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Delirium in the Elderly

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Slide 1 :

Delirium in the Elderly Bree Johnston MD MPH UCSF Division of Geriatrics Primary Care Geriatric Lectures

Slide 2 :

Case Study Mrs. M. is a 70 year old woman with a history of thalamic CVA, bipolar illness, chronic pain, and osteoarthritis. She takes tylenol with codeine, valproate, lithium, conjugated estrogens with progesterone, and aspirin. Two months ago, her daughter died unexpectedly, and she has been more depressed. One week ago, she became agitated and uncooperative. She was seen in the ER, where labs and CXR were normal. A consulting psychiatrist recommended clonezapam.

Slide 3 :

Despite the clonazepam, she worsened, and became uncontrollable at home. She went back to the ER, where she had a fluctuating level of consciousness. CBC, renal panel, and CXR were normal. An EKG showed a LBBB (old) with slight ST changes from last EKG. Troponin level was 2.9. On further questioning, the patient admitted that she has some shortness of breath 5 days prior. The admitting team concluded that her delirium was due to ischemia/infarction. She was treated with aspirin and beta blockers and did well. A persantine thallium showed a large fixed inferior defect and no reversible disease.

Slide 4 :

Presentation of MI in the Elderly AGE # CP SOB Neuro >65 387 19% 20% 33% 74 87 59% 22% 16% 76 777 66% 42% 30% >62 110 22% 35% 18% Pathy 1967 Tinker 1981 Bayer 1986 Aronow 1987

Slide 5 :

Atypical Presentations “Well Elderly” “Frail elderly” % with atyp. present 25% 59% Type of Presentation Delirium 32% 61% Falls 37% 9% Immobility 5% 6% Functional decline 26% 19% Other 0 5% Jarrett et al. Arch Int Med 1995

Slide 6 :

Learning Objectives Recognize that delirium is a common presentation of disease in the elderly Recognize that delirium is associated with adverse outcomes Know how to distinguish between delirium and other diagnoses (dementia, depression) Identify risk factors for delirium and strategies for risk reduction Discuss management strategies, recognizing the limitations of current data

Slide 7 :

Definition “an acute disorder of attention and cognition” (de lira “off the path”) Standard definition not use until 1980 with publication of DSM III Other terms used include organic brain syndrome, metabolic encephelopathy, toxic psychosis, acute mental status change, exogenous psychosis, sundowning

Slide 8 :

Prevalence Schor 1992 Medical & surgical >65 N=325 11% Prevalence, 31% incidence Johnson 1990 Medical >70 N=235 16% prevalence, 5% incidence Francis 1990 Medical >70 N=229 16% prevalence, 8% incidence Gufstafson 1988 Femoral neck Fx >65 N=111 33% prevalence before surgery, 42% incidence after srugery

Slide 9 :

Pathophysiology Nonspecific manifestation of a widespread reduction in cerebral metabolism & derangement of neurotransmission due to: Cholinergic deficiency GABA Dopamine NE Specific receptors ( e.g., steroid) Alteration of blood flow, inflammation

Slide 10 :

Delirium Risk Factors Age Cognitive impairment 25% delirious are demented 40% demented in hospital delirious Male gender Severe illness Hip fracture Fever or hypothermia Hypotension Malnutrition High number of meds Sensory impairment Psychoactive medications Use of lines and restraints Metabolic disorders: Azotemia Hypo- or hyperglycemia Hypo- or hypernatrmiea Depression Alcoholism Pain

Slide 11 :

Delirium Risk Model Baseline Risk Group Precipitating Factor Group Incidence of delirium per day Inouye JAMA 1996 Patient Factors + Extrinsic Factors

Slide 12 :

Surgical Prediction Rule Alcohol abuse 1 TICS score < 30 (dementia ) 1 SAS Class IV (severe impairment) 1 Abnormal pre-operative Na, K, glucose 1 A3 surgery 2 Noncardiac thoracic surgery 1 Age > 70 1 Marcantonio et al. JAMA 1994 134-139

Slide 13 :

Clinical Prediction Rule for Post-surgical Delirium Total Points Risk of Delirium (incidence, validation cohort) 0 2 1 or 2 11 3 or more 50 Marcantonio et al. JAMA 1994 134-139

Slide 14 :

Outcomes Death: 8% vs. 1%, 90 day mortality 11% vs. 3% Lengthened hospital stay: 12 days vs. 7 days Increased nursing home placement: 16% vs. 3% Functional decline Iatrogenesis Francis J et al. JAMA 1990;263:1097. Levkoff SE et al. Arch Intern Med 1992;152:334 Pompei et al. JAGS 1994; 42: 809

Slide 15 :

Does delirium worsen outcomes, or is it just a marker of poor outcomes? Does delirium itself worsen cognitive outcomes? Will drug treatment of delirium improve outcomes? Are some drugs better than others? Are sitters better than drugs?

