Topic review: “Delirium” - Siriraj Hospital · Validity of thai delirium rating scale 6 items...
84
“DELIRIUM” J. Sukanya 28.Jun.12
Transcript of Topic review: “Delirium” - Siriraj Hospital · Validity of thai delirium rating scale 6 items...
ldquoDELIRIUMrdquo
J Sukanya 28Jun12
Outline
Why What How Whatrsquos next
ldquoDeliriumrdquo
Introduction Delirium An acute decline in attention and cognition
The most frequent neuropsychiatric syndrome
A common life-threatening potentially preventable
Acutely admitted elderly patients
Nat Rev Neurol 5 210ndash220 (2009) wwwthelancetcomneurology Vol 9 September 2010
Introduction Disadvantages of Delirium Increased risk of morbidity and mortality
Increased health care costs
New data link this syndrome to poor long-term outcome
Nat Rev Neurol 5 210ndash220 (2009) wwwthelancetcomneurology Vol 9 September 2010
Geriatr Gerontol Int2012 Jun 7
Why
ldquoDeliriumrdquo
Epidemiology Delirium hypoactive form More common
Often unrecognized
N Engl J Med 20063541157-65 Dtsch Arztebl Int2012 May109(21)391-400
Epidemiology
Vary depending on The patientsrsquo characteristics Setting of care Sensitivity of the detection method
Among general hospital populations The prevalence 14 - 24 percent The incidence 6 - 56 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
The overall prevalence in the community 1 - 2 percent Up to 14 percent - if more than 85 years old
At the emergency departments 10 - 30 percent of older patients presenting with delirium Often heralds the presence of life-threatening conditions
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Outline
Why What How Whatrsquos next
ldquoDeliriumrdquo
Introduction Delirium An acute decline in attention and cognition
The most frequent neuropsychiatric syndrome
A common life-threatening potentially preventable
Acutely admitted elderly patients
Nat Rev Neurol 5 210ndash220 (2009) wwwthelancetcomneurology Vol 9 September 2010
Introduction Disadvantages of Delirium Increased risk of morbidity and mortality
Increased health care costs
New data link this syndrome to poor long-term outcome
Nat Rev Neurol 5 210ndash220 (2009) wwwthelancetcomneurology Vol 9 September 2010
Geriatr Gerontol Int2012 Jun 7
Why
ldquoDeliriumrdquo
Epidemiology Delirium hypoactive form More common
Often unrecognized
N Engl J Med 20063541157-65 Dtsch Arztebl Int2012 May109(21)391-400
Epidemiology
Vary depending on The patientsrsquo characteristics Setting of care Sensitivity of the detection method
Among general hospital populations The prevalence 14 - 24 percent The incidence 6 - 56 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
The overall prevalence in the community 1 - 2 percent Up to 14 percent - if more than 85 years old
At the emergency departments 10 - 30 percent of older patients presenting with delirium Often heralds the presence of life-threatening conditions
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Introduction Delirium An acute decline in attention and cognition
The most frequent neuropsychiatric syndrome
A common life-threatening potentially preventable
Acutely admitted elderly patients
Nat Rev Neurol 5 210ndash220 (2009) wwwthelancetcomneurology Vol 9 September 2010
Introduction Disadvantages of Delirium Increased risk of morbidity and mortality
Increased health care costs
New data link this syndrome to poor long-term outcome
Nat Rev Neurol 5 210ndash220 (2009) wwwthelancetcomneurology Vol 9 September 2010
Geriatr Gerontol Int2012 Jun 7
Why
ldquoDeliriumrdquo
Epidemiology Delirium hypoactive form More common
Often unrecognized
N Engl J Med 20063541157-65 Dtsch Arztebl Int2012 May109(21)391-400
Epidemiology
Vary depending on The patientsrsquo characteristics Setting of care Sensitivity of the detection method
Among general hospital populations The prevalence 14 - 24 percent The incidence 6 - 56 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
The overall prevalence in the community 1 - 2 percent Up to 14 percent - if more than 85 years old
At the emergency departments 10 - 30 percent of older patients presenting with delirium Often heralds the presence of life-threatening conditions
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Introduction Disadvantages of Delirium Increased risk of morbidity and mortality
Increased health care costs
New data link this syndrome to poor long-term outcome
Nat Rev Neurol 5 210ndash220 (2009) wwwthelancetcomneurology Vol 9 September 2010
Geriatr Gerontol Int2012 Jun 7
Why
ldquoDeliriumrdquo
Epidemiology Delirium hypoactive form More common
Often unrecognized
N Engl J Med 20063541157-65 Dtsch Arztebl Int2012 May109(21)391-400
Epidemiology
