ACUTE CONFUSION IN THE ELDERLY
Dr. Barbara PowerApril, 2013
Major Objectives from the LMCC
1. Describe common causes of delirium2. Recognize risk factors, and means of
prevention of delirium3. Identify the difference between Delirium and
Dementia4. Work up and treatment of delirium when it
does occur, and management of behavioral problems
Synonyms for Delirium
• Acute confusional state• Organic brain syndrome• Toxic/metabolic
encephalopathy• Out of it• Uncooperative
So What?Why is Delirium Important?
3 criteria:
Common, Morbidity & Costly!
•on admit? 15-24%
•in hospital?14-31%
•Ortho? 25-65%
•ICU: 70%!
•Death ~20-35%
•Cognitive drop in 40%
•Premature institutionalization
•LOS doubles
• ++ hospital $
•Caregiver burden
Case - Delirium
Mrs G. 79 year old lady• lives alone, manages own
apartment• slightly forgetful (according to
daughter)• PMed Hx: HTN; Insomnia• Meds:
– Hydrochlorothiazide 25 mg OD– Amitriptyline 50 mg qhs– Oxazepam 15-30 mg qhs– Occasional alcohol use
Case - Delirium
Admisssion to Hospital
• Tripped on rug, sustained a hip
fracture
• Brought to hospital. Spends 12
hours in ER waiting for bed
1) What are the risk factors that make Mrs. F vulnerable to developing delirium?
2) Suggest actions that could be initiated to reduce her risk of developing delirium
Case - Delirium
Admisssion to Hospital
• ORIF the following day
• 1st POD– climbing over bedrails– shouting all night– sleeping in day– pulling out her IV’s
3. What are the key features of delirium that the MD should elicit in Mrs. G?
The First Question –What is this?
Is this Delirium?
Dementia??
Or something else???
Delirium
Definition:
• a disturbance of consciousness with inattention that develops over a short time & fluctuates
Delirium (DSM-IV)A: Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attentionB: Change in cognition (eg. memory deficit, disorientation, language disturbance) or development of a perceptual disturbance not due to pre-existing, established or developing dementiaC: The disturbance develops over a short period of time (hours to days) and tends to fluctuate during the course of the day.D. Evidence of aetiology
Delirium versus Dementia?
DELIRIUM• Acute • Inattention• AbN LOC• Fluctuations/minutes• Reversible• Hallucinations
common
DEMENTIA• Gradual• Memory disturbance• N LOC• None/days• Irreversible• Hallucinations
common only in advanced disease
It is common for Delirium to be superimposed on Dementia!
Confusion Assessment Method (CAM)
1. History of acute onset of change in patient’s normal mental status & fluctuating course?
AND2. Lack of attention?
AND EITHER
3. Disorganized thinking?4. Altered Level of Consciousness?
Inouye SK: Ann Intern Med 1990;113(12):941-8
Arch Intern Med. 1995; 155:301
Sensitivity: 94-100%Specificity: 90-95%Kappa: 0.81
Testing Attention
• Formal methods:– MMSE: Serial 7’s, WORLD backwards– Digit Span: 5 forwards, 4 backwards– Days of Week, Months of Year backwards
• Affects all other areas of cognition
Delirium: Cognitive Evaluation
• MMSE:– inaccurate tool to diagnose delirium as the patient:
• fluctuates• has poor attention/concentration
– helpful tool to demonstrate improvement in cognitive status when following patient.
Psychomotor Variants of Delirium :
• Hyperactive ("wild man!"); 25%
• Hypoactive ("out of it!“, “pleasantly confused”); 50% - Individuals often not recognized as they may not cause a disturbance so they don’t get ATTENTION
• Mixed delirium (features of both), with reversal of normal day-night cycle (“sundowning”)
Case – Delirium: CAM• Acute /Fluctuating Course• Altered level of
Consciousness• Inattention• Disorganized Thinking
9 am
1 pm
What are the risk factors that make Mrs. F vulnerable to developing
delirium?
Top 4 Independent Risk Factors for Delirium
Vision impairment: RR=3.5 (1.2-10.7)
Any severe illness: RR=3.5 (1.5-8.2)
Cognitive impairment: RR=2.8 (1.2-6.7)
High Urea/Creatinine: RR= 2.0 (0.9-4.6)
Inouye S. Ann Intern Med 1993: 119-474
What causes delirium:Inouye Delirium Model
Fit 65 y.o. who plays senior’s hockey Frail 89 y.o. with baseline dementia
Strong or repeated precipitant needed
Minimal precipitant needed
Causes of Delirium?
• brain’s way of demonstrating “acute organ dysfunction”
• Anything that hurts the brain or impairs its proper functioning can provoke a delirium!
