new snow from the driveway, slips, falls, and fractures his hip. During the post operative period, he is confused, disorientated at times, especially at night. Confusion waxes and wanes. Delirium 2° to the surgery/hip fracture Presentation 5

9. Common One third of hospitalized patients have delirium, especially the elderly. Serious It has higher mortality rates, and slows recovery. Hospital mortality rate is 22 - 76% (as high as the rates for myocardial infarction or sepsis). One year mortality is 35 - 40%. Unrecognized 32 – 67% percent of cases are missed. Delirium Is...

10. 23% had delirium One week after admission, status of delirium 14% recovered 52% no change 22% better 12% worse Delirium was associated with significantly worse recovery in ADL’s and IADL’s A study of delirium in nursing homes (n=551) This study illustrates delirium is very common on rehab units and Skilled Nursing Units (where patients are often discharged to from acute care). Some get worse, some better, but it has a negative impact on recovery. Marcantonio ER et al. JAGS, Jan. 2003 Vol. 51, No. 1, page 4-9

11. A prospective, observational study of 2 cohorts, of patients  65 years old 243 patients with hospital delirium and 118 matched controls Adjusted hazard ratio 2.11, (C.I., 1.18-3.77) Effect stronger in patients without dementia Worse symptoms  higher mortality! Delirium Predicts 12 Month Mortality This study shows the effect of delirium on Mortality. Those who experience delirium are twice as likely to die in the next year, relative to those who don’t have it. The effect was more pronounced in persons without dementia. McCusker JM, et al. Arch. Intern Med. Vol.162, Feb 25, 2002. Pp. 457-463.

12. Delirium is an considered an acute condition, but it may take as long as four to six weeks for a patient to return to their previous cognitive baseline and make a full recovery. Many persons with underlying dementia, never return to their previous functional or cognitive level after an episode of delirium. If the underlying condition that is causing the delirium is not corrected, then the state of delirium can continue indefinitely, and become a “chronic” delirium. The duration of Delirium

13. Delirium Acute confusion Acute confusional state Metabolic encephalopathy Toxic encephalopathy Acute brain syndrome Brain Failure Terms for the same thing There are many terms for delirium, which may cause some confusion. These terms all refer to the same condition.

14. Clinical Characteristics of Delirium

15. Reduced ability to maintain attention to external stimuli attention wanders have to ask the question again Can not shift attention perseverates (repeats answer to prior question) Disorganized thinking, speech rambling, irrelevant, or incoherent Delirium: A Disorder of Attention

16. Reduced level of consciousness Perceptual disturbance (hallucinations) Disrupted sleep wake cycle Increased or decreased psychomotor activity Disorientation to time, place and person Memory impairment Delirium: Clinical Features (Usually at least two present)

17. Clinical features develop over a short period of time (hours to days) Clinical feature fluctuates of the coarse of the day waxes and wanes medical student sees in AM, doing well, then attending sees in afternoon, doing very differently Delirium: More clinical features(Acute, waxes/wanes)

18. The history, physical or lab tests will usually show some organic or medical cause No functional disorder, (bipolar disorder, schizophrenia) Delirium: More clinical features(History and Causation)

19. Disturbance of consciousness: can’t focus, can’t sustain, or can’t shift attention Change in cognition: memory, orientation, language or perceptual disturbance Disturbance develops over a short time and fluctuates History, physical, tests point to a physiologic cause DSM-IV Criteria for Delirium

20. Two Basic Types of Delirium An acute change in mental status (delirium), can present as an excited, hyper-sympathetic state (fast heart rate, tremors) or as an obtunded, sleepy patient, or as a mixture of both.

21. Types of Delirium

22. Key Concepts

23. Heart Failure + Stress = Brain Failure + Stress = Key to understanding delirium Delirium is analogues to heart failure. Given enough stress or metabolic demand, any heart or brain will fail to keep up with demand.

24. Heart Failure + Stress = Brain Failure + Stress = Heart/Brain Failure more likely to occur with baseline damage A damaged brain is much more vulnerable to failure. With Parkinson’s Disease, a closed head injury, or dementia, one is more likely to suffer delirium when exposed to a physiologic stress.

25. All Delirium is Multi-factorial

26. Animal studies and imaging studies show a deranged cortical glucose metabolism. Cerebral metabolic insufficiency is the underlying mechanism. After multiple cortical insults, “cortical reserves” are depleted, triggering global metabolic insufficiency. Pushed over the threshold. The metabolism/threshold model

27. Disturbances in cholinergic transmission is consistently implicated. Atropine induces delirium in animal models. The elderly have depleted acetylcholine Alzheimer’s patients have depleted acetylcholine. Anticholinergic medications induce delirium (other neurotransmiters also important). Cholinergic Model

28. Furosemide = 0.22 Digoxin = 0.25 Theophylline = 0.44 Cimetidine = 0.86 Ranitidine = 0.22 Nifedipine = 0.22 Warfarin = 0.12 Anti-cholinergic Effects in Atropine Equivalents

29. Common causes of delirium

30. Delirium in the Emergency Room Age > 70, Seventy-two consecutive cases; 2 reviewers 87.6% agreement. This study illustrates the types of causes of delirium seen in a typical ER. Note the diagnosis of delirium is somewhat objective, thus the 87.6% agreement between two reviewers – which is fairly good agreement. JAGS: Sept. 1999, 47;9,S10 (abstract A34)

31. Electrolytes (especially Na, K, Ca) Hyperglycemia or hypoglycemia Hypoxia or hypercapnea Liver or kidney failure Thyroid disorder Fever Metabolic or Endocrine

32. Pneumonia Sepsis UTI URI Infections

33. Anticholinergics Neuroleptics or tricyclic antidepressants Lithium Steroids Drug and alcohol withdrawal Drug Toxicity

34. Seizures: postictal states and electroconvulsive therapy Raised intracrainial pressure Head trauma Encephalitis, meningitis Vasculitis Central Nervous system insults

35. Treatment and Management

36. Treat the Cause

37. Low dose neuroleptics or new “atypicals” Haloperidol still the drug of choice Benzodiazipines another option Re-evaluate daily Supportive care (IV fluids if needed) Acetlycholinesterace inhibitors might help Management of Delirium

38. Avoid Restraints whenever possible, try the least restrictive measures. Restraints can exacerbate combativeness and agitation. Only use as a last resort, when agitation prevents vital therapy, like IV antibiotic and essential IV fluids. In managing delirium, you should… Keep them in a well lit room, at night keep a night light on. Avoid over-stimulation. It is helpful to have familiar people around, like family members to reorient them.

39. A large calendar and clock in the room Family/staff reorient patient frequently Familiar things (don’t move rooms) Glasses, hearing aids: Psychological management

40. Other than… Supportive care Address the cause Don’t exacerbate the delirium No medication or specific intervention has been shown to improve outcomes Treatment limitations

41. Delirium is common, serious and often overlooked. Disturbed consciousness, change in cognition, acute onset, fluctuating course. Remember “Brain Failure”. It usually is multi-factorial, many potential causes. Treat the cause and give supportive care. Conclusions

42. The End…