Sundowning & Delirium

1. Sundowning & Delirium Francisco Fernandez, M.D., USF Health, Department of Psychiatry, Tampa, FL www.thecjc.org

3. Sundowning: Definition • Sundowning  a group of behaviors occurring in some older patients with or without dementia at the time of nightfall or sunset. • BEHAVIORS: • Confusion • Anxiety, agitation, or aggressiveness • Psychomotor agitation (pacing, wandering) • Disruptive, resistance to redirection • Increased verbal activity • Overlap with dementia, delirium, and sleep disturbance.

4. Epidemiology of Sundowning Syndrome • Not uncommon phenomenon • Exact prevalence unknown • Reports have ranged between 2.4% and 25% • In patients with Alzheimer’s disease or dementia, the range is widened up to 66%

5. Risk Factors for Sundowning: Physiologic Factors • Circadian abnormalities in elderly and in patients with Alzheimer’s disease progress concomitantly with their behavioral and cognitive dysfunction. • Sundowning is more common in AzD. • Neurofibrillary tangles found in the hypothalamus of patients with Alzheimer’s may lead to the behavioral changes of sundowning through mechanical disruption of brain tissue. • Pathologic damage to the suprachiasmatic nucleus (SCN) is believed to result in disruptive behaviors associated with sundowning.

6. Amount of daily light exposure Activities during the day Noise level Disruptions at night Medications Medical comorbidities Nursing home residents with sundowning were more likely to Recent admission Moved to a new room Staff shift changes Low levels of lighting during the day and bright hallway lighting during the night Increased naptime during daytime hours and reduced nighttime sleep Risk Factors for Sundowning: Environmental Factors

7. Etiology of Sundowning • Dysfunction of the circadian rhythm result in disturbed sleep and agitation • Deterioration of the SCN seen in patients with Alzheimer’s disease is actively investigated to be an important factor in the disruption of the circadian rhythms. • Suprachiasmatic nucleus volume and cell number are found to be decreased in those between the ages of 80 and 100 years. • Melatonin is found to be decreased in the cerebrospinal fluid levels of patients with Alzheimer’s disease.

8. Mrs. Flabeetz • 84 yo female, living at the NH for the last 8 years after a stroke; was having problems managing at home • Axis III: Type II Diabetes and hypertension • Active in her NH, using her walker; also a little more forgetful and repetitive, and this has been getting slowly worse over the last year

9. In the ER… • Came into ER after being found on the floor of the NH • Unable to get up and complaining of L hip and abdominal pain • In the ER, very muddled up & disoriented • incontinent of foul smelling urine • Picking at imaginary things, scared, and very frightened

10. Initial work up… • No fracture on X-ray • Normal CBC, lytes and troponins • CT head shows mild atrophy & bilateral lacunar infarcts • Urine collected from foley inserted shows E. coli; started ABX • Admitted to Medicine for further assessment and work up of confusion Alas! It’s been 5 days later, and she’s still not better … TRANSFER TO PSYCHIATRY!!!!!!!

11. What would you do? Is this Delirium? Dementia?? Or something else??? Would you transfer to Psychiatry Service?

12. Delirium • Most common psychiatric disorder in the medically ill • Point prevalence - 20% of all admissions • 30% new onset among medical inpatients • 50% medical and surgical patients > 60 yo • 89% of patients with known dementia • Higher prevalence with increasing age, CNS disease, CABG, and THR • NOT a benign condition - sign of impending death in 25% cases • Etiology - multifactorial Rothschild et al, Arch Int Med 2000; Burns et al, JNNP 2004

13. Diagnostic Criteria: DSM-IV • Disturbance of consciousness (reduced clarity of awareness of environment) • Reduced ability to focus, sustain or shift attention • A change in cognition (memory, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted by dementia

14. Diagnostic Criteria: DSM-IV • The disturbance develops over a short period of time (usually hours to days) • All abnormalities tend to fluctuate during the course of the day

15. Diagnostic Criteria: DSM-IV • There is evidence from the medical history, physical examination, or laboratory findings of: • A general medical condition etiologically related • Sepsis, seizures, tumor, hypercalcemia, hypoglycemia • Substance induced intoxication or withdrawal • More than one etiology • NOS

16. “Motoric” Subtypes Various levels of psychomotor activity are associated with delirium: • Hypoactive • Hyperactive • Mixed

17. Adapted from Ross et al., Int Psychoger 1991

18. “Motoric” Subtypes • Subtyping not fully accepted by all disciplines • Subtyping may have implications for treatment

