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Subacute Befuddlement: The Identification of Delirium

Subacute Befuddlement: The Identification of Delirium. Learning Objectives. List 4 key factors to distinguish dementia and delirium Use the CAM tool for rapid identification of elderly patients with delirium in the hospital or clinic setting Identify “flavors” of delirium:

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Subacute Befuddlement: The Identification of Delirium

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  1. Subacute Befuddlement: The Identification of Delirium

  2. LearningObjectives • List 4 key factors to distinguish dementia and delirium • Use the CAM tool for rapid identification of elderly patients with delirium in the hospital or clinic setting • Identify “flavors” of delirium: • Hyperactive (agitated) • Hypoactive • Mixed

  3. Origins… • Latin: • De = away from • Lira = furrow in a field • “going off the plowed track” • coined by Roman author Celsus in 1AD?

  4. Why does delirium matter to patients? In hospital: After discharge: longer LOS more institutionalization greater mortality persistence of cog sx functional disability higher 2 yr mortality

  5. Delirium is common & missed(throughout the hospital course) “Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes” • Patients in emergency dept >65 years N=303 • 25(8.3%) were found CAM + for delirium • 19 were missed in emergency dept • 16 admitted to hospital • 15 missed on hospital admission Han JH, Zimmerman EE, Schnelle J, Morandi A, Dittus RS, Ely EW, Acad Emerg Med, 2009 Mar; 16 (3):193-200 Epub 2009 Jan 20.

  6. Delirium vs. Dementia

  7. Flavors of delirium Quiet withdrawn state – hypoactive delirium – lethargy and decreased activity • More common in older patients. • Also more common in ICU patients.

  8. Flavors of delirium Acutely agitated – hyperactive delirium • more commonly seen in younger patients • but can present in elderly patients

  9. Flavors of delirium Both hypoactive and hyperactive delirium in the same patient at various times: Mixed delirium

  10. DSM IV criteria for delirium due to a general medical condition: • 1. Disturbance of consciousness with a reduced ability to focus, sustain, or shift attention.

  11. DSM IV criteria for delirium due to a general medical condition: • 1. Disturbance of consciousness with a reduced ability to focus, sustain, or shift attention. • 2. A change in cognition or a perceptual disturbance that cannot be explained by a coexisting dementia.

  12. DSM IV criteria for delirium due to a general medical condition: • 1. Disturbance of consciousness with a reduced ability to focus, sustain, or shift attention. • 2. A change in cognition or a perceptual disturbance that cannot be explained by a coexisting dementia. • 3. It develops quickly, and fluctuates during the course of the day.

  13. DSM IV criteria for delirium due to a general medical condition: • 1. Disturbance of consciousness with a reduced ability to focus, sustain, or shift attention. • 2. A change in cognition or a perceptual disturbance that cannot be explained by a coexisting dementia. • 3. It develops quickly, and fluctuates during the course of the day. • 4. There is evidence that this is caused by a medical condition.

  14. Medical problems can contribute to delirium: • Acute cardiac events • Acute pulmonary events • Bed rest • Sedative or EtOH withdrawal • Fluid/lyte abnormalities • Infections • Intracranial events • Meds • Anemia • Uncontrolled pain • Urinary retention or fecal impaction • Indwelling devices • Restraints

  15. Drugs we give patients may contribute to delirium: • Anticholinergic agents • Antipsychotics • Antidepressants • Anxiolytics, especially benzodiazepines • Cardiac • H2 blockers • Narcotic analgesics • Sedative hypnotics

  16. Pathophysiology: of our drugs • Cholinergic inhibition: meds, medical/surgical illness • GABA activation: meds, hepatic failure • Serotonin deficiency: med/surg illnesses -> phenylalanine elevation/tryptophan depletion • Cytokine excess • Dopamine activation: meds, CVA • Cortisol excess: glucocorticoids, Cushings, CVA, surgery Flacker JM. J Geront Biol Sci 1999;54:B239-46.

  17. On top of predisposing risk factors: • age (>70 y/o) • dementia • functional ADL impairments • high medical co-morbidity • EtOH abuse • Male • Sensory impairment Marcantonio ER: Delirium. In: Rakel RE Conn’s Current Therapy 2001.

  18. How do you identify Delirium? Assess the patient using the CAM test To be “CAM Positive” for delirium, the patient must meet the following criteria: Mental status changes: acute onset or fluctuating course & Inattention & Disorganized thinking OR Altered level of consciousness

  19. #1 Acute onset or fluctuations? • Do not use the current hospital status to define the baseline. • Establish the temporal course and severity to distinguish pre-existing dementia from delirium. • Knowing baseline level of function can help.

  20. #2 Is there inattention? • Is the patient having difficulty focusing attention, easily distractible, having difficulty tracking?

  21. #3 Is there disorganized thinking? • Is there disorganized thinking, rambling, irrelevant conversation, unclear flow of ideas, tangential or loose associations? • Screened by: • Yes/No logic questions. • Simple conversation if verbal. • Simple commands.

  22. #4 Decreased (or changed) level of consciousness? Agitation? Somnolence?

  23. Delirium prevention through “Hospital Elder Life Program” principles Inouye, SK. Delirium in older persons. NEJM 2006;354:1157-6 Cognitive stimulation:Keep oriented/Current events Word games Vision/Hearing:Glasses, hearing aids Mobility: Ambulate/Ex/ROM Avoid restraints, catheters Sleep:Quiet! Avoid disruptions Avoid hypnotics – try behavioral techniques Hydration: Assess (consider oral vs. IV)

  24. Identification & treatment of underlying causes: • Find & treat delirium underlying cause(s) (30% may be unknown) • Through: History taking Physical exam Labs Imaging (when clinically indicated)

  25. In the meantime—non-pharmacologic measures first General Support Hydration Nutrition Comfort Safety Review/reduce medications Avoid restraints!

  26. Management of Delirium Sx:(Pharmacologically) • Currently there is controversy over the use and efficacy of medications to manage agitation associated with delirium • Could consider antipsychotic medications Only If agitated & risk of harm to self or others • Side effects may include: extrapyramidal side effects, long QT syndrome, hypotension, anticholinergic effects, confusion, cardiac effects

  27. Summary approach to delirium Recognize the urgency of delirium in geriatric patients Prevent delirium when possible Recognize delirium Act! Keep patient safe Initiate evaluation Treatment: Underlying causes Non-pharmacologic support Pharmacologic (when necessary only)

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