Delirium in Hospitalized Older Persons

Educational Leadership Immersion Training in ELDERcare (ELITE)Liza Isabel Genao, MD

Assistant Professor Geriatric Medicine

4/12/2019

Learning Objectives

Describe rate, cost, and complications of delirium Effectively diagnose delirium Describe multicomponent model to approach delirium Name non-pharmacological interventions to prevent and treat

delirium Name 1-2 pharmacological regimen for treating symptoms of

delirium Describe pearls for communicating with the agitated patient

By the end of the session, participants will be able to:

The case of Mrs. Setting

PMH: HTN, HLD, HFrEF, h/o breast cancer, venous insufficiency, obesity class III, obesity hypoventilation syndrome (BiPaP)

Social history: married living with spouse in an apartment. Completed high school. Retired from working in a factory. Lifetime non smoker, no regular alcohol intake.

Medications: amLODIPine (NORVASC) 10 MG tablet by mouth once daily,

FUROsemide (LASIX) 20 MG tablet by mouth once daily,

isosorbide mononitrate (IMDUR) 30 MG ER tablet by mouth once daily,

letrozole (FEMARA) 2.5 mg tablet by mouth once daily,

omeprazole (PRILOSEC) 20 MG DR capsule by mouth once daily,

pregabalin (LYRICA) 75 MG capsule by mouth 2 (two) times daily.

76 yo female being admitted to your service for elective exploratory laparotomy for abnormal uterine bleeding

Mrs. Setting continued

She underwent Total abdominal hysterectomy with Bilateral Salpingo-oophorectomy & Cystoscopy last night

You are called by nursing because patient is unarousable VS: 108/90, 88, 14, 98% RA. She slept with her BiPaP last night. She

opens her eyes on verbal command. She appears on no respiratory distress. RRR. NHS. Poor air exchange bilaterally. Abdominal incision looks clean. Abdomen is soft and mildly tender. Lower extremities 2+ edema (chronic) with SCD’s on.

You asked the nurse to help you reposition and patient begins to mumble, please call my mother. She is right there in the bathroom door, she tells you. She tries multiple times to get out of the bed

What is the most likely diagnosis?

a. Respiratory failureb. New onset dementiac. Urinary tract infectiond. Deliriume. Depression

Delirium is common Emergency Department: 8-17% prevalence (present on

admission) Surgical wards: Cardiac (11-46% incidence), non-cardiac (13-

50% incidence; 17.5% gynecologic malignancy surgery) and orthopedic (17% prevalence, 12-51% incidence)

Medical ward: 18-35% prevalence, 11-14% incidence ICU: 7-50% prevalence, 19-82% incidence End of life: up to 88% present at the time of death Post acute and/or long term care: 14% prevalence, 20-22%

incidenceDelirium in Elderly People. Lancet. 2014;383(9920):911-922

The incidence and risk factors associated with postoperative delirium in geriatric patients undergoing surgery for suspected gynecologic malignancies. Gynecologic Oncology.2008; 109 (2): 296-30

Delirium is deadly

ED: RR=1.7 risk for deathGeneral medicine wards: RR=1.5-1.9 risk for death ICU: RR=1.4-13 risk for death Post acute and/or long term care: RR= 4.9 risk for death If after a stroke: RR= 2 or in the setting of dementia RR=

5.4 risk for death

Delirium in Elderly People. Lancet. 2014;383(9920):911-922

Delirium leads to high disease burden, disability and cost

Functional decline: RR=1.9 (cardiac surgery), RR=2.1 (non-cardiac surgery), RR=1.5 (general medicine ward)

Need for Long-Term Care placement: RR=5.6 (orthopedic surgery), RR=2.5 (gen med ward), RR= 9.3 (if dementia present)

Cognitive impairment: RR=1.7 (cardiac surgery), RR=2.1 (non-cardiac surgery), RR=6.4-41.2 (ortho)

Increased length of stay: RR= 1.4-2.1 (ICU) Higher costs: US$164 billion/year (USA), $182 billion/year (18

European countries combined)Delirium in Elderly People. Lancet. 2014;383(9920):911-922

Delirium is under-recognized Delirium is missed in nearly 60% of cases. This rate has not improved in the past

decade. Factors that contribute to under detection include:

Preexisting dementia and/or depression,

Sensorial alterations,

the hypoactive presentation,

its fluctuating nature

the lack of formal cognitive assessment as part of routine screening across care settings,

ageist attitudes toward older people with an expectation of confusion.