Vary depending on The patientsrsquo characteristics Setting of care Sensitivity of the detection method
Among general hospital populations The prevalence 14 - 24 percent The incidence 6 - 56 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
The overall prevalence in the community 1 - 2 percent Up to 14 percent - if more than 85 years old
At the emergency departments 10 - 30 percent of older patients presenting with delirium Often heralds the presence of life-threatening conditions
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Why
ldquoDeliriumrdquo
Epidemiology Delirium hypoactive form More common
Often unrecognized
N Engl J Med 20063541157-65 Dtsch Arztebl Int2012 May109(21)391-400
Epidemiology
Vary depending on The patientsrsquo characteristics Setting of care Sensitivity of the detection method
Among general hospital populations The prevalence 14 - 24 percent The incidence 6 - 56 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
The overall prevalence in the community 1 - 2 percent Up to 14 percent - if more than 85 years old
At the emergency departments 10 - 30 percent of older patients presenting with delirium Often heralds the presence of life-threatening conditions
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Epidemiology Delirium hypoactive form More common
Often unrecognized
N Engl J Med 20063541157-65 Dtsch Arztebl Int2012 May109(21)391-400
Epidemiology
Vary depending on The patientsrsquo characteristics Setting of care Sensitivity of the detection method
Among general hospital populations The prevalence 14 - 24 percent The incidence 6 - 56 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
The overall prevalence in the community 1 - 2 percent Up to 14 percent - if more than 85 years old
At the emergency departments 10 - 30 percent of older patients presenting with delirium Often heralds the presence of life-threatening conditions
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Epidemiology
Vary depending on The patientsrsquo characteristics Setting of care Sensitivity of the detection method
Among general hospital populations The prevalence 14 - 24 percent The incidence 6 - 56 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
The overall prevalence in the community 1 - 2 percent Up to 14 percent - if more than 85 years old
At the emergency departments 10 - 30 percent of older patients presenting with delirium Often heralds the presence of life-threatening conditions
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Epidemiology
The overall prevalence in the community 1 - 2 percent Up to 14 percent - if more than 85 years old
At the emergency departments 10 - 30 percent of older patients presenting with delirium Often heralds the presence of life-threatening conditions
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Epidemiology
Postoperative 15 - 53 percent
In intensive care setting 70 - 87 percent
In nursing homes or postndashacute care settings
Up to 60 percent
At the end of life Up to 83 percent
N Engl J Med 20063541157-65 Nat Rev Neurol 5 210ndash220 (2009)
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Epidemiology
Incidence of post-stroke delirium and 1-year outcome N =314
Acute stroke unit
729 years
Incidence 274
Higher functional impairmentnursing home placementmortality
Geriatr Gerontol Int2012 Jun 7
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Epidemiology
The mortality rates Range from 22 - 76 percent
As high as the rates with acute myocardial infarction or sepsis
The one-year mortality rate 30 - 40 percent
N Engl J Med 20063541157-65 Geriatr Gerontol Int2012 Jun 7
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Prevalence and incidence of delirium in Thai older patients a study at general medical wards
in Siriraj Hospital
Praditsuwan R Limmathuroskul D Assanasen J Pakdeewongse S Eiamjinnasuwat W Sirisuwat A Srinonprasert V
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
OBJECTIVE
To determine prevalence and incidence of delirium In older patients Admitted to general medical wards In a university hospital in Thailand
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
MATERIAL AND METHOD
A prospective observational study Age 70 years or older In general medical wards during study period
Delirium assessments Initially within the first 24 hours of admission
And serially every 48 hours
Until developed delirium or were discharged
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
MATERIAL AND METHOD
Delirium was diagnosed by experienced geriatricians Based on the DSM-IV criteria Prevalence Based on delirium identified at the first assessment
Incidence Based on cases developed during hospitalization
