Delirium in the Elderly

1. Delirium in the Elderly Bree Johnston MD MPH UCSF Division of Geriatrics Primary Care Geriatric Lectures

2. Case Study Mrs. M. is a 70 year old woman with a history of thalamic CVA, bipolar illness, chronic pain, and osteoarthritis. She takes tylenol with codeine, valproate, lithium, conjugated estrogens with progesterone, and aspirin. Two months ago, her daughter died unexpectedly, and she has been more depressed. One week ago, she became agitated and uncooperative. She was seen in the ER, where labs and CXR were normal. A consulting psychiatrist recommended clonezapam.

4. Presentation of MI in the Elderly Patients could have more than one presentation in these studies Neuro sx including dizziness, focal neuro sx, and mental status changes On this slide I try to make the point that neuro manifestations are typical, not atypical presentations of MI in the elderlyPatients could have more than one presentation in these studies Neuro sx including dizziness, focal neuro sx, and mental status changes On this slide I try to make the point that neuro manifestations are typical, not atypical presentations of MI in the elderly

5. Atypical Presentations This is kind of a confusing study. This was a cohort study that looked at hospitalized �well� or previously �frail� (as defined by Barthel index) elders who were hospitalized for various reasons (pneumonia, MI, CHF, etc.) and categorized as having �typcial� or �atypical� presentations. The points are: Atypical presentations are common Delirium is the most common atypical presentation Frail elders are more likely to have atypical prsenations than well eldersThis is kind of a confusing study. This was a cohort study that looked at hospitalized �well� or previously �frail� (as defined by Barthel index) elders who were hospitalized for various reasons (pneumonia, MI, CHF, etc.) and categorized as having �typcial� or �atypical� presentations. The points are: Atypical presentations are common Delirium is the most common atypical presentation Frail elders are more likely to have atypical prsenations than well elders

6. Learning Objectives Recognize that delirium is a common presentation of disease in the elderly Recognize that delirium is associated with adverse outcomes Know how to distinguish between delirium and other diagnoses (dementia, depression) Identify risk factors for delirium and strategies for risk reduction Discuss management strategies, recognizing the limitations of current data

7. Definition �an acute disorder of attention and cognition� (de lira �off the path�) Standard definition not use until 1980 with publication of DSM III Other terms used include organic brain syndrome, metabolic encephelopathy, toxic psychosis, acute mental status change, exogenous psychosis, sundowning

8. Prevalence Schor 1992 Medical & surgical >65 N=325 11% Prevalence, 31% incidence Johnson 1990 Medical >70 N=235 16% prevalence, 5% incidence Francis 1990 Medical >70 N=229 16% prevalence, 8% incidence Gufstafson 1988 Femoral neck Fx >65 N=111 33% prevalence before surgery, 42% incidence after srugery I like to highlight how common delirium is after hip fracture and get audience to speculate why. Some possible reasons: Frail elders get hip fracturs Dementia and hip fracture Maybe delirium is causative for the fracture Fat emboli Pain meds OtherI like to highlight how common delirium is after hip fracture and get audience to speculate why. Some possible reasons: Frail elders get hip fracturs Dementia and hip fracture Maybe delirium is causative for the fracture Fat emboli Pain meds Other

9. Pathophysiology Nonspecific manifestation of a widespread reduction in cerebral metabolism & derangement of neurotransmission due to: Cholinergic deficiency GABA Dopamine NE Specific receptors ( e.g., steroid) Alteration of blood flow, inflammation I like to highlight here that there are probably many subtypes of delirium and we tend to treat them all the same. Maybe different sybtypes require different treatmentsI like to highlight here that there are probably many subtypes of delirium and we tend to treat them all the same. Maybe different sybtypes require different treatments

10. Delirium Risk Factors Age Cognitive impairment 25% delirious are demented 40% demented in hospital delirious Male gender Severe illness Hip fracture Fever or hypothermia Hypotension Malnutrition High number of meds Sensory impairment Psychoactive medications Use of lines and restraints Metabolic disorders: Azotemia Hypo- or hyperglycemia Hypo- or hypernatrmiea Depression Alcoholism Pain Multiple risk factors for delirium have been sited in the literature, and not all of them pan out when controlling for other factors. Of note, when a patient is delirius is NOT the time to make a diagnosis of demenita, and one must be very careful in labeling a person as demented during a hospital stay. Most appropriate to question dementia and follow up as outpatientMultiple risk factors for delirium have been sited in the literature, and not all of them pan out when controlling for other factors. Of note, when a patient is delirius is NOT the time to make a diagnosis of demenita, and one must be very careful in labeling a person as demented during a hospital stay. Most appropriate to question dementia and follow up as outpatient

