Dr. Peter Chan, MD, FRCPC Consult-Liaison and Geriatric Psychiatrist, Vancouver General Hospital....
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Transcript of Dr. Peter Chan, MD, FRCPC Consult-Liaison and Geriatric Psychiatrist, Vancouver General Hospital....
Dr. Peter Chan, MD, FRCPC
Consult-Liaison and Geriatric Psychiatrist,
Vancouver General Hospital.
Clinical Associate Professor,
UBC Dept. of Psychiatry
Collaborators
UBC Care for Elders ModuleDr. Martha Donnelly, MD, FRCPCDr. Ram Randhawa, MD, FRCPC
VGH Nursing Education Module (VCHA)Ms. Wendy Marr, RNMs. Maureen Shaw, RN, MN
Disclosure
Honouraria for speaker engagements:
Astra-Zeneca Eli-Lilly Janssen-Ortho
Guidelines: Categories of Evidence:
Ia Evidence from meta-analysis of randomized controlled trialsIb Evidence from at least one randomized controlled trialIIa Evidence from at least one controlled study without randomizationIIb Evidence from at least one other type of quasi-experimental
studyIII Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control
studiesIV Evidence from expert committees reports or opinions and/or clinical experience of respected authorities
Shekelle et al 1999
Guidelines: Strength of Recommendation
A Directly based on category I evidenceB Directly based on category II evidence or extrapolated recommendation from category I evidenceC Directly based on category III evidence or extrapolated recommendation from category I or II evidenceD Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence
Shekelle et al 1999
What’s in the Guideline Background Prevention Detection, Assessment, Diagnosis &
Monitoring Management Legal and Ethical Issues Education Systems of Care Research on Delirium Future Considerations
Canadian Coalition For Senior’s Mental Health: Practice Guidelines
Predisposing FactorsInouye, SK et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993; 119:474-481
cognitive impairment sleep deprivation immobility visual impairment hearing impairment dehydration
Screening Under-recognition, esp. in those:
Over 80 y.o. with hypoactive delirium with visual impairment and/or pre-existing dementia○ Inouye et al. Arch Int. Med 2001
No reliable screening tool to differentiate delirium and dementia
Practically, acute-onset and/or fluctuation in cognition/function/abnormal behaviours
Others signsNew onset aphasia or dysarthriaNew onset or worsening incontinence
Confusion Assessment Method (Inouye et al. Ann.Int.Med. Dec.15/90)
acute onset and fluctuation AND inattention AND disorganized thinking OR altered level of consciousness
excellent sensitivity, good specificity
Screening Instruments
We recommend…
The Confusion Assessment Method is recommended for screening on acute medical/surgical wards and in the ER (C)
CIWA-Ar is recommended for monitoring symptoms of alcohol withdrawal (C)
Precipitating Factorsin HospitalInouye and Charpentier, JAMA 1996; 275: 852-57
Physical restraints (RR=4.4)
Malnutrition (RR=4.0)
More than 3 medications added (RR=2.9)
Use of bladder catheter (RR=2.4)
Any iatrogenic event (RR=1.9)
Use of RestraintsWe recommend…
Physical restraints for geriatric patients suffering from delirium should be applied only in exceptional circumstances when: (D)
a) There is a serious risk for bodily harm to self or others OR
b) Other means for controlling behaviours leading to harm have been explored first, including pharmacologic treatments, but were ineffective AND
c) The potential benefits outweigh the potential risks of restraints
Pharmacologic ManagementWe recommend…
Psychotropic medications should be reserved for older persons with delirium that are in distress due to agitation or psychotic symptoms, in order to carry out essential investigations or treatment, and to prevent older delirious persons from endangering themselves or others. (D)
In the absence of psychotic symptoms causing distress to the patient, treatment of hypoactive delirium with psychotropic medications is not recommended (D)
The use of psychotropic medications for the specific purpose of controlling wandering in delirium is not recommended (D)
Pharmacologic Management
We recommend…
Antipsychotics are the treatment of choice to manage the symptoms of delirium (with the exception of alcohol or benzodiazepine withdrawal delirium). (B)
Haloperidol is suggested as the antipsychotic of choice based on the best available evidence to date. (B) Initial dosages are in the range of 0.25 mg- 0.5 mg. Od-bid (D)
Atypical antipsychotics may be considered as alternative agents as they have lower rates of extra-pyramidal signs. (B)
Benztropine should not be used prophylactically with haloperidol in the treatment of delirium. (D)
Pharmacologic ManagementWe recommend…
In older persons with delirium who also have Parkinson’s Disease or Lewy Body Dementia, atypical antipsychotics are preferred over typical antipsychotics. (D)
Sedative-hypnotic agents are recommended as the primary agents for managing alcohol withdrawal delirium (B). Their use in other forms of delirium should be avoided (D).