In hospice the moaning, groaning, and grimacing that often accompany delirium in the last few days of life may lead to its missed diagnosis and may instead be interpreted as physical pain.

Delirium in Elderly People. Lancet. 2014;383(9920):911-922Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA. 2017 Sep 26;318(12):1161-1174

The APA’s DSM-V criteria for DELIRIUM

Disturbance in attention (reduced ability to direct, focus, sustain, and shift attention) and awareness.

The disturbance develops over a short period of time (usually hours to days), represents a change from baseline, and tends to fluctuate during the course of the day.

An additional disturbance in cognition (memory deficit, disorientation, language, visuospatial ability, or perception)

The disturbances are not better explained by another preexisting, evolving or established neurocognitive disorder, and do not occur in the context of a severely reduced level of arousal, such as coma

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Society; 2013.

There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect.

Additional features that may accompany delirium and confusion include the following: Psychomotor behavioral disturbances such as hypoactivity, hyperactivity with

increased sympathetic activity, and impairment in sleep duration and architecture.

Variable emotional disturbances, including fear, depression, euphoria, or perplexity

The APA’s DSM-V criteria for Delirium continued

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Society; 2013.

Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

Inouye SK et al. Ann Intern Med. 1990; 113: 941-948

Sensitivity: 94-100%, Specificity: 90-95%

CAM-ICU flowsheet

Copyright © 2002, E. Wesley Ely, MD, MPH and Vanderbilt University, all rights reserved

Delirium versus Dementia

Condition Time Course Distinguishing FeaturesDelirium Acute onset, lasting days

to weeks (though could be longer)

Impaired attentionAltered level of consciousness

Dementia Progressive worsening, permanent

Unimpaired attention and level of consciousness until

severe stages

However, there are features that are common in both:Disorientation

Sleep-wake cycle reversalMemory impairment

Hallucinations

14

Delirium and depression: inter-relationship and clinical overlap in elderly people. Lancet Psychiatry. 2014 Sep;1(4):303-11The interface between delirium and dementia in elderly adults. Lancet Neurol. 2015 Aug;14(8):823-832

Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA. 2017 Sep 26;318(12):1161-1174

Back to Mrs. Setting

You proceed to review her medications and noted that she has been given fentanyl 25 mcg IV q2h since surgery. You also noted that she was given Phenergan given her history of PONV

You decide to continue to monitor, put her BiPAP on, and put restrains so that she doesn’t fall while trying to get out of the bed.

Several hours later, while rounding with your attending, the patient’s mental state worsens. She is unarousable to sternal rub. Bilateral crackles and wheezing in her lungs. Her BP is 80/60, HR 96, RR 12.

An RRT is called. EKG shows diffuse ST elevation on Apical lateral leads. Labs showed elevated troponins. She is promptly intubated to protect airways and transferred to ICU for further care.

Assume it is Delirium until Proven Otherwise

16

Delirium may be the only manifestation of a life-threatening illness in the older person

It is a medical emergency!

A model for Delirium

Predisposing factors or vulnerability

Precipitating factors or insults

Vul

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bilit

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Nox

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Insu

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Delirium in Elderly People. Lancet. 2014;383(9920):911-922

A model for Delirium cont.

