Incidence Among Elderly Patients is HIGH

2. Incidence Among Elderly Patients is HIGH • 1/3 of patients presenting to ER • 1/3 of inpatients aged 70+ on general med units • Incidence ranges 5.1% to 52.2% after noncardiac surgery • 15-53% of older patients post op • Highest rates after hip fracture and aortic surgeries • 70-87% of patients in the ICU Dasgupta M et al. J Am Geriatr Soc 2006;54:1578-89

3. Delirium: Increased Mortality • One-year mortality: 35-40% • Independent predictor of higher mortality up to 1 year after occurrence • Hazard Ratio between 2 and 3 • Elderly medical inpatients: Adjusted for dementia, comorbidity, clinical severity, APACHE II score, admitting service (med vs. geri), demographic variables (McCusker J et al. Arch Intern Med. 2002; 162:457-463) • Mechanically ventilated MICU & CCU patients: Adjusted for coma, age, CharlsonComorbidity Index, APACHEII score, SOFA, admitting diagnosis of sepsis or ARDS, sedative and narcotic use Ely EW et al. JAMA. 2004; 291:1753-62

4. Delirium: Increased Risk of… • Functional decline • New nursing home placement • Persistent cognitive decline: • 18-22% of hospitalized elders with complete resolution 6-12 months after discharge • CAVEAT: Many subjects with preexisting cognitive impairment Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704

5. Delirium: Costs • Complicates the hospital stays for >7.3 older pts • Diagnosis increases the hospital costs by $2,500 per patient • 6.9 billion (2004) of Medicare hospital expenditures

6. Diagnosis: Call it what it is… • DELIRIUM: ICD-9 code 780.09 • “Δ MS” or “mental status change”: • No ICD-9 code

7. Why is diagnosis not made? • Fluctuating course • Overlap with dementia • Lack of formal cognitive assessment • Under appreciation of consequences • Failure to consider it important

8. Diagnosis: Confusion Assessment Method (CAM) • Acute change in mental status with a fluctuating course • Inattention AND 3. Disorganized thinking or 4. Altered level of consciousness Sensitivity: 94-100%; Specificity: 90-95% Inouye SK et al. Ann Intern Med. 1990; 113: 941-948

9. How to Distinguish Delirium from Dementia • Features seen in both: • Disorientation • Memory impairment • Paranoia • Hallucinations • Emotional lability • Sleep-wake cycle reversal • Key features of delirium: • Acute onset • Impaired attention • Altered level of consciousness

10. Assume it is Delirium until Proven Otherwise Delirium may be the only manifestation of life-threatening illness in the elderly patient.

11. A Model of Delirium A multifactorialsyndrome that arises from an interrelationship between: • Predisposing factors a patient’s underlying vulnerability AND • Precipitating factors noxious insults

12. Predisposing Factors (vulnerability) versus Precipitating Factors (insults)

13. Predisposing Factorsi.e. baseline underlying vulnerability • Baseline cognitive impairment • 2.5 fold increased risk of delirium in dementia patients • 25-31% of delirious patients have underlying dementia • Medical comorbidities: • Any medical illness • Visual impairment • Hearing impairment • Functional impairment • Depression • Advanced age • History of ETOH abuse • Male gender

14. Precipitating Factorsi.e. noxious insults • Medications • Bed rest • Indwelling bladder catheters • Physical restraints • Iatrogenic events • Uncontrolled pain • Fluid/electrolyte abnormalities • Infections • Medical illnesses • Urinary retention and fecal impaction • ETOH/drug withdrawal • Environmental influences

15. Some Drug Classes Associated with Delirium • Medications with psychoactive effects: • 3.9-fold increased risk • 2 or more meds: 4.5-fold • Sedative-hypnotics: 3.0 to 11.7-fold • Narcotics: 2.5 to 2.7-fold • Anticholinergic drugs: 4.5 to 11.7-fold • Risk of delirium increases as number of meds prescribed rises

16. Prevention of Delirium: It can be done! Find patients with 1 to 4 of the following predisposing characteristics: • Visual impairment (worse than 20/70 corrected) • Severe illness • Cognitive impairment (MMSE<24/30) • High BUN/Cr ratio (>18) Inouye SK et al. Ann Intern Med. 1993; 119:474-481

17. Prevention = Good Hospital Care for the Elderly Patient Inouye SK et al. NEJM. 1999;340:669-76

18. A Multicomponent Intervention to Prevent Delirium Inouye SK et al. NEJM. 1999;340:669-76

19. Keys to Effective Management Find and treat the underlying disease(s) and contributing factors • Comprehensive history and physical • Including neurological and mental status exams • Choose lab tests and imaging studies based on the above • Review medication list

20. Always Try Nonpharmacologic Measures First • Presence of family members • Interpersonal contact and reorientation • Provide visual and hearing aids • Remove indwelling devices: i.e. Foley catheters • Mobilize patient • A quiet environment with low-level lighting • Uninterrupted sleep

21. Management: Hyperactive, Agitated Delirium • Use drugs only if absolutely necessary: harm, interruption of medical care • First line agent:haloperidol (IV, IM, or PO) • For mild delirium: • Oral dose: 0.25-0.5 mg • IV/IM dose: 0.125-0.25 mg • For severe delirium: 0.5-1 mg IV/IM repeated q30 min until calm • Patient will likely need 2-5 mg total as a loading dose • Maintenance dose: 50% of loading dose divided BID • May use olanzepine and risperidone Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD05594

22. What about Ativan (lorazepam)? • Second line agent • Reserve for: • Sedative and ETOH withdrawal • Parkinson’s Disease • Neuroleptic Malignant Syndrome

23. Delirium in the Elderly: Take Home Points AVOID RESTRAINTS AT ALL COSTS:Measure of LAST(!!!) resort

24. Delirium in the Elderly: Take Home Points • A multifactorial syndrome: predisposing vulnerability and precipitating insults • Delirium can be diagnosed with high sensitivity and specificity using the CAM • Prevention should be our goal • If delirium occurs, treat the underlying causes • Always try nonpharmacologic approaches • Use low dose antipsychotics in severe cases