Delirium in the Elderly

Didactics Lecture

Belinda Setters, MD, MS

Learning Objectives:

*Define delirium & describe the various forms

*Review the pathophysiology of delirium

*Utilize objective tools to diagnose delirium

*Recognize the risk factors for the development of delirium and measures to take for prevention

*Learn pharmacologic and non-pharmacologic treatment of delirium

Delirium

Delirium Defined:

*What is Delirium?

*What is “not” Delirium ?

Delirium

Delirium

Delirium Defined:

DSM IV Criteria

Disturbance of consciousness with reduced ability to focus, sustain, or shift attention

Change in cognition (memory deficit, disorientation, language disturbance) or a perceptual disturbance not better accounted for by existing dementia

Development over a short time (hours to days) and fluctuation during the day

Evidence from history, physical, or labs that the disturbance is a direct physiologic consequence of a medical condition or a drug

Delirium

Delirium Defined:

DSM-IV Criteria for DeliriumA. Disturbance of consciousness (i.e., reduced clarity of awareness of the environment) with

educed ability to focus, sustain or shift attention.___yes___no

B. A change in cognition or the development of a perceptual disturbance that is not betteraccounted for by a preexisting, established or evolving dementia.

___yes___noC. The disturbance develops over a short period of time (usually hours to days) and tends to

fluctuate during the course of the day___yes___no

D. There is evidence from the history, physical examination or laboratory findings that thedisturbance is caused by the direct physiological consequences of a general

medicalcondition.

___yes___no

Adapted from American Psychiatric Association: Diagnostic and Statistical Manual of MentalDisorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.Copyright © 2000, American Psychiatric Association.

Delirium

Delirium Defined:

*DSM-IV criteria precise but difficult to apply

*Confusion Assessment Method (CAM)Clinically more useful>95% sensitivity and specificityCan be administered by RN or other care

providerICU version available for intubated, critically ill

patients

Delirium

Delirium Defined:

Confusion Assessment Method (“CAM”)

1. Acute change in mental status w/ fluctuating course

2. Inattention

3. Disorganized thinking

4. Altered level of consciousness

Delirium

Delirium Defined:

CAM-ICU1. Acute Onset or Fluctuating Course

A. Is there evidence of an acute change in mental status from baseline? (or)

B. Did the abnormal behavior fluctuate during the past 24 hours (e.g., tend to come and go, or increase and decrease in severity as evidenced by fluctuation of the VAMASS, GCS or previous delirium assessment)?

2. Inattention ○ Did the patient have difficulty focusing attention as

evidenced by scores less than 8 on either the auditory or visual component of the Attention Screening Examination (ASE)

○ Use the 5+5 pictures, or recognize a letter intermixed in a sequence of 10 letters

Delirium

Delirium Defined:

CAM-ICU

3. Disorganized Thinking ○ Does the patient have disorganized or incoherent thinking as

evidenced by incorrect answers to 2 or more of the following 4 questions and/or demonstrate an inability to follow commands?

Set A1) Will a stone float on water? 2) Are there fish in the sea?3) Does 1 pound weigh more than 2 pounds? 4) Can you use a hammer to pound a nail? Set B1) Will a leaf float on water?2) Are there elephants in the sea?3) Does 2 pounds weigh more than 1 pound? 4) Can you use a hammer to cut wood?

Delirium

Delirium Defined:

CAM-ICU4. Altered Level of Consciousness * Is the patient’s level of consciousness anything other than alert (e.g.

vigilant, lethargic or stuporous), or is VAMASS < or > 3 (and not decreased due to sedation)?

* Alert: Looks around spontaneously, fully aware of environment, interacts appropriately.

* Vigilant: Hyper-alert.

* Lethargic: Drowsy but easily aroused. Unaware of some elements in the environment, or no appropriate spontaneous interaction with interviewer. Becomes fully aware and appropriate with minimal noxious stimulation.

* Stupor: Becomes incompletely aware with strong noxious stimulation. Can be aroused only by vigorous and repeated stimuli. As soon as stimulus removed, subject lapses back into

unresponsive state

Delirium

Delirium

Delirium Defined:

An Alias by any other name . . .