Pharmacologic Management: Guidelines
Frequency:• Regular vs. Prn; nighttime dosing
Dosages:
haloperidol 0.25-0.5 bid (watch QTc) risperidone initiated at 0.25 mg od-bid olanzapine at 1.25-2.5 mg per day quetiapine at 12.5-50 mg per day
Haloperidol in Delirium Management
“Evidence” based on 1 RCT (Breitbart 1996)AIDS Dementia population
Comparator to atypicals (3 RCT’s in Cochrane)
Prolonged QTc, especially I.V.– baseline ECG
Risk of Extrapyramidal Symptoms, esp. elderly>4.5 mg/day in Cochrane Review
Loxapine in Delirium Management
Conventional antipsychotic with atypical properties Singh et al Journal of Psychiatry and Neuroscience, 21:29-35
Mid-potency in D2 receptor blockade
Effect on D1, D4, 5-HT2, NMDA receptors
Parenteral IM/SC (IV in monitored setting)
Widespread use in Vancouver Over 3500 VGH inpatients with Delirium since 1989 Use in all settings, including CCU, CSICU, ICU, ACE units Dosing 5-150 mg/d (B.I.D. dosing at 1600h and 2000h)
Subsequent Considerations
Risks of Atypical AntipsychoticsMortalityCVA or related eventsMetabolic syndrome (less likely if short duration)
Use of Cholinesterase Inhibitors
Treatment of Hypoactive Delirium
Summary of Key Points in Managing Geriatric Delirium
Screening is important in identifying cases.
Haloperidol is recommended based on available evidence, but atypicals are alternatives, esp. in those sensitive. Loxapine a viable alternative.
The elderly can have prolonged delirium, and slower to recover in cognition and function when delirium has cleared.
Guideline and Literature Review
1. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. 1999.
2. British Geriatrics Society. Guidelines for the diagnosis and management of delirium in the elderly. 1999-2000
3. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30(3):119-41.
4. Management of alcohol withdrawal delirium: an evidence-based guideline. Arch Intern Med 2004;164(13):1405-12.
5. Iowa Veterans Affairs Nursing Research Consortium. Research-based protocol: acute confusion/delirium. Iowa City, Iowa: The University of Iowa Gerontological Nursing Interventions Research Centre: Research Dissemination Core; 1998.
6. Screening for delirium, dementia and depression in older adults. Toronto (ON): Registered Nurses Association of Ontario; 2003.
7. Caregiving strategies for older adults with delirium, dementia and depression. Toronto (ON): Registered Nurses Association of Ontario; 2004.
8. Sharon Inouye. Delirium in Older Persons. NEJM 354:1157-1165 March 16, 2006 Number 11
9. Gregory Fricchione. Postoperative Delirium. Am J Psychiatry 165:803-812, July 2008
Web Resources Care for Elders Interactive Delirium Module
UBC Division of Geriatric Psychiatrywww.careforelders.ca
VIHA Delirium informationhttp://www.viha.ca/ppo/learning/delirium
Virginia Case StudyCare for Elders Interactive Delirium Module
A Quality Improvement Project
M. McKnight, H. Nagi, K. Ng, C. Reid, P. TamSponsored by Dr. A. Hill and Dr. P. Lee
Delirium Working Group
Why: Problem of idiosyncratic & disparate patterns of practice
Mission: Use literature & expert opinion to establish best practice Standardize approach to patient careImplement best practice through PPOs and staff education
Collaboration of experts at VGH and the region, established Nov 2006
Geriatricians& Internists
Psychiatrists& Geri-psychiatrists
Intensivists
GeneralSurgeons
Nurses
1
1
2
2
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PRISME: Maureen Shaw, RN, MN
P - PAINR- RESTRAINT, RETENTIONI - INFECTIONS - SENSORY IMPAIRMENT,
SLEEPLESSNESSM - MEDICATION, METABOLICE - ENVIRONMENT, EMOTIONS
PPO: Pg 1
PPO: Pg 1
PPO: Pg 2
PPO: Pg 2