I WATCH DEATHMnemonic
• I Infection: Most common are pneumonias & UTI in elderly, but sepsis, cellulitis, SBE and meningitis can also occur
I WATCH DEATH
• I Infection
• W Withdrawal: benzodiazapines, ETOH,
I WATCH DEATH
• I Infection
• W Withdrawal• A Acute metabolic:
electrolytes, renal failure, acid-base disorders, abnormal glycemic control, Calcium
I WATCH DEATH
• I Infection
• W Withdrawal• A Acute metabolic• T Trauma: head injury
(SDH, SAH), pain, vertebral or hip fracture, urinary retention, fecal impaction
I WATCH DEATH
• I Infection
• W Withdrawal• A Acute metabolic• T Trauma• C CNS pathology• H Hypoxia from COPD
exacerbation, CHF
I WATCH DEATH
• I Infection
• W Withdrawal• A Acute metabolic• T Trauma• C CNS pathology• H Hypoxia
• D Deficiencies• E Endocrine• A Acute vascular/MI• T Toxins-drugs:• H Heavy metals
Medication review:
• Look at all prescriptions• include PRNs, regular,
ETOH and OTC meds• Ask if anything has been
added, changed or stopped• Watch for sleeping meds ie
Gravol; Nytol,
In other words, anything that makes an older person very
very sick…
…can cause a delirium in a vulnerable older person!
Delirium Workup
• On History: – time course of
mental status changes?
– association with other events (i.e.. meds, illness)?
– Pre-existing impairments of cognition or sensory modalities?
Physical Exam
– Vitals: normal range of BP, HR Spo2, Temp? – Good physical exam: particular emphasis on
Cardiac, pulmonary and neurologic systems
– Hydration status ? (dry axilla=dehyd!; + LR ~3)
– Also rule out • fecal impaction (DRE) • urinary retention (bladder U/S, in-and-out catheter)• Infected decubatis ulcer
Delirium workup: Lab testing
• Basic labs most helpful!– CBC, lytes, BUN/Cr,
glucose– TSH, B-12, LFTs
Calcium, & albumin
• Infection workup (Urinalysis, CXR) +/- blood cultures
• Other investigations based on Hx- EKG/CT Scan/Drug levels
Case - Delirium
Admisssion to Hospital
• ORIF the following day
• 1st POD– climbing over bedrails– shouting all night– sleeping in day– pulling out her IV’s
5. What are the main immediate treatments you would initiate?
Delirium Reduction:• You can get
improvement of delirium with such simple measures as:– Glasses– Using hearing aids– Fluids/nutrition– reducing noise– Early mobility– Familiar faces
S Inouye A multicomponent intervention to prevent delirium in hospitalized older patients.
N Engl J Med. 1999 Mar 4;340(9):669-76.
Can We Prevent Delirium
• Multi component intervention strategy
targeted to 6 delirium risk factors
Ref: Inouye SK, NEJM. 1999;340:669-676
Yale Delirium Prevention Trial Risk Factors Intervention
Cognitive Impairment Reality orientation / therapeutic activities program
Vision/Hearing impairment Vision / hearing aids / adaptive equipment
Immobilization Early mobilization / Reduce immobilizing equipment
Psychoactive medication Non pharmacologic approaches to sleep / anxiety / Restricted use of
sleeping medicationDehydration Early recognition / Volume
expansionSleep deprivation Noise reduction strategies/sleep
enhancement programRef: Inouye SK, NEJM. 1999;340:669-676
Yale Delirium Prevention TrialSignificance
• Practical intervention towards evidence based risk factors
• Significant reduction in risk of delirium
( 9.9% in intervention group vs 15% in usual care)
• Significant reduction in total delirium days
Pharmacological Rx: Goals
• Reverse psychotic signs and symptoms
• stop dangerous or potentially dangerous behavior
• To calm the patient sufficiently to conduct the necessary evaluation and treatment
Drug Treatment of Agitation• Only 4 RCTs (largest N=73):
– Neuroleptics preferable to benzodiazepines in most cases (except: PD, DLBD, ETOH)
– Low dose high potency neuroleptics (e.g., starting at haloperidol 0.25-1 mg)
– Newer “atypical” agents: no better than haloperidol
• Avoid Combination Drugs – SINGLE Drug is better
Lacasse et. al., Ann Pharm, 2006
IF SEVERE AGITATION consider Rx w/ high potency antipsychotic:
• Haloperidol: po/IM/(IV short acting):
– start with 0.5 - 1 mg initial dose – Repeat dose of 0.25-0.5 mg Q30 minutes if patient remains
unmanageable without adverse events until sedation achieved and continue monitoring
– repeat cycle until acceptable response or adverse events occur– max suggested Haldol dose in frail elderly 3-4mg/24 hr
• Maintenance: 50% loading dose in divided doses over next 24 hrs
• Taper the dose as soon as possible• Avoid in individuals with Parkinson’s Disease
Benzodiazepines
1. Avoid use in combination with
antipsychotics - SINGLE drug is better.
2. May cause disinhibition/increased agitation.
3. Best reserved for Delirium 2o to alcohol /
Benzodiazepine withdrawal.
4. Relatively contraindicated in Delirium from
Hepatic Encephalopathy.
Summary - Recognition of Delirium
• Delirium is Common
• Yale- New Haven study
– 65% of cases unrecognized by Physicians
• Don’t be part of that group!
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