DELIRIUM Barbara Power, MD FRCP(C)

Division of Geriatrics

Ottawa Hospital

April 2008

Delirium - Objectives

• Main diagnostic criteria• Common Symptoms and Signs of

presentation of Delirium• Differential Diagnosis• Risk Factors• Investigations• Management - Non-pharmacological and

Pharmacological

Delirium

• Latin ”de” and “lira”, together mean “off track”

• over 30 synonyms:• acute brain syndrome, acute confusion state,

metabolic encelopathy, toxic psychosis,”reversible madness”

Epidimiology

• Prevalence 10-40%• Incidence 25-60%• 3-31% on medical wards, 30% of open

heart surgery patients, over 50% of hip fracture admissions

• Hospital Mortality 10-65%

Delirium -Prognosis

• Increased mortality (25-33%)• Permanent impairment (~25%)• Recovery (50%)• Following recovery, annual incidence of dementia

is 20%

• ( George J et al:Age and Aging 1997;26:423-427• Rockwood K)

•

Impact Of Delirium (US data)

• 35 % of US population >65 hospitalized yearly

• Assuming delirium rate 20% 7% of persons >65 will develop delirium annually

• estimated cost > $8 billion • $6000.00 US per episode delirium

RECOGNITION

• Acute onset and fluctuating course• Inattention• Disorganized thinking• Altered level of consciousness

(Un)Recognition

• 32% -66% of cases unrecognized by physicians

• 43% of cases unrecognized by RN’s

Diagnosis

Confusion Assessment Method(CAM)

1. Acute Onset & Fluctuating course:

- change from baseline and does the behavior fluctuate

2. Inattention:

- difficulty focusing attention, distractible, difficulty keeping track of conversation

Diagnosis (cont’d)

3. Disorganized thinking:

- speech disorganized/incoherent, rambling

4. Altered level of Consciousness:

- vigilant, lethargic, lethargic, stupor, coma

* for delirium diagnosis recquire(1),(2), and either (3) or (4) ref. Innouye SK, et al. Ann Intern Med 1999;113:941-8

CAM-validation

• Sensitivity 94-100%• Specificity 90-95%• good screening

instrument

Delirium vs Dementia

Delirium Dementia

ONSET Develops abruptly Develops slowly

DURATION Brief, hours to days Chronic, months to years

ATTENTION Impaired Normal, except severe cases

CONSICOUSNESS Fluctuating, reduced Clear

SPEECH Incoherent, Ordered, disorganized anomic/aphasic

NOTE: Disorientation and memory impairment may be present with both

Delirium-Risk factors

• Old age(esp. >80)• low level of albumin• electrolyte disturbances• hepatic or renal dysfunction• alcohol/sedative dependence• previous episode of delirium• visual impairment• fractures

– (Trzepacz PT Psych Clin North Am;19(3):429-49

Etiology-Multifactorial

• Dementia (multi-infarct, AD)• Electrolytes• Lungs,liver,heart,kidney,brain(ex.PD)• Infection• Rx• Injury• Unfamiliar• Metabolic

Medications and delirium

• Sedative Hypnotics (Dalmane,Valium,Chloral Hydrate)

• Narcotics (Demerol)• Anticholinergics(TCA,AntiPD,antihistamines,

Antispasmodics;Belladona,lomotil)• Cardiac (digoxin,lidocaine)• Antihypertensives (B-blockers)• Miscellaneous: H2 blockers, steroids,

Lithium, Anticonvulsants, NSAIDS

Delirium-Prevention

Risk Factor Intervention

Cognitive impairment Reality Orientation,Therapeutic Therapeutic Activities

Sensory Impairment Vision/Hearing Aids

Adaptive Equipment (HA, glasses,dentures)

Immobilization Early Mobilization, avoid bed rest orders

Minimize Immobilizing equip.

Psychoactive Medications Nonpharmacologic approach to sleep/anxiety

Dehydration Early Recognition,volume repletion

Sleep Deprivation Noise Reduction Strategies, sleep

enhancement strategies

(Inouye SK et al., JAGS 2000;48:1697-1706)

Delirium-The Hospital Elder Care Program

• n=852 (426 intervention and 426 usual care) new delirium cases: 9.9% vs 15% usual care (OR.6, p=.02) total days of delirium episodes(105 vs 161, p=.02 total number of delirium episodes (62 vs 90, p=.03) targeted risk factors per patient• once delirium occurred, intervention ns for severity or

recurrence of delirium; ie. 1 prevention most effective (Inouye SK et al., JAGS 2000;48:1697-1706)

Delirium:multidisciplinary care

• n=113 intervention vs. 114 usual care• intervention: seen by geriatric consultant and followed by

intervention nurse• overall no difference in MMSE, delirium or function• subgroup analysis: those without dementia potentially could benefit

the most, but study lacked power• study flawed in some respects (Hawthorne effect, lack of adherence

with recommendations etc.)• emphasizes importance of prevention, once delirium starts hard to

treat• (RCT Cole et al. CMAJ October 1, 2002;176(7):753-759)

Delirium-Evaluation

1. Cognitive evaluation: MMSE,CAM,collateral history

2. Search for underlying cause: review medication list (especially anticholinergic drugs)

Evaluation (con’d)

3. Metabolic workup: CBC, Lytes, BUN/Cr, glucose, LFT’s, Calcium, pO2

4. Search for infection; urine C&S, CXR, blood culture

5. EKG +/- abdomen flat plate, PVR

6. CNS work up (if indicated): LP, CT head (<10% need this)

Delirium - Treatment

Indicated when severe agitation could cause interruption of essential medical therapy or pose safety hazard to pt or staff

• Haloperidol 0.5-1.0 mg i.m. or p.o. (maintenance dose 3-5mg/24hrs)

• 50% loading dose in divided doses over next 24 hours

• taper dose over few days

Delirium: Newer treatment options

• Risperidone: 0.25-0.5 mg bid to start, to a max. of 1.0 mg bid

– caution re DM (follow wt gain, B/S)• Seroquel(quetiapine): 25 mg bid

– most sedating, least EPS• Zyprexa (olanzepine):2.5-5 mg daily

– +++ sedating, blood work q weekly– wt gain

Delirium: withdrawal states

• Benzodiazepines indicated for delirium associated with:

– alcohol withdrawal– benzodiazepine withdrawal

Delirium-Conclusions

• An acute medical emergency!!• Under-recognized• Treatment:

– address the underlying cause– often multifactorial in etiology– may require several trials with neuroleptics, often of limited efficacy

• Prognosis guarded