Age 75+ (RR= 3.3-6.6) Dementia (RR= 2.3-4.7) Prior delirium (RR= 3.0) Functional impairment (RR=

2.5-4.0) Visual impairment (RR= 1.1-3.5) Hearing impairment (RR= 1.3) Depression (RR= 1.2-3.2) Prior TIA or CVA (RR= 1.60) Alcohol misuse (RR= 1.4-5.7)

Medications (sedatives/psycho-actives) (RR= 2.9-4.5)

Indwelling bladder catheters (RR= 2.4), or physical restraints (RR= 3.2-4.4)

Fluid/electrolyte abnormalities (RR =3.4)

Infections (RR = 3.1)

Surgery admission (RR = 3.5-8.3)

Trauma admission(RR= 3.4)

Urinary retention and fecal impaction, uncontrolled pain, interrupted sleep, noise, etc.

ETOH/drug withdrawal

VULNERABILITY NOXIOUS INSULTS

Delirium in Elderly People. Lancet. 2014;383(9920):911-922

Hospital Elder Life Program (HELP)

Risk factor Targeted Protocol Outcome

Cognitive impairment Orientation and therapeutic activities Orientation score

Sleep deprivationNon-Rx sleep protocolQuiet nights

Use of sleep meds

ImmobilityEarly mobilizationRemoval of tethers

ADL score

Vision problems Visual aids and adaptive equipment Early vision correction

Hearing loss Wax disimpaction, amplifying devices, other comm. techniques Whisper test

Dehydration Early recognition and volume repletion BUN/Cr < 18

Inouye SK et al. NEJM. 1999;340:669-76Hospital Elder Life Program: Systematic Review and Meta-analysis of Effectiveness.

The American Journal of Geriatric Psychiatry Vol 26, Issue 10, October 2018, Pages 1015-1033

Outcome Intervention Control1st delirium

episode 9.9% 15% OR= 0.39-0.92

Total deliriumdays 105 161 P=0.02

# delirium episodes 62 90 P=0.03

A recently published systematic review of the literature showed that HELP, across health care settings:- continues to be effective in reducing incidence of delirium (OR 0.47, 95% CI 0.35-

0.95). - It reduced the rate of falls (OR 0.58% 95% CI 0.35-0.95), - It had a trend toward decreasing length of stay and preventing institutionalization.- It saved $1600–$3800 per patient in hospital costs and over $16,000 per person-year in

long-term care costs in the year following delirium

Population Intervention Incidence Duration Author

Medical HELP (cognition, immobility, hydration, sleep, hearing, vision)

↓OR = 0.60 (CI =0.39-0.92)

↓ Inouye 1999

Prophylactic Environmental Management of In-hospital

Delirium (PEMID)- family delivered↓

6% vs. 13% (p<.03) = Martinez 2012

SurgicalProactive geriatric consult- 10

modules (hydration, pain, nutrition, mobilization)

↓RR = 0.64 (CI =0.37-0.98)

↓ Marcantonio 2001

Screen, geriatric consult, pain (RN lead)-orthopedics ↓ Milisen 2001

HELP RN-lead (any surgery) ↓0% vs. 17%

= Chen 2011

Preoperative geriatrics consult-orthopedics

↓37% vs. 53% (p=.04)

Deschodt 2012

ICU Earplugs at night ↓HR= 0.47 (CI 0.27, 0.82)

Van Rompaey 2012

PT/OT with interruption of sedation ↓ Schweickert 2009

Modified from Delirium in Elderly People. Lancet. 2014;383(9920):911-922

Non-pharmacological prevention of delirium

Population Intervention Incidence Duration

ICU Dexmedetomidine(Midazolam) ↓ 54% vs. 77% (p<.001) ↓

Riker 2009 Pandharipande

2007

Dexmedetomidine(Propofol, Midazolam)

↓ RR=0.23 (0.08-0.61)RR= 0.24 (0.09-0.64) ↓ Maldonado 2008

Medicine Melatonin vs placeboRamelteon vs placebo

↓ 3.6% vs 19% (p<0.02)3% vs 32% (p0.003)

Al-Aama 2011Hatta 2014

Cardiac Surgery Dexmedetomidine(Morphine) = ↓ Shehabi 2009

Dexmedetomidine vs Placebo

↓ 7.9% to 4.6% OR=0.43 (0.27-0.7)

↓ 23% vs 44% (p<0.01)↓ Li 2014

Liu 2016

Orthopedic Surgery Melatonin (Midazolam, Clonidine)

↓(9.43% vs. 32.65% vs. 44% vs.