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
RESULTS
N = 225 The prevalence of delirium 404
The incidence of delirium 84
The total occurrence rate of delirium 489
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
RESULTS
Occurrence rate of delirium significantly increased with Age (p = 0003)
Illness severity (p lt 0001)
Number of impaired activities of daily living
J Med Assoc Thai2012 Feb95 Suppl 2S245-50
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Nat Rev Neurol 5 210ndash220 (2009)
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
A review and meta-analysis of published studies Death 2 years
Hazard ratio 195 151ndash252
Institutionalisation 15 months
Odds ratio [OR] 241 177ndash329
Developing dementia 4 years
OR 1252 186ndash8421
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
A review and meta-analysis of published studies Poor outcome independent of important confounders Age
Sex
Comorbid illness or illness severity
Baseline dementia
wwwthelancetcomneurology Vol 9 September 2010 JAMA 2010 304 443ndash51
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Incidence of post-stroke delirium and 1-year outcome
Nursing home placement 62 vs 112
Mortality Inpatient mortality 18 vs 22
1-year mortality 30 vs 74
Longer hospital stay 45 vs 22 days
Geriatr Gerontol Int2012 Jun 7
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Adverse Outcomes After Hospitalization and Delirium in Persons With Alzheimer Disease
Death 116 Institutionalization 17 Cognitive decline 15 Any adverse outcome 18
Ann Intern Med 2012156848-856
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
What
ldquoDeliriumrdquo
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Clinical features
J Neuropsychiatry Clin Neurosci 2012 Dec 124(1)95-101
Symptom profile of delirium In northern India
Assessed 100 consecutive cases of DSM-IV delirium
Mean age 444 [standard deviation 194] years
Most frequent symptoms
Attention Orientation Visuospatial ability Sleep disturbance
Less frequent Language Thought-process abnormality Motor agitation
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Hazzard Geriatric Medicine and Gerontology 6thEd
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Incidence of post-stroke delirium and 1-year outcome
Independent risk factors of post-stroke delirium
Chest infection OR = 220
Total anterior circulation infarct OR = 188 Presence of acute urinary retention OR = 767
posterior circulation infarct OR = 352
pre-existing cognitive impairment OR = 251
National Institutes of Health Stroke Scale OR 113
Age OR 105 Geriatr Gerontol Int2012 Jun 7
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Risk Factors for Developing Delirium in Older Patients Admitted to General Medical Wards
A prospective observational study Risk factors Preexisting dementia (OR = 552 95 CI = 251-1214)
Severe illness (OR = 518 95 CI = 210-1276)
Presence of infection (OR = 254 95 CI = 115-561)
Azothemia (OR = 255 95 CI = 120- 540)
J Med Assoc Thai 2011 94 (Suppl 1) S99-S104
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Etiology- case report
Exp Gerontol 2012 Jul47(7)534-5
Cognitive decline in an old woman Do not miss a rare etiology Brussels Belgium
Report a case of a woman with neurological symptoms dementia
Final diagnosis Late-onset SLE
Leads to misdiagnosis
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Nat Rev Neurol 5 210ndash220 (2009) Critical Care 2011 15R78 J Am Geriatr Soc 2012 Apr60(4)669-75
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Pathophysiology Plasma levels of procalcitonin and CRP Critically ill patients
High baseline inflammatory biomarkers Predicted prolonged periods of acute brain dysfunction
Critical Care 2011 15R78
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Pathophysiology Plasma cholinesterase activity
(acetylcholinesterase (AChE) and butyrylcholinesterase (BuChE))
Inflammatory mediators (C-reactive protein (CRP) interleukin (IL)-1 beta tumor necrosis
factor alpha IL-6 IL-8 IL-10)
Unbalanced inflammatory response Dysfunctional interaction
Between the cholinergic and immune systems
J Am Geriatr Soc 2012 Apr60(4)669-75
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
How
ldquoDeliriumrdquo
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Diagnostic Criteria ICD-10
ICD-10 Diagnostic Criteria For a definite diagnosis symptoms mild or severe should be present in each
one of the following areas
A Impairment of consciousness and attention
B Global disturbance of cognition
C Psychomotor disturbances
D Disturbance of the sleep - wake cycle
E Emotional disturbances