*Acute confusional state*Acute mental status change*Altered mental status*Organic brain syndrome*Reversible dementia*Toxic or metabolic encephalopathy

Delirium

BRAIN

FAILURE BRAIN

FAILURE

Delirium Diagnosis:

Nurses document < 50% of cases

MD document < 20% of cases

Delirium

Delirium Defined:

Numbers don’t lie . . .

*1/3 of older patients presenting to the ED

*1/3 of inpatients aged 70+ on general medical units, half of whom are delirious on admission

*Up to 50% postoperatively will become delirious

*70 – 87% of those in ICU will develop delirium

Delirium

Delirium Defined:

Variations on a theme . . .

*Hypoactive

*Mixed

*Hyperactive

Delirium

Delirium Defined:

Hyperactive *Only 25% of delirium*But most commonly recognized*Heightened response to stimuli*Heightened psychomotor behavior*Hypervigilance, restlessness, excitable* Fast and/or loud speech*Distractable * Irritable *Combative, uncooperative

Delirium

Delirium

Hypoactive*Much less recognized*Reduced response to stimuli

and reduced psychomotor behavior*Apathy, lethargy*Sparse or slowed speech*Limited awareness*But usually cooperative with staff*Behaviors often attributed to “old age” or dementia*About 40% of delirium

Delirium

Delirium Defined:

Mixed

*Fluctuations between hyperactive & hypoactive states

Delirium

Pathophysiology:

Cholinergic deficiency*Delirium is associated with serum

anticholinergic activity

*Anticholinergic activity is found in delirious patients taking no anticholinergic drugs

*Acetylcholine is an important neurotransmitter for cognitive processes

*Delirium: caused by anticholinergic drug poisoning, reversed by physostigmine

Delirium

Pathophysiology:

*Serotonin excess or deficiency: result of altered tryptophan-to-phenylalanine ratio*Cytokines (interleukin-2, tumor necrosis factor),

as seen in patients with cancer or infections

*Other neurotransmitters: GABA and dopamine

*Different mechanisms may pertain in different situations

*Bottom line: pathophysiology remains unknown

Delirium

Delirium

Delirium

Dopamine

Cytokine Excess

Serotonin Activation

CholinergicActivation

Cholilergic Inhibition

Reduced GABA Activity

GABAActivation

GlutamateActivation

Cortisol Excess

Serotonin Deficiency

MedsStroke

BenzosETOH w/d

Med/Sx Illness

MedsETOH w/d

MedsSubst w/d

Cushings/StrokeSx/Stroke

Liver FailureETOH w/d

BenzosLiver failure

MedsMed/Sx Illness

Pathophysiology:

The sum is greater than the individual parts . . .

*Delirium “caused” by “sum” of predisposing and precipitating factors

*The more predisposing factors present, the fewer precipitating factors required to cause delirium

Delirium

Predisposing Factors:

“Honey, what do you expect . . . I’m 85.”

* Advanced age

* Dementia

* Functional impairment in ADLs

*Medical comorbidity

* History of alcohol abuse

*Male sex

* Sensory impairment ( vision, hearing)

Delirium

Predisposing Factors (Etiologies):

Acute cardiac events Acute pulmonary events Bed rest Drug withdrawal (sedatives, alcohol) Fecal impaction Fluid or electrolyte disturbances Indwelling devices Infections (esp. respiratory, urinary) Medications Restraints Severe anemia Uncontrolled pain Urinary retention

Delirium

Evaluation:

*History* Focus on time course of cognitive changes, esp. their

association with other symptoms or events

*Medication review, including OTC drugs, alcohol

*Physical examination* Vital signs* Oxygen saturation* General medical evaluation* Neurologic and mental status examination

Delirium

Evaluation:

Based on history and physical

* Include CBC, electrolytes, renal function tests

*Also helpful: UA , LFTs, serum drug levels, arterial blood gases, chest x-ray, ECG, cultures

*Cerebral imaging rarely helpful, except with head trauma or new focal neurologic findings

* EEG and CSF rarely helpful, except with associated seizure activity or signs of meningitis

Delirium

Delirium

Treatment:

Prevention is still the best medicine . . .