37.25%).Sultan 2010

Modified from Delirium in Elderly People. Lancet. 2014;383(9920):911-922Modified from Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA. 2017 Sep 26;318(12):1161-

1174

Pharmacological Prevention of Delirium

Evidence does not support the use of antipsychotics for prevention or treatment of Delirium

Antipsychotics do not prevent Delirium: 7 studies antipsychotics vs placebo for delirium prevention after surgery: (OR = 0.56, 95% CI = 0.23–1.34).

Antipsychotics do not shorten the duration of Delirium

reduce the severity of Delirium

Shorten length of stay

Improve survival

Antipsychotics have anticholinergic adverse effects

Are associated with increased risk of death in patients with dementia

Antipsychotics in the prevention and treatment of delirium in hospitalized older adults: and systematic review and meta-analysisi. J Am GeriatrSoc 64:705–714, 2016.

Doing Harm in Delirium. Lancet Psychiatry 2014; 1: 312-5

Consensus recommendation based on review of evidence is to reserve the use of antipsychotics for treatment of severe agitation that poses risk to the safety of the patient/staff or

threatens interruption of essential medical therapies.

Older Patient on Admission

Assess for vulnerability for delirium Assess baseline

cognitive function

Screen for DELIRIUM at entry and often

High risk for delirium

Implement multicomponent prevention strategies

DELIRIUM confirmed

Identify & treat noxious insults Prevent Complications Treat symptoms: see following slide

Determine severity & change overtime

History, physical Examination, medication review, basic labs,

targeted infection screen.

Prevent aspiration/protect airway, prevent pressure ulcers, ensure euvolemia,

adequate nutrition, monitor for urinary

retention & constipation, maintain mobility

Modified from Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA. 2017 Sep 26;318(12):1161-1174

Treat symptoms of delirium

Non pharmacological multicomponent intervention Pharmacological

Environmental modifications: Blinds open during the day/closed at night, reduce noise or white noise.

Early mobility tailor to the patient

Family /staff involvement, orientation, cognitive stimulation, reminiscence therapy

Ensure patient wears glasses and hearing aids while awake

Sleep promotion protocols: avoid interruptions overnight, ear plugs, herbal tea, massage, etc.

Management of sleep-awake cycle: Melatonin 3-5 mg po QHS or Ramelteon 8 mg po QHS

Management of severe agitation: start with low dose of one of the drugs below, keep at steady dose for 2 days, then taper off: Risperidone 0.5-1 mg po qd or bid

Olanzapine 2.5-5 mg po/IM qd or bid

Quetiapine 12.5-25 mg po QHS or bid

Haloperidol 0.25-0.5 mg po/IV/IM q4h

Avoid benzodiazepines except in BDZ or ETOH withdrawal

Modified from Delirium in Older Persons: Advances in Diagnosis and Treatment. JAMA. 2017 Sep 26;318(12):1161-1174

Approach to the agitated patient Provide quiet environment (to improve hearing), minimize glare (improve vision),

graduate room temperature to patients comfort. Keep the space tidy and clutter free (minimize distraction).

Approach from the front (face-to-face), with a gentle voice (lower tone/pitch instead of yelling) and light touch

Say what you are going to do before and while you do it Provide simple, one-step directions

Ask simple, yes or no questions or questions with 2 choices. Verify the response. If needed use simple writing while you talk

Give at least 10 seconds for a response- count silently Do not argue; Use positive statements Find the missing word Reminiscence therapy, folding cloths, painting, cards, etc.

Modified from Helpful communication tips. Duke Speech Pathology and Audiology. 2010.

In summary

A multifactorial syndrome: predisposing vulnerability and precipitating insults

Delirium can be diagnosed with high sensitivity and specificity using the CAM

Prevention should be our goal If delirium occurs, treat the underlying causes Always try non-pharmacologic approaches Use low dose antipsychotics in severe cases, use for short periods