11. Delirium Risk Model Baseline characteristics on admission: Vision impairment (< 20/70) Cognitive impairment (MMSE <24) Severe illness (APACHE II>16) BUN/Cr ratio > 18 Precipitating Factors Use of physical restraints RR 4.4 Malnutrition RR 4 3 new meds RR 2.9 Use of bladder catheter RR 2.4. Iatrogenic event 1.9 Graph shows Validation (not derivation) cohort numbers Note that 11.6% incidence of delirium per day corresponds to a rate of 67% for an average hospital stayBaseline characteristics on admission: Vision impairment (< 20/70) Cognitive impairment (MMSE <24) Severe illness (APACHE II>16) BUN/Cr ratio > 18 Precipitating Factors Use of physical restraints RR 4.4 Malnutrition RR 4 3 new meds RR 2.9 Use of bladder catheter RR 2.4. Iatrogenic event 1.9 Graph shows Validation (not derivation) cohort numbers Note that 11.6% incidence of delirium per day corresponds to a rate of 67% for an average hospital stay

12. Surgical Prediction Rule Alcohol abuse 1 TICS score < 30 (dementia ) 1 SAS Class IV (severe impairment) 1 Abnormal pre-operative Na, K, glucose 1 A3 surgery 2 Noncardiac thoracic surgery 1 Age > 70 1

13. Clinical Prediction Rule for Post-surgical Delirium Total Points Risk of Delirium (incidence, validation cohort) 0 2 1 or 2 11 3 or more 50 Marcantonio et al. JAMA 1994 134-139

14. Outcomes Death: 8% vs. 1%, 90 day mortality 11% vs. 3% Lengthened hospital stay: 12 days vs. 7 days Increased nursing home placement: 16% vs. 3% Functional decline Iatrogenesis Francis J et al. JAMA 1990;263:1097. Levkoff SE et al. Arch Intern Med 1992;152:334 Pompei et al. JAGS 1994; 42: 809

16. Differential Diagnosis CNS pathology Dementia, particularly frontal lobe Other Psychiatric disorders Psychosis Depression: 41% misdiagnosed as depression Farrell Arch Intern Med 1995 Bipolar disorder Aconvulsive status epilepticus Akathisia Overall, 32-67% missed or misdiagnosed I like to make the point here that some delirium presents quietly and some with agitation, and we probably do a better job ofidentifying activated versus somnolent patients. In one study, about 2/3 of patients with somnolent and 1/3 activated (ROSS et al, international pyshcogeriatrics, 1991 Vol 3, page 135)I like to make the point here that some delirium presents quietly and some with agitation, and we probably do a better job ofidentifying activated versus somnolent patients. In one study, about 2/3 of patients with somnolent and 1/3 activated (ROSS et al, international pyshcogeriatrics, 1991 Vol 3, page 135)

17. Diagnosis DSM-IV A. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention. B. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. C. The disturbance develops over a short period of time and tends to fluctuate during the course of the day D. There is evidence from the history, PE, or labs that the disturbance is caused by the direct physiologic consequences of a general medical condition

19. Diagnostic Tools Sensitivity Specificity CAM* .46-.92 .90.92 Delirium Rating Scale* .82-.94 .82-.94 Clock draw .87 .93 MMSE (23/24 cutoff) .52-.87 .76-.82 Digit span test .34 .90 *validated for delirium & capable of distinguishing delirium from dementia

20. Diagnosis

21. Delirium versus Dementia Delirium Rapid onset Primary defect in attention Fluctuates during the course of a day Visual hallucinations common Often cannot attend to MMSE or clock draw Dementia Insidious onset Primary defect in short term memory Attention often normal Does not fluctuate during day Visual hallucinations less common Can attend to MMSE or clock draw, but cannot perform well

22. Medications and Delirium Sedative-hypnotics, especially benzos Narcotics, especially meperidine Anticholinergics Miscellaneous Lidocaine -Propranolol Amiodorone -Digoxin H2 Blockers -Lithium Steroids -Metoclopromide NSAIAs -Levodopa Consider any drug a possible cause

23. Searching for the cause History and PE (consider possible urinary retention & PVR, impaction) Discontinue or substitute high risk meds Labs: CBC, lytes, BUN, Cr, glucose, calcium, LFTs, UA, EKG And if those don�t tell you, consider: Neuroimaging CSF Tox screen, thyroid, B12, drug levels, ammonia, cultures, ABG EEG - in difficult cases to r/o occult seizures or psych disorders - 17% false neg, 22% false pos

24. Can Interventions Prevent Delirium?

25. Possible Benefit From: Preoperative psychiatric assessment followed by nursing reorienation (33% vs 14%) Postoperative reorienation (87% vs 6%) Preoperative education about delirium (78% vs. 59%) Pre and post operative psychiatric intervention (13% vs 0) British J. Psych 1996 512-515 Can Med Ass J 1994 965-70 Nurs Res 1974 341-348 Res Nurs Health 1985 329-337