19. Epidemiology & Risk Factors • Depending on the cohort, the prevalence of delirium ranges from 8% to 80% • Post-surgical rates > general medical patients • Advancing age increases the risk (> 60 yoa) • 15-20% of patients on a medical surgical ward have an undetected delirious process Burns et al, JNNP 2004; Kales et al, JNNP 2002; vanZyl & Davidson, Can J Psych 2003

20. Epidemiology and Risk Factors • The Commonwealth-Harvard Study (Levekoff et al., Int Psychoger, 1991) • Patients 65 yoa or older • Admissions to Beth Israel Hospital from Hebrew Rehabilitation Center (n=114) and East Boston CHC (n=211) • CHC  24.2% were delirious • HRC  64.9% were delirious

21. Epidemiology and Risk Factors • CNS abnormality • Dementia, coexisting structural brain disease, and HIV-1 infection increase the risk • Drug dependency • Alcohol, sedative hypnotics, stimulants, steroid (rapid taper) increase the risk • Low serum albumin • Malnutrition, chronic disease, aging, nephrotic syndrome, hepatic insufficiency

22. Why is Delirium important? Delirium has a poor prognosis • Ý LOS (>7d more) • Ý risk dementia dx (55%/2y) • Ý ADL decline • Ý institutionalization • Ý mortality (2.1x/12 mos) McCusker et al, JAGS 2003; McCusker et al, Arch Int Med 2002; Rahkonen et al, JNNP; Inouye et al, JGIM 1998

23. Delirium Risk : A Predictive model • Independent risk factors on admission in a prospective cohort of elderly medical inpts 1. Vision < 20/70 2. Severe illness (APACHE > 16) 3. MMSE <24 Inouye et al, Ann Int Med 1993

24. Diagnosis • Rapid recognition of either prodromal or fully developed clinical features • “A,B,C’s” of Neuropsychiatry (Affect, Behavior and Cognition) • Prodromal features • Restlessness, anxiety, irritability, sleeplessness, hypervigilance, distractibility, fatigue, disinterest, hypersomnolence, inattentiveness, depressed, disillusionment

25. Diagnosing Delirium Delirium Sx Interview 1. Orientation 2. Sleep disturbance 3. Perceptual disturbance 4. Speech disturbance 5. Disturbance of consciousness 6. Psychomotor activity 7. Affect & behavior Albert et al, J Ger Psych Neurol 1992

26. Diagnosis: MSE • Mental status examination • Cognitive history  chart review • What changes (consciousness, restlessness, anxiety, moodiness) • When did changes occur (starting/stopping drug, fever, hypotension, deteriorating renal function, rhythm changes) • MMSE, focused NBE

27. Diagnosis Testing - Standard • MMSE & CDT • -Not designed for delirium • -Useful at separating “normal” from “abnormal” • -Not specific for distinguishing delirium from dementia • -May be useful as change from baseline • -Overkill  add TMT-A, TMT-B

28. Diagnostic Testing: Tools Sensitivity Specificity • CAM* .46-.92 .90.92 • Delirium Rating Scale .82-.94 .82-.94 • Clock draw+ .87 .93 • MMSE (24 cutoff) .52-.87 .76-.82 • Digit span test .34 .90 *validated for delirium & capable of distinguishing delirium from dementia +validated for delirium, correlated with deterioration of dominant frequencies on EEG

29. 1. [Acute Onset] Is there evidence of an acute change in mental status from the patient's baseline? 2A. [Inattention] Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? 2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come and go or increase and decrease in severity? 3. [Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. [Altered level of consciousness] Overall, how would you rate this patient's level of consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain) 5. [Disorientation] Was the patient disoriented at any time during the interview, such as thinking that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day? 6. [Memory impairment] Did the patient demonstrate any memory problems during the interview, such as inability to remember events in the hospital or difficulty remembering instructions? 7. [Perceptual disturbances] Did the patient have any evidence of perceptual disturbances, for example, hallucinations, illusions or misinterpretations (such as thinking something was moving when it was not)? 8A. [Psychomotor agitation] At any time during the interview did the patient have an unusually increased level of motor activity such as restlessness, picking at bedclothes, tapping fingers or making frequent sudden changes of position? 8B. [Psychomotor retardation]. At any time during the interview did the patient have an unusually decreased level of motor activity such as sluggishness, staring into space, staying in one position for a long time or moving very slowly? 9. [Altered sleep-wake cycle]. Did the patient have evidence of disturbance of the sleep-wake cycle, such as excessive daytime sleepiness with insomnia at night?