Slide 16 :

Differential Diagnosis CNS pathology Dementia, particularly frontal lobe Other Psychiatric disorders Psychosis Depression: 41% misdiagnosed as depression Farrell Arch Intern Med 1995 Bipolar disorder Aconvulsive status epilepticus Akathisia Overall, 32-67% missed or misdiagnosed

Slide 17 :

Diagnosis DSM-IV A. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. B. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. C. The disturbance develops over a short period of time and tends to fluctuate during the course of the day D. There is evidence from the history, PE, or labs that the disturbance is caused by the direct physiologic consequences of a general medical condition

Slide 18 :

CAM (Confusion Assessment Method) 1. Acute change & fluctuation in mental status and behavior AND 2. Inattention AND EITHER 3. Disorganized thinking OR 4. Altered consciousness (not alert) Inouye SK et al. Ann Intern Med 1990;113:941-948.

Slide 19 :

Diagnostic Tools Sensitivity Specificity CAM* .46-.92 .90.92 Delirium Rating Scale* .82-.94 .82-.94 Clock draw .87 .93 MMSE (23/24 cutoff) .52-.87 .76-.82 Digit span test .34 .90 *validated for delirium & capable of distinguishing delirium from dementia

Slide 20 :

Diagnosis MMSE & Clock draw -Not designed for delirium -Useful at separating “normal” from “abnormal” -Not specific for distinguishing delirium from dementia -May be useful as change from baseline

Slide 21 :

Delirium versus Dementia Delirium Rapid onset Primary defect in attention Fluctuates during the course of a day Visual hallucinations common Often cannot attend to MMSE or clock draw Dementia Insidious onset Primary defect in short term memory Attention often normal Does not fluctuate during day Visual hallucinations less common Can attend to MMSE or clock draw, but cannot perform well

Slide 22 :

Medications and Delirium Sedative-hypnotics, especially benzos Narcotics, especially meperidine Anticholinergics Miscellaneous Lidocaine -Propranolol Amiodorone -Digoxin H2 Blockers -Lithium Steroids -Metoclopromide NSAIAs -Levodopa Consider any drug a possible cause

Slide 23 :

Searching for the cause History and PE (consider possible urinary retention & PVR, impaction) Discontinue or substitute high risk meds Labs: CBC, lytes, BUN, Cr, glucose, calcium, LFTs, UA, EKG And if those don’t tell you, consider: Neuroimaging CSF Tox screen, thyroid, B12, drug levels, ammonia, cultures, ABG EEG - in difficult cases to r/o occult seizures or psych disorders - 17% false neg, 22% false pos

Slide 24 :

103 treatment and 111 controls Intervention: Surgery as soon as possible & geriatric evaluation pre and post op vs usual care Outcomes Treatment Control Severe Confusion 7% 30% Confusion 48% 61% LOS 11.6 days 17.4 days Gustafson et al JAGS 1991 Can Interventions Prevent Delirium?

Slide 25 :

Possible Benefit From: Preoperative psychiatric assessment followed by nursing reorienation (33% vs 14%) Postoperative reorienation (87% vs 6%) Preoperative education about delirium (78% vs. 59%) Pre and post operative psychiatric intervention (13% vs 0) British J. Psych 1996 512-515 Can Med Ass J 1994 965-70 Nurs Res 1974 341-348 Res Nurs Health 1985 329-337

Slide 26 :

Can Interventions Prevent Delirium? 852 patients aged 70+ Prospective matching of patients on intervention unit with patients on 2 usual care units Risk factor reduction strategy targetting: cognitive impairment sleep deprivation immobility visual impairment dehydration

Slide 27 :

Intervention Protocol Cognition Orientation, activities Sleep Bedtime drink, massage, music, noise reduction Immobility Ambulation, exercises Vision Visual aids and adaptive equipment Hearing Portable amplifiers, cerumen disimpaction Dehydration BUN, volume repletion Inouye NEJM 1999

Slide 28 :

Results Study Control Any episode 9.9% 15% p=0.02 OR .6 # episodes 62 90 p=0.03 Delirium days 105 161 p=0.02 Inouye NEJM 1999

Slide 29 :

Preventing Delirium post Hip fracture RCT of 126 patients Intervention: “Proactive” Geriatric Consultation with Daily Visits and structured protocols Control Group: Management by orthopedist + consultation on as-needed basis Outcomes: MMSE, delirium, LOS Marcantonio, JAGS 2001

Slide 30 :

Protocols for: Fluid/electrolytes Pain treatment Eliminating unnecessary medications Bowel/bladder function Nutrition Mobilization CNS oxygenation Prevention of complications (MI, PE, UTI, pneumonia) Environmental stimuli Treatment of agitated delirium Marcantonio, JAGS 2001

Slide 31 :

Delirium in Hip fracture Marcantonio JAGS 2001

Slide 32 :

Interventions that May Help Eliminate extra meds, reverse metabolic abnormalities, hydration, nutrition Geriatric consultation? Education of patients and family Re-orientation by staff, family, sitters, clocks, calendars Remove nonessential lines and tubes Quiet, noninterrupted sleep at night Stimulation (but not too much) during day Discharge home?

