Delirium in the Elderly

1. Delirium in the Elderly Terhi Rahkonen, MD, PhD, Specialist in Geriatric Medicine and General Practice Head of Geriatrics, J�ms� District Municipal Federation of Helthcare, J�ms�, and Researcher, Division of Geriatrics, Dept. of Public Health and General Practice, University of Kuopio, Finland

2. Terhi Rahkonen, EAMA, Jan 2004 Delirium Non-specific manifestation of a widespread reduction in cerebral metabolism & derangement of neurotransmission due to: Cholinergic, GABAergic, Dopamine, NE,� Specific receptors (e.g., steroid) Alteration of blood flow, inflammation Pathophysiology still unrevealed previous synonyms: acute brain failure, acute confusional state, acute organic syndrome, encephalopathy, postoperative and toxic psychosis, etc.

3. Terhi Rahkonen, EAMA, Jan 2004 Prevalence and incidence rates of delirium in the elderly

4. Terhi Rahkonen, EAMA, Jan 2004 Diagnostic criteria for deliriumDSM�IV Disturbed consciousness, with reduced ability to focus, sustain or shift attention Altered cognition (memory, orientation, language) or the development of a perceptual disturbance that is not better accounted for by dementia Disturbance develops over hours to days and tends to fluctuate during the course of the day There is evidence of an aetiological cause

5. Terhi Rahkonen, EAMA, Jan 2004 Variety of symptoms in delirium disturbances in attention, consciousness and alertness disorientation and memory deficits alterations in psychomotor behaviour hallucinations and delusions disorders of sleep-wake cycle emotion and mood changes physical symptoms

6. Terhi Rahkonen, EAMA, Jan 2004 different types of delirium hyperactive hypoactive mixed subsyndromal delirium one or more symptoms of delirium (reduced ability to think or concentrate, restlessness, anxiety, irritability, drowsiness, hypersensitivity to stimuli, nightmares) that will not progress to a DSM-defined delirium

7. Terhi Rahkonen, EAMA, Jan 2004 Unrecognition of delirium? � Questions that may help Has the mental status or behaviour of the patient changed quickly from the baseline ? Has the abnormal behaviour been fluctuating? Has the patient difficulties on focusing attention? Is the patient easily distractible or having difficulty keeping track of what is being said? Was the patients thinking disorganised or incoherent, such as rambling or irrelevant conversation? Is the patients level of consciousness or alertness other than normal? alert (normal) vigilant (hyperalert, overly sensitive to environmental stimuli) drowsy stupor (difficult to arouse) coma Memory impairment or disorientation? Inouye et al. Ann Intern Med 1990;113:941-48

8. Terhi Rahkonen, EAMA, Jan 2004 Rating scales for delirium Delirium Rating Scale (DRS) (Trzepacz et al. 1988) Confusion Assessment Method (CAM) (Inouye et al. 1990) Delirium Symptom Interview (DSI) (Albert et al. 1992) Cognitive Test for Delirium (CTD) (Hart et al. 1997) Organic Brain Syndrome (OBS) (Jensen at al. 1993) Delirium Observation Screening Scale (DOS) (Schuurmans et al. 2003) Delirium Assessment Scale (DAS) (O�Keeffe 1994) Neecham Confusion Scale (Neelon et al. 1996) Memorial Delirium Assessment Scale (MDAS) (Breitbatr et al. 1997) Delirium Severity Scale (DSS) (Bettin et al. 1998) Confusional State Evaluation (Robertsson 1999)

9. Terhi Rahkonen, EAMA, Jan 2004 Delirium versus Dementia(modified from Lipowski 1990 and Mulligan and Fairweather 1997). 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 Psychomotor activity varied Triggering factor! Reversible Dementia Insidious onset Primary defect in short term memory Attention often normal Does not fluctuate during day (Dementia with Lewy bodies does!) Visual hallucinations less common Can attend to MMSE or clock draw, but cannot perform well

10. Terhi Rahkonen, EAMA, Jan 2004 Predisposing factors for delirium  (baseline vulnerability factors) (Elie et al. (1998), Inouye (1999)) older age male sex cognitive impairment 25% delirious are demented 40% demented in hospital delirious co-morbidity or severe illness visual or hearing impairment medication alcohol abuse metabolic abnormalities azotemia or dehydration hypotension infection or fever fracture on admission to hospital thoracic surgery any iatrogenic event low social interaction depression