30. Dx Delirium with CAM http://www.hartfordign.org/publications/trythis/issue13.pdf 1. Acute onset, fluctuating course AND 2. Inattention AND EITHER 3. Disorganized thinking OR 4. Altered level of consciousness *sensitivity 94 - 100%; specificity 90 - 95% Inouye et al, Ann Int Med 1990

31. Diagnostic Testing: EEG • Diffuse slowing • Most helpful to get a baseline • Patients with AzD may have abnormally slowed EEG • Worsens from baseline with delirium • Patients with minimal slowing may have test read as “normal” • Alpha (13 cps) may slow down (9 cps) and still be in normal range • Comparison with baseline • Comparison with repeat EEG post delirium

32. What Causes Delirium? The Importance of DDx

33. Differential Diagnosis: Urgent • When in doubt, throw out the • Wernicke’s • Withdrawal • Hypoxia • Hypoglycemia • Hyper- hypotension • Infection • Intracranial bleed • Meningitis • Poisoning • Failure to make these diagnoses may lead to permanent CNS damage

34. IInfection:   Most common are pneumonias & UTI in elderly, but sepsis, cellulitis, SBE and meningitis can also occur I WATCH DEATH

35. I  Infection  WWithdrawal:benzodiazapines, ETOH, opiates I WATCH DEATH

36. I  Infection  W  Withdrawal AAcute metabolic: electrolytes, renal failure, acid-base disorders, abnormal glycemic control, pancreatitis I WATCH DEATH

37. I  Infection  W  Withdrawal A  Acute metabolic TTrauma: head injury (SDH, SAH), pain, vertebral or hip fracture, concealed bleed, urinary retention, fecal impaction I WATCH DEATH

38. I  Infection  W  Withdrawal A  Acute metabolic T Trauma CCNS pathology: tumor, dementia, encephalitis, meningitis, abscess I WATCH DEATH

39. I  Infection  W  Withdrawal A  Acute metabolic T Trauma C  CNS pathology HHypoxia from COPD exacerbation, CHF I WATCH DEATH

40. I  Infection  W  Withdrawal A  Acute metabolic T Trauma C  CNS pathology H  Hypoxia  DDeficiencies: B-12, folate, protein, calories, water I WATCH DEATH

41. I  Infection  W  Withdrawal A  Acute metabolic T Trauma C  CNS pathology H  Hypoxia  D  Deficiencies EEndocrinethyroid, cortisol, cancer I WATCH DEATH

42. I  Infection  W  Withdrawal A  Acute metabolic T Trauma C  CNS pathology H  Hypoxia  D  Deficiencies E  Endocrine AAcute vascular/MI : stroke, myocardial infarction I WATCH DEATH

43. I  Infection  W  Withdrawal A  Acute metabolic T Trauma C  CNS pathology H  Hypoxia  D  Deficiencies E  Endocrine A Acute vascular/MI TToxins-drugs Really anything, but anti-cholinergics, long acting benzodiazepines, narcotics (meperidine) and other psychotropics are common bad actors, OTC, OPM I WATCH DEATH

44. 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: HHeavy metals(lead, mercury, platinum) I WATCH DEATH

45. Dementia and Delirium • Dementia is a risk factor for delirium • Diagnosis of delirium in context of dementia is often missed • Of 2000 consecutive admissions: • 9.1% of patients had diagnosis of dementia • 41.4% of these demented patients had delirious process on admission Erkinjuntii et al., Arch Int Med, 1986

46. 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 Delirium versus Dementia? It is common for Delirium to be superimposed on Dementia!

47. So What? Who Cares?Delirium is unimportant! 3 criteria: Common, Morbidity & Costly! • On admit? 15-20% • In hospital? 7-31% • Ortho - 25-65% • ICU: 90% • Death ~20-35% • Cognitive drop in 40% • Premature institutionalization • LOS doubles • ++ hospital $ • Caregiver burden

48. What can trigger Delirium? ANYTHING!!!

49. Age Dementia Male Dehydration Malnutrition ↓ Physical fn/ immobility ↓ Hearing ↓ Vision Severity of illness Comorbid psych dx (Depression; EtOH abuse) Patient Predisposing Factors Elie et al, JGIM 1998; Burns et al, JNNP 2004

50. # of room changes Absent clock/watch Absent reading glasses Absence of family Bladder catheter ICU or LTC Restraints Environmental Predisposing Factors McCusker et al, JAGS 2001