Slide 33 :

Drug therapy All drug therapy has side effects Use only if delirium interfering with therapy, or risking patient’s or others’ safety and welfare Almost no data on outcomes in drug treated versus non drug treated patients No good RCTs Approach based on case reports and expert opinion

Slide 34 :

Drug Therapy of Delirium One small RCT of neuroleptics vs. benzos in AIDS associated delirium/dementia found higher SE’s with benzos Improved outcomes with neuroleptics (N=67) Small sample, generalizability uncertain Breitbart et al Am J Psych 1996 231-237

Slide 35 :

Neuroleptics Considered agents of choice for most cases of delirium RCTs in agitation and dementia suggest benefit (NNT = 5) Side effects can include extrapyramidal SE’s, hypotension, sedation, akathisia Sedation effect before antipsychotic effect Haloperidol, droperidol Atypicals: Respiridone, olanzapine

Slide 36 :

Use of Haloperidol Lowest possible dose, e.g., .5-1.0 BID tapering down as delirium clears 0.5mg, repeat every 30 minutes until agitation is controlled Some advocate doubling of dose every 30 minutes until agitation is controlled (probably not wise in elderly!) Droperidol can be used IV - more rapid onset Caution: sedation, hypotension, less anti-psychotic than haloperidol

Slide 37 :

Atypical neuroleptics Risperidone: for those with side effects from haloperidol or contraindications Starting dose: .5mg HS or BID Olanzapine: agent of choice for patients with PD with hallucinations/delirium Starting dose 2.5mg PO HS or BID

Slide 38 :

Benzodiazepines Should usually be avoided Agents of choice for ETOH, benzo withdrawal More rapid onset than neuroleptics Peak effects brief, sedation more common, can prolong delirium May be useful in terminal delirium associated with high dose narcotics and myoclonus Lorazepam .5-1 mg IV or PO (t1/2 15-20 hours)

Slide 39 :

Other agents ?Trazadone 25-100mg Physostigmine (don’t try this) reverses delirium due to anticholinergic activity SE’s: bradycardia, asystole, bronchospasm, seizures ?Donepezil ?Mood stabilizers Narcotics and pain medications (empiric use in patients with dementia often helpful)

Slide 40 :

Delirium in the ICU Unlikely to be entirely preventable due to burden of illness, interventions, and environment Restraints less humane than sedation (my opinion) Sitters versus sedation? Depth of sedation? Sedative of choice? Bottom Line: RCTs needed

Slide 41 :

Review of 32 studies of ICU sedation, 20 short Review term and 14 long term 20 compared propofol with midazolam Propofol may result in faster time to extubation, but higher rate of hypotension, higher cost Long term cognitive outcomes? Conclusion: More RCTs needed Sedation in the ICU Osterman et al. JAMA 2000; 283: 1451-1459

Slide 42 :

Sedation in the ICU RCT of 128 inpatients receiving mechanical ventilation and continuous sedation in medical ICU Intervention: Interrupt sedation until patient awake on a daily basis versus usual care Duration of ventilation 4.9 vs 7.3 (p=0.004) in intervention vs control group Median Length of stay 6.4 vs 9.9 days (p=0.02) Kress et al NEJM May 18, 2000

Slide 43 :

Prevention is the Best Medicine All evidence suggests that it is easier to PREVENT delirium than to TREAT delirium Prevention of delirium is least likely to be possible in the intensive care unit Treatment of delirium in the intensive care unit is particularly challenging and most likely to require medications, sitters, and/or physical restraints

Slide 44 :

Summary Delirium is common in older inpatients, associated with poor outcomes, and commonly missed or misdiagnosed Prevention is the best approach Management involves treating underlying causes, minimizing medications, supportive care, and avoidance of restraints when possible ICU delirium poses particular challenges Further research and RCTs are needed

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Desc : Delirium and its symptoms. What leads to various types of disorders, like Bipolar disorders. Deliri more Delirium and its symptoms. What leads to various types of disorders, like Bipolar disorders. Delirium in elderly,and its cause. Reasons for such disorders. delirium is a common presentation of disease in the elderly and one need to recognize it. - Slides less