11. Terhi Rahkonen, EAMA, Jan 2004 List of the common precipitating (etiologic) factors for delirium in the elderly (modified from Lipowski 1994) Alcohol and sedative-hypnotic withdrawal Cardiovascular disorders (myocardial infarction, congestive heart failure, cardiac arrhytmias, pulmonary embolism, endocarditis, malignant hypertension) Cerebral and cerebrovascular disorders (degenerative dementia, multi-infarct dementia, stroke, transient ischaemic attacks, subdural haematoma, vasculitides, hypotension and orthostatic hypotension) Drugs (anticholinergics, sedative-hypnotics, diuretics, digitalis, antihypertensive and antiarrhythmic agents, cimetidine, lithium, levodopa, nonsteroidal anti-inflammatory drugs, narcotics, cancer chemotherapeutic drugs, hypoglycaemic agents) Epilepsy Infections (notably pulmonary and urinary tract; bacteraemia, septicaemia, meningitis, encephalitis) Metabolic disorders (encephalopathies) (electrolyte, fluid and acid-base imbalance, endocrine disorders, hepatic, renal and pulmonary failure, nutritional (including vitamin) deficiency, hypothermia and heat stroke) Neoplasms (intracranial, extracranial) Trauma (head injury, burns, surgery)

12. Terhi Rahkonen, EAMA, Jan 2004 Primary etiologic factors for delirium in the healthy elderlyKuopion delirium Study Infection 43 % Cerebrovascular attack 25 % Cardiovascular disorder 18 % Drug related disorder 12 % Other 2 % Every second patient has multiple causes for delirium!! (Rahkonen et al. 2000)

13. Terhi Rahkonen, EAMA, Jan 2004 Prognosis of delirium I LOS twice as long (e.g.. Gustafson 1988, Williams-Russo 1992, Jitapunkul 1992, Levkoff 1992, Marcantonio 1994, O�Keeffe and Lavan 1997, McCusker 2003) Risk for institutional care 2.8 � 7.3 times higher delirium significant predictor (Francis 1990, Jitapunkul 1992, Levkoff 1992, Marcantonio 1994, George 1997, O�Keeffe and Lavan 1997)

14. Terhi Rahkonen, EAMA, Jan 2004 Prognosis of delirium II: Mortality Higher mortality delirium is an independent marker intrahospital 8 - 35% (vs. 1 - 8%) 6 mo after discharge 15 - 31% (vs. 10 � 15%) 1 year mortality 38 - 42% (vs. 14 � 21%) (Francis 1990, Jitapunkul 1992, Francis and Kapoor 1992, Pompei 1994, George 1997, McCusker 2002) 5 yr mortality of non-demented delirious pts after a hip fracture operation was 72.4% (vs. 35% in non-delirious pts) (Lundstr�m 2003)

15. Terhi Rahkonen, EAMA, Jan 2004 Prognosis of delirium III: Functional decline slower and poorer recovery walking ability ADL functioning (Gustafson 1988, Br�nnstr�m 1991, Murray 1993, Dolan 2000, Marcantonio 2000, Edlund 201, McCusker 2001 vs. Williams-Russo 1992, Pompei 1994)

16. Terhi Rahkonen, EAMA, Jan 2004 Prognosis of delirium VI: Cognitive decline 60 - 80% of geriatric patients have some of the delirium symptoms left at discharge (demented included) (e.g. Levkoff 1992, Rockwood 1993) grater decline in MMSE scores in demented: mean difference in change after 1 yr �3.4 points in non-demented: �5.0 points (delirious v.s. non-delirious) (Dolan 2000, McCusker 2001) in surgical patients 18 - 24% were still delirious at discharge (Brauer 2000, S�rensen Duppils and Wikblad 2000) cognitive decline after 6 mo in 13% of delirious patients (vs. 5%) (Williams-Russo 1995)

17. Terhi Rahkonen, EAMA, Jan 2004 Incidence of dementia after a delirium episode

18. Terhi Rahkonen, EAMA, Jan 2004 Age-adjusted Incidence of Dementia in General population, per 100 person years Age 65-69 70-74 75-79 80-84 85+ Paquid 0.2 0.7 1.7 3.2 5.0 Nottingham* 0.2 0.7 1.3 2.3 2.2 Liverpool 0.4 (65-74) 1.2 (75-84) 2.9 Lundby 0.7 (70-79) 2.5 (80+) Framingham* 0.1 0.5 1.0 1.6 2.4 *average annual incidence (Modified from Letenneur et al. Int J Epidemiol 1994)

