delirium - university of california, irvine definition of delirium disturbance in attention or...
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DELIRIUM
Michelle Le – July 2017
Objectives Define delirium and understand its implications
Review common causes and presenting symptoms
Learn non-pharmacologic and pharmacologic
interventions
Epidemiology Delirium complicates at least 25% of all hospitalizations in
the elderly
0%
25%
50%
75%
100%
Community Hospitaladmission
Post-op ICU
Fong, T.G. Delirium in elderly adults: diagnosis, prevention and treatment. Nat. Rev. Neurol. 5, 210-220. 2009.
Prevalence of delirium
Effects of Delirium
0%
10%
20%
30%
40%
50%
Control Delirium0
5
10
15
20
Control Delirium
McCusker, J. M. Cole, M. Abrahamowicz, F. Primeau, E. Belzile. Delirium predicts 12-month mortality. Arch Intern Med 162:457-463. 2002. McCusker, J., M. Cole, N. Dendukuri, L. Han, E. Belzile. The course of delirium in older medial inpatients. J Gen Intern Med 18: 696-704. 2003.
12 month mortality post-discharge Hospital length of stay (days)
Increased incidence of cognitive impairment More hospital-acquired complications (falls, pressure ulcers) $2500/patient or $6.9 billion/year for Medicare (2004)
DSM-V Definition of Delirium Disturbance in attention or awareness
Acute onset Change from baseline
Fluctuating severity
Change in cognition not better accounted for by a pre-existing dementia
Evidence that disturbance is caused by a direct physiologic
consequence of a general medical condition, an intoxicating substance, medication, or combination of causes
Other Diagnostic Tools Confusion Assessment Method (CAM) – 94-100%
sensitivity, 90-05% specificity
ICU setting (level A)1
CAM- ICU Intensive Care Delirium Screening Checklist (ICDSC)
1. Barr J, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical care medicine. 2013 Jan 1;41(1):263-306.
Risk Factors Age ≥ 65 Current hip fracture, history of HTN, alcoholism
High severity of illness
Pre-existing cognitive impairment and/or dementia
Common Underlying Causes Hydration Constipation Hypoxemia Infections Mobility Pain Polypharmacy Nutritional status Sensory impairment – impaired hearing/vision Poor sleep pattern/hygeine
Presentations – Case 1 An elderly woman is admitted to your team for sepsis
secondary to UTI. At baseline she has mild dementia, but is pleasant and functional. Yesterday she was doing well. Today, hospital day #4, she is talking to herself, and it is difficult to understand what she is saying. She is anxious and yelling at you. She argues with the nursing staff and refuses blood draws. She has pulled out her IV.
Does she have delirium?
Presentations – Case 2 An elderly man is on your team for a hip fracture.
Previously he was independent and active. He is POD #1 s/p ORIF and you have not heard any calls from the RN overnight. On your morning rounds, he is sleepy and falls asleep as you talk to him. You return to his room at 2:00 PM and he is napping again. He missed his breakfast and lunch because he was asleep. He has not used any of his prn medications.
Does he have delirium?
Types of Delirium
More than half of elderly patients present with hypoactive or mixed type Hypoactive delirium is more typically unrecognized or
mistaken for dementia1
Hyperactive Restlessness, agitation, hallucinations, delusions
Hypoactive Lethargy, decreased motor activity, slower responses
Mixed Components of both
1. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015;63(1):142-50.
Symptoms Cognition - poor concentration, slow responses,
confusion
Perception – visual or auditory hallucinations
Physical function – reduced movement, restlessness, agitation, changes in appetite, sleep disturbance
Social behavior – lack of cooperation, withdrawal, changes in mood or attitude
Case 3 – Causes of delirium? 81 y/o F who is POD#3 s/p ORIF for R hip fracture has
been getting more confused and agitated. She was initially in the MICU, then transferred to telemetry floor, then moved again to an isolation room after developing C dif. Her room is always dark with blinds closed. She was ambulatory PTA but now remains bed-bound. Last weight was 5 kg lower than her prior admission weight. On exam, HR 100s, she is hard of hearing, AAOx1 (self), and appears very sleepy. Per overnight signout, pt has been highly agitated at night and pulling out her IV.
Preventions & Interventions Keep familiar setting - healthcare team, room, visitors
Address cognitive impairment & disorientation Lighting, signage Clock, Date Orientation Stimulating activity (story telling, music therapy, etc.)
Preventions & Interventions Hydration, constipation, hypoxemia, infections, pain, etc.
Mobility – early mobilization, DMEs, ROM exercises
Nutrition – dentures, dysphagia evaluation, dietician
Sensory impairment – hearing aids, glasses
Sleep pattern/hygeine – nursing care/procedures/meds during
day time, minimize noise & light at night
Polypharmacy – AGS Beers Criteria
Benzodiazepines
Anticholinergics
Antihistamines
Sedative-hypnotics
Meperidine
1. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 63:2227–2246. 2015.
Pharmacological Treatments When to use? Verbal & non-verbal de-escalation techniques ineffective or not
possible AND pt highly distressed or at risk to themselves or others (weak recommendation, low evidence)1,3
Haloperidol or atypical antipsychotics 1,3
No evidence that Haldol reduces delirium duration in ICU pts2
Atypical antipsychotics may reduce delirium duration in ICU pts (C)2
Cautious use in patients with Parkinson’s disease or dementia with Lewy bodies
Avoid if at risk for torsades de pointes (-2C) 2
1. Young J, et al. Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ: British Medical Journal. 2010 Jul 28;341. 2. Barr J, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical care medicine. 2013 Jan
1;41(1):263-306. 3. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. J Am Geriatr Soc. 2015;63(1):142-50.
Pharmacological Treatments Haldol: 0.5 – 1 mg PO, IV, or IM (Limit to 5mg/day)
Seroquel: start at 50mg BID PO (max 400mg/day)
Side effects Prolongs QTc Extrapyramidal symptoms Increased risk of death (in chronic use for elderly patients with
dementia-related psychosis)
Don’t use benzos unless it is for alcohol or benzo withdrawal
Summary - Delirium Has many costly implications for both our patients and
healthcare system
Recognize risk factors and presenting symptoms (hypo/hyperactive or mixed features)
Identify underlying causes to target interventions
Use non-pharmacologic interventions as first line tx Low level of evidence for pharmacologic treatments
Guidelines American Geriatrics Society (2014) - Clinical Practice
Guideline for Postoperative Delirium in Older Adults
Journal of Critical Care Medicine (2013) - Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the ICU
National Institute for Health and Care Excellence (2010) – Delirium: prevention, diagnosis and management
References American Geriatrics Society 2015 Updated Beers Criteria for
Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc 63:2227–2246. 2015.
Fong, T.G. Delirium in elderly adults: diagnosis, prevention and treatment. Nat. Rev. Neurol. 5, 210-220. 2009.
McCusker, J. M. Cole, M. Abrahamowicz, F. Primeau, E. Belzile. Delirium predicts 12-month mortality. Arch Intern Med 162:457-463. 2002.
McCusker, J., M. Cole, N. Dendukuri, L. Han, E. Belzile. The course of delirium in older medial inpatients. J Gen Intern Med 18: 696-704. 2003.
O'Mahony R, Murthy L, Akunne A, Young J, for the Guideline Development Group. Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of Delirium. Ann Intern Med. 2011;154:746-751.
Happy Birthday Steven!