*Maximize Prevention / Minimize RiskEnvironmentMedicationsPredictorsFamily & RN Support“Restraints”

Delirium

Treatment:

* Interventions for cognitive impairment, sleep deprivation, immobility, sensory impairment, dehydration

*Focus on nonpharmacologic approaches (eg, sleep protocol involving warm milk, back rubs, soothing music)

*Limit or avoid psychoactive and other high-risk medications

Delirium

Treatment:

*Treat the underlying disease

*Address contributing factors

*Avoid the complications of delirium:Remove indwelling devices ASAPPrevent or treat constipation and urinary

retentionEncourage proper sleep hygiene, avoid

sedatives

*Optimize medication regimen

Delirium

Meds, Meds, Meds . . .

*Alcohol Barbituates

*Anticholinergics Benzodiazepines

*Anticonvulsants Chloralhydrate

*Antidepressants (anticholinergic only) Opiods

*Antihistamines (anticholinergic only) Antipsychotics

*H2-blocking agents Parkinson meds

Delirium

Treatment:* Provide “social” restraints

consider a sitter or allow family to stay in room

* Avoid physical or pharmacologic restraints

* If absolutely necessary, use haloperidolMild delirium: 0.25–0.5 mg po or 0.125–0.25 mg IV/IMSevere delirium: 0.5–2 mg IV/IMAdditional dosing q 60 min, as required Assess for akathisia and extrapyramidal effectsAvoid in older persons with parkinsonism Monitor for QT interval prolongation, torsade de pointes,

neuroleptic malignant syndrome, withdrawal dyskinesias

Delirium

Delirium Outcomes:

*Marker for poor prognosis * Not an independent risk factor for outcome* Problems

* Increased costs of hospitalization* Longer length of stay (LOS)

* Increased risk of functional decline * Predisposing factors (present on admission)

* Dementia Depression Altered Na+ level* Decreased basic functional level (ADLs)

* Precipitating factors (occur during hospitalization) * MedicationsImmobilization Catheters* Infection Restraints Metabolic disturbance

Delirium

Delirium Outcomes:

Financial Disclosures. . .

*Delirium increases hospital costs on the average by about $2500

*Which expands to about $6.9 billion in Medicare hospital expenditures

Delirium

Delirium

References1. Castle C, Leipzig R, Cohen HJ, Larson E & Mier DE. Geriatric

Medicine. Springer. New York, 2003.

2. Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. CMAJ 1993; 149:41–6

3. Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29(7):1370-9.

4. Ferreira FL, Bota DP, Bross A, et al. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001;286(14):1754-8.

5. Gunther ML, Morandi A, Ely EW. Pathophysiology of Delirium in the Intensive Care Unit. Crit Care Clin 2008;45-65.

6. Hazard W, Blass JP, Halter JB. Delirium. Principles of Geriatric Medicine & Gerontology. McGraw Hill, York, PA. 2003: 1503-15.

7. Inouye SK, Viscoli CM, Horwitz RI, et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993;119:474–81

Delirium

References

8. Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275:852–7

9. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999;106(5):565-573.

10. Inouye SK, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990;113:941–8.

11. McNicoll L, Pisani Margaret et al. Detection of Delirium in the Intensive Care Unit: Comparison of Confusion Assessment Method for the Intensive Care Unit with Confusion Assessment Method Ratings. JAGS 2005;53:495–500.

12. Pandharipande P, costabile S, Cotton B, et al. Prevalence of delirium in surgical ICU patients. Crit Care Med 2005;33(12)A45.

Delirium

References

13.Pandharipande P, Ely EW,. Sedative and analgesic medications: risk factors for delirium and sleep disturbances in the critically ill. Crit Care Clin 2006;22(2):313-327.

14.Pompei P, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42:809–15. Pompei P, et al.

15.Pompei P, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42:809–15. Pompei P, et al. Delirium in hospitalized older persons: outcomes

16. and predictors. J Am Geriatr Soc 1994;42:809–15.

Delirium