Spotlight Case

1. Spotlight Case Delirium or Dementia?

2. Source and Credits • This presentation is based on the May 2009 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: James L. Rudolph, MD, SM • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Sumant Ranji, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • State the key diagnostic differences between delirium and dementia • Describe the Confusion Assessment Method for workup of suspected delirium • Explain the risks associated with using physical restraints in geriatric inpatients • Describe the initial workup of delirium in a hospitalized patient

4. Case: Delirium or Dementia? An 86-year-old woman, admitted with complaints of shortness of breath and cough, was found to have pneumonia. Her past medical history included cataract surgery, hypertension controlled with medications, and type 2 diabetes controlled by diet. She was ambulatory, lived alone, and at baseline completed all activities of daily living independently. According to her daughter, the patient was never disoriented.

5. Case: Delirium or Dementia? (2) At admission, the patient appeared mildly dehydrated. Her oxygen saturation was 94% on 2 liters oxygen by nasal cannula, and an arterial blood gas showed a normal pCO2 of 40 mmHg. Her daughter requested to spend the night at the bedside, but was told she could not stay, per hospital policy.

6. Case: Delirium or Dementia? (3) Overnight, nursing staff noted the patient to be disoriented. She began pulling at her intravenous lines and attempting to get out of bed. The covering physician was called, and ordered that the patient be placed in four-point restraints. The next morning, the daughter returned to find her mother in restraints, speaking incoherently and severely short of breath. The daughter asked the nurse what happened, and reiterated that her mother had never been confused before.

7. Altered Mental Status in Hospitalized Patients • All patients should be screened for cognitive impairment at admission in order to assess for delirium and establish a baseline • ~25% of general ward patients and ~80% of intensive care unit patients experience delirium during hospitalization • Dementia cannot be diagnosed if delirium is present See Notes for references.

8. Delirium vs. Dementia

9. Delirium Prediction Rule The points are added. The incidence of delirium for 0 points is 3%-9%, 1-2 points is 16%-23%, and for ≥3 points is 32%-83%. MMSE = Mini Mental State Examination; APACHE = Acute physiology, age, and chronic health evaluation; BUN = blood urea nitrogen. See Notes for reference.

10. Hospital Environment Predisposes To Delirium • Many new faces: 10-20 staff may see patient in one day, leading to disorientation • Decreased cognitive stimuli: urinary catheters and restraints confine patients to bed, with attendant risks • Loss of sleep due to noise or intrusions See Notes for references.

11. Psychomotor Variants of Delirium • Hyperactive (25%) • These patients are more likely to receive chemical or physical restraints • Hypoactive (50%) • May be misdiagnosed as depression or dementia • Mixed (25%) See Notes for reference.

12. Risks of Delirium in Hospitalized Patients • Underlying cause of delirium may be missed • Over-medication (especially in hyperactive and mixed subtypes) • Amplifies risks of hospitalization • Deconditioning and malnutrition • Aspiration pneumonia • Nosocomial infection (especially due to urinary catheters) • Pressure ulcers See Notes for reference.

13. Physical Restraints • Risky for several reasons • Independently associated with development of delirium • Reduce external stimuli  may exacerbate delirium • May exacerbate hyperactive behavior See Notes for references.

14. Before Applying Restraints • Consider: • What is intended effect of restraint? • Can intended effect be achieved by other means? • Is this the least invasive restraint? • Is using restraints in the patient’s best interest? • Are restraints being used for secondary benefits (i.e., to limit calls or pages)? • When will restraint be removed? See Notes for references.

15. Case: Delirium or Dementia? (4) The doctor was called and an arterial blood gas was performed. The patient’s PaO2 was 91 mmHg, but the PaCo2 was 58 mmHg, a marked increase since admission. Despite the patient’s deteriorating clinical condition, the patient’s worsening level of consciousness was attributed to “senile dementia” and not impending respiratory failure (as evidenced by the significant carbon dioxide retention). No further action was taken.

16. Case: Delirium or Dementia? (5) Over the course of the day, the patient developed worsening respiratory distress, became comatose, and was transferred to the intensive care unit. She subsequently developed respiratory failure requiring intubation and renal failure requiring dialysis. Her condition did not significantly improve, and she died 2 weeks later.

17. Feature 1 Acute onset and fluctuating course Feature 2 Inattention Feature 4 Altered consciousness Feature 3 Disorganized thinking Confusion Assessment Method • Diagnosis of delirium requires features 1 and 2, and either 3 or 4 See Notes for references.

18. History and physical examination Neurological examination Collateral information from family, nursing Review of medications Especially benzodiazepines, anticholinergics, and antipsychotics Drugs that were recently stopped and may cause withdrawal syndrome (opioids, antidepressants, alcohol) Basic laboratory tests for electrolytes, kidney function, workup of suspected infection Workup of Delirium Identify and treat underlying cause that precipitated delirium

19. The Role of Family Members at the Bedside • Reorienting stimulus for patient • 10-20 staff may see patient daily, facilitating disorientation • Source of cognitive stimulation • Participate in care of patient to the extent possible See Notes for reference.

20. Take-Home Points • Delirium, an acute change in cognition and attention, is common, morbid, and costly • In the inpatient setting, all new changes in mental status should be assumed to be delirium until proven otherwise • The treatment of delirium is to identify and remedy the underlying causes • Elements of the hospital environment can contribute to delirium and expose patients to safety risk • Family members and caregivers are crucial to the diagnosis and management of delirium; incorporating them into the plan of care is strongly recommended