26. Can Interventions Prevent Delirium? 852 patients aged 70+ Prospective matching of patients on intervention unit with patients on 2 usual care units Risk factor reduction strategy targetting: cognitive impairment sleep deprivation immobility visual impairment dehydration

27. Intervention Protocol Cognition Orientation, activities Sleep Bedtime drink, massage, music, noise reduction Immobility Ambulation, exercises Vision Visual aids and adaptive equipment Hearing Portable amplifiers, cerumen disimpaction Dehydration BUN, volume repletion

28. Results

29. Preventing Delirium post Hip fracture RCT of 126 patients Intervention: �Proactive� Geriatric Consultation with Daily Visits and structured protocols Control Group: Management by orthopedist + consultation on as-needed basis Outcomes: MMSE, delirium, LOS Marcantonio, JAGS 2001

30. Protocols for: Fluid/electrolytes Pain treatment Eliminating unnecessary medications Bowel/bladder function Nutrition Mobilization CNS oxygenation Prevention of complications (MI, PE, UTI, pneumonia) Environmental stimuli Treatment of agitated delirium Marcantonio, JAGS 2001

31. Delirium in Hip fracture

32. Interventions that May Help Eliminate extra meds, reverse metabolic abnormalities, hydration, nutrition Geriatric consultation? Education of patients and family Re-orientation by staff, family, sitters, clocks, calendars Remove nonessential lines and tubes Quiet, noninterrupted sleep at night Stimulation (but not too much) during day Discharge home?

33. Drug therapy All drug therapy has side effects Use only if delirium interfering with therapy, or risking patient�s or others� safety and welfare Almost no data on outcomes in drug treated versus non drug treated patients No good RCTs Approach based on case reports and expert opinion

34. Drug Therapy of Delirium One small RCT of neuroleptics vs. benzos in AIDS associated delirium/dementia found higher SE�s with benzos Improved outcomes with neuroleptics (N=67) Small sample, generalizability uncertain Breitbart et al Am J Psych 1996 231-237

35. Neuroleptics Considered agents of choice for most cases of delirium RCTs in agitation and dementia suggest benefit (NNT = 5) Side effects can include extrapyramidal SE�s, hypotension, sedation, akathisia Sedation effect before antipsychotic effect Haloperidol, droperidol Atypicals: Respiridone, olanzapine

36. Use of Haloperidol Lowest possible dose, e.g., .5-1.0 BID tapering down as delirium clears 0.5mg, repeat every 30 minutes until agitation is controlled Some advocate doubling of dose every 30 minutes until agitation is controlled (probably not wise in elderly!) Droperidol can be used IV - more rapid onset Caution: sedation, hypotension, less anti-psychotic than haloperidol

37. Atypical neuroleptics Risperidone: for those with side effects from haloperidol or contraindications Starting dose: .5mg HS or BID Olanzapine: agent of choice for patients with PD with hallucinations/delirium Starting dose 2.5mg PO HS or BID

38. Benzodiazepines Should usually be avoided Agents of choice for ETOH, benzo withdrawal More rapid onset than neuroleptics Peak effects brief, sedation more common, can prolong delirium May be useful in terminal delirium associated with high dose narcotics and myoclonus Lorazepam .5-1 mg IV or PO (t1/2 15-20 hours)

39. Other agents ?Trazadone 25-100mg Physostigmine (don�t try this) reverses delirium due to anticholinergic activity SE�s: bradycardia, asystole, bronchospasm, seizures ?Donepezil ?Mood stabilizers Narcotics and pain medications (empiric use in patients with dementia often helpful)

40. Delirium in the ICU Unlikely to be entirely preventable due to burden of illness, interventions, and environment Restraints less humane than sedation (my opinion) Sitters versus sedation? Depth of sedation? Sedative of choice? Bottom Line: RCTs needed

41. Sedation in the ICU

42. Sedation in the ICU RCT of 128 inpatients receiving mechanical ventilation and continuous sedation in medical ICU Intervention: Interrupt sedation until patient awake on a daily basis versus usual care Duration of ventilation 4.9 vs 7.3 (p=0.004) in intervention vs control group Median Length of stay 6.4 vs 9.9 days (p=0.02) Kress et al NEJM May 18, 2000

43. Prevention is the Best Medicine All evidence suggests that it is easier to PREVENT delirium than to TREAT delirium Prevention of delirium is least likely to be possible in the intensive care unit Treatment of delirium in the intensive care unit is particularly challenging and most likely to require medications, sitters, and/or physical restraints

44. Summary Delirium is common in older inpatients, associated with poor outcomes, and commonly missed or misdiagnosed Prevention is the best approach Management involves treating underlying causes, minimizing medications, supportive care, and avoidance of restraints when possible ICU delirium poses particular challenges Further research and RCTs are needed