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Diagnostic Criteria CAM
The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1 Acute onset and fluctuating course
Feature 2 Inattention
Feature 3 Disorganized thinking
Feature 4 Altered level of consciousness
The diagnosis by CAM Requires the presence of features 1 and 2 and of either 3 or 4
The Supplementary Appendix of N Engl J Med 20063541157-65
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Diagnosing delirium in elderly Thai patients Utilization of the CAM algorithm
Wongpakaran et al BMC Family Practice 2011
Sensitivity 919 Specificity 1000 PPV 1000 NPV 906
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Nat Rev Neurol 5 210ndash220 (2009)
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Confusion Assessment Method
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
CONFUSION ASSESSMENT METHOD IN THE ICU (CAM-ICU)
TARGET POPULATION Should be used on all older adults admitted to the ICU
Promptly identify
Any potential delirium and prevent negative outcomes
httpconsultgerirnorguploadsFiletrythistry_this_25pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
wwwicudeliriumorg
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
(The Richmond Agitation-Sedation Scale)
wwwicudeliriumorg
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Thai Delirium Rating Scale
Develop Thai Delirium Rating Scale Thai Delirium Rating Scale (TDRS) Good reliability and validity
For discriminate delirium from other psychiatric patients
Sensitivity 97
Specificity 91
TDRS is a reliable and valid instrument to diagnose delirium for medical personal and for delirium research
J Psychiatr Assoc Thailand 2000 45(4) 325-332
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
J Psychiatr Assoc Thailand 2000 45(4) 333-338
Study the correlation between total scores of TDRS VS the severity of delirium
5-item scores in Thai Delirium Rating Scale psychomotor activity cognitive status during formal testing sleep-wake
cycle disturbance lability of mood and variability of symptoms
The 5-item version of TDRS can be used to indicate the severity of delirium
Dose the Scores of Thai Delirium Rating Scale Correlate with the Severity of Delirium
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Development of Thai Version of Delirium Rating Scale
Develop and validate TDRS for nonpsychiatric physicians
Thai version of Delirium Rating Scale appeared to be useful for detecting delirium by trained physicians with good levels of validity and reliability
J Psychiatr Assoc Thailand 2000 45(4) 339-346
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Validity of thai delirium rating scale 6 items version
The Thai Delirium Rating scale 6 items version A brief feasible and valid instrument to diagnose delirium
instead of the Thai Delirium Rating Scale 10 items version
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Siriraj Hospital Gazette Vol 53 No 9 September 2001 Page 672-677
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
สถาบนจตเวชศาสตรสมเดจเจาพระยา
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
สถาบนจตเวชศาสตรสมเดจเจาพระยา
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Assessment of risk factors for delirium
First present to hospital or long term care Any risk factors
Keep observation Every opportunity
For any changes in the risk factors for delirium
BMJ 2010341c3704
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Assessment of risk factors for delirium
Risk factors Age 65 years or older
Cognitive impairment (past or present) and or dementia If cognitive impairment is suspected confirm it using a standardised and
validated cognitive impairment measure (mini mental state examination )
Current hip fracture
Severe illness
BMJ 2010341c3704
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Fong T G et al Nat Rev Neurol 5 210ndash220 (2009)
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Whatrsquos next
ldquoDeliriumrdquo
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Prevention is the best
N Engl J Med 20063541157-65
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Prevention
Non-pharmacologic approach Pharmacologic approach
N Engl J Med 20063541157-65
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Cognitive impairment disorientation or both
Dehydration constipation or both
Hypoxia
Immobility or limited mobility
BMJ 2010341c3704
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Interventions to prevent delirium
Within 24 hours of admission assess precipitating factors Infection
Multiple medications
Pain
Poor nutrition
Sensory impairment
Sleep disturbance
BMJ 2010341c3704
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