19. Terhi Rahkonen, EAMA, Jan 2004 Dementia diagnosis Kuopio delirium Study

20. Terhi Rahkonen, EAMA, Jan 2004 Management of delirium Recognition of delirium - Constant vigilance ! Searching for the etiologic factors and treating them Relieving the symptoms Follow-up

21. Terhi Rahkonen, EAMA, Jan 2004 Examination of delirious pts history of present illness and baseline situation complete physical examination laboratory tests, EKG and chest x-ray pulse oximetry Ct/MRI of the head (indicated if neurological symptoms/signs, suspicion of trauma, etiology of delirium remains otherwise unknown or symptoms are not subsiding) additional tests if warranted due to patients situation (e.g.. blood cultures, lumbar puncture, serum/urine drug screens, EEG,�)

22. Terhi Rahkonen, EAMA, Jan 2004 Management of delirious pts I stabilise the vital signs promptly treat any precipitating causes reduce previous medication provide support and feelings of security and orientation communicate clearly and concisely correct sensory impairments (eye glasses�) reminders of day, time, location consistency of staff, environment lighting, noises family members physical restraints only in emergency chemical sedation preferable, lowest possible dose!

23. Terhi Rahkonen, EAMA, Jan 2004 Delirium: medical symptom control in the elderly I haloperidol po, im, iv po 0,5 � 2 mg/day for agitation 2,5 � 5 mg im/iv, repeated every 30 � 60 min prn risperidone po 0,25� 2.0 mg/day olantzapine po 2,5� 5 mg/day Neuroleptics (haloperidol) is often the drug of choice extrapyramidal SE�s, hypotension,sedation, akathisia Sedation before antipsychotic effect Risperidone: for those with side effects from haloperidol or contraindications Olanzapine: agent of choice for patients with PD with hallucinations/delirium

24. Terhi Rahkonen, EAMA, Jan 2004 Delirium: medical symptom control in the elderly II loratzepam po, im, iv 0,5 � 1mg, repeated every 30 � 60 min prn diatzepam po, iv in alcohol withdrawal 10 � 20mg po every hour until pts not agitated, max 150 � 200mg/day To ensure sleep tematzepam 10 � 30mg zopiclon 5mg avoid if possible in addition to a neuroleptic faster effect

25. Terhi Rahkonen, EAMA, Jan 2004 Delirium: medical symptom control in the elderly III Trazadone 25-100mg Donepezil Mood stabilizers Pain medications Studied ? No Possible ? Yes

26. Terhi Rahkonen, EAMA, Jan 2004 Kuopio delirium Study:Supporting community care after a delirium episode (Rahkonen et al. 2001) the non-demented community dwelling delirious patients aged 65+ without any serious predisposing factors search for the causes of delirium, adequate treatment geriatric comprehensive evaluation intensive geriatric rehabilitation and 3-year follow-up nurse case manager to take comprehensive responsibility in supporting the patients during community care to solve problematic situations threatening the continuity of community care control group: age and gender matched patients admitted to the same hospital for delirium fulfilling the same inclusion and exclusion criteria during preceding 4 years

27. Terhi Rahkonen, EAMA, Jan 2004 The intervention and the control patients in the community care, in institutionalised care and patients who had died at the end of each year (Rahkonen et al. 2001)

28. Terhi Rahkonen, EAMA, Jan 2004 The duration of the community care in the intervention and the control patients using Kaplan-Meier Method (p=0.025, log rank test) (Rahkonen et al. 2001)

29. Terhi Rahkonen, EAMA, Jan 2004 Prevention of delirium; programs1) Gustafson 1991, 2) Inouye 1999, 3) Marcantonio 2001, 4) Milisen 2001

30. Terhi Rahkonen, EAMA, Jan 2004 Prevention of delirium in the elderly

31. Terhi Rahkonen, EAMA, Jan 2004 Summary: Delirium is common in older inpatients, associated with poor outcomes, and commonly missed or misdiagnosed Management involves treating underlying causes, minimizing medications, supportive care, and avoidance of restraints when possible Delirium is often the first sign of the undetected or becoming dementia Prevention is possible Further research and RCTs are needed