BMJ 2010341c3704
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
The Hospital Elder Life Program
A model of care to prevent cognitive and functional decline in older hospitalized patients
Screened on admission for six risk factors Cognitive impairment sleep deprivation immobility
dehydration vision or hearing impairment
Interdisciplinary team
Other experts consultation twice-weekly
J Am Geriatr Soc 2000 Dec48(12)1697-706
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
httpwwwagingpitteduseniorspdfElderLifeBrochurepdf
Meal Program
Recreation and Relaxation Program
Exercise Program
Communication and
Comfort Program
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Reducing delirium after hip fracture a randomized trial
ldquoProactive geriatrics consultationrdquo One case of delirium was prevented for every 56 patients
Reduced delirium by over one-third
Reduced severe delirium by over one-half
J Am Geriatr Soc 2001 May49(5)516-22
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
The REACH-OUT trial
Homebased rehabilitation vs Inpatient hospital setting Frail older patients
Lower incidence of delirium lower cost greater satisfaction
Age Ageing 2006 Jan35(1)53-60
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
J Am Geriatr Soc 2011 Nov59 Suppl 2S282-8
Pilot randomized trial of donepezil hydrochloride fordelirium after hip fracture
N = 16 aged 70 and older with hip fracture Donepezil 5 mg or placebo Initiated within 24 hrs of surgery prepostoperatively Daily treatment was continued for 30 days or until side
effects or the clinical situation required termination Donepezil had no significant improvement
in delirium presence or severity but experienced more side effects
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
Short-term low-dose intravenous haloperidol Prospective randomized double-blind and placebo-
controlled trial in two centers
Crit Care Med 2012 Mar40(3)731-9
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Haloperidol prophylaxis decreases delirium incidence in elderly patients after noncardiac surgery a randomized controlled trial
The primary end point Incidence of delirium within the first 7 days after surgery
Secondary end points Time to onset of delirium
Number of delirium-free days
Length of intensive care unit stay
Crit Care Med 2012 Mar40(3)731-9
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
N = 10 70 to 90 years DEX 02-04 microg kg hr 30 to 60 min before the end of the
operation
01-02 microg kg hr by the time of extubation
Increased 01 microg kg hr depend
Masui 2012 Apr61(4)379-83
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Dexmedetomidine for postoperative sedation in elderly patients with cognitive impairment
710 calm 310 the dose had to be increased by 01 microg x kg(-1)
x hr(-1) No serious complication except bradycardia (210) Low-dose DEX is safe and useful for postoperative
sedation in elderly patients with cognitive impairment
Masui 2012 Apr61(4)379-83
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
1
2 3
4
5 6
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
6 5
7 8
9 10 11
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
9 10
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
N Engl J Med 20063541157-65
11
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Management
Indication of pharmacologic management Threaten their own safety
Safety of other persons
Interruption of essential therapy Mechanical ventilation or central venous catheters
N Engl J Med 20063541157-65
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Nat Rev Neurol 5 210ndash220 (2009)
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Lancet 2010 Nov 27376(9755)1829-37
Effect of rivastigmine as an adjunct to usual care with haloperidol on duration of delirium and mortality in critically ill patients a multicentre double-blind placebo-controlled randomised trial
Higher mortality 3-time Longer median duration of delirium 53 days
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Summary
ldquoDeliriumrdquo
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Summary Why Common
Morbidity and mortality
Poor quality of life
What Identify risk group
Interaction Between the cholinergic and immune systems
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly) hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
Summary How CAM CAM-ICUTDRS
DeliriumDementiaDepressionAcute pshychosis
Whatrsquos next
Preventive measure
Early diagnosis and early intervention
วรศกด เมองไพศาล ldquoอาการซม สบสนเฉยบพลนในผสงอาย (Delirium in the Elderly)
hppt2031571845researchcenterdownload0601201015pdf
