division of geriatrics & palliative medicine department of

Renee Flores, MD

Division of Geriatrics & Palliative Medicine

Department of Internal Medicine

• Define AMS and delirium

• Describe how to recognize and diagnose delirium

• Identify the predisposing or precipitating risk factors for delirium in elderly patients

• Demonstrate how to evaluate and treat elderly patients with delirium

• Evaluate and apply interventions to prevent delirium

Approx. ⅓ of pts. ≥ 70 years old admitted to the medicine

service experience delirium: ½ of these are delirious on

admission while other ½ develop delirium in the hospital.

A systematic review found that persistence rates for delirium

at hospital D/C and at 1, 3 and 6 months after D/C were 45%,

33%, 26% and 21%, respectively.

In SNF, approx. 15% of new admissions meet criteria for

delirium.

• Literature shows that when delirium persists beyond 6

months, it is likely that the patient will have cognitive decline,

• resulting condition could be dementia/mild cognitive

impairment (MCI), depending on its severity.

A meta-analysis of 3,000 patients followed for a mean of 22.7

months found that delirium was

independently associated with an increased risk of death (OR

2.0; 95% CI 1.5-2.5),

institutionalization (OR 2.4; 95% CI 1.8-3.3)

dementia (OR 12.5; 95% CI 11.9-84.2).

Under-recognition of delirium is a major problem, with only

12%-35% of all cases recognized in routine care.

CAM is the most useful bedside assessment tool for delirium.

4 key features of CAM are:

Acute change or fluctuating course

Inattention

Disorganized thinking

Altered level of consciousness

SAS Score

Underlying co-morbid conditions must be taken into account

Depression can sometimes be confused with hypoactive

delirium and mania with hyperactive delirium.

Hyperactive delirium accounts for only 25% of cases with the

remaining being hypoactive “quiet” delirium.

Hypoactive delirium is associated with an equal or poorer

prognosis than delirium with hyperactive or normal

psychomotor features.

One of the best documented mechanism is cholinergic deficiency.

This is classically seen in overdoses of anticholinergic medications like atropine.

A second potential mechanism is inflammation, seen classically in post-op patients and in those with cancer or infection.

Literature shows an association of delirium with increased levels of CRP, IL-1, IL-6 and TNF-α.

Inflammation can break the blood-brain barrier allowing toxic medications and cytokines greater access to the CNS.

Baseline factors:

Advanced age

Preexisting dementia

Preexisting functional

impairment in ADL

Medical comorbidity

Male gender

Sensory impairment

(hearing and visual loss)

Depressive symptoms

Can be classified into 2 groups: baseline factors that

predispose patients to delirium and acute factors that

precipitate delirium.

Acute precipitating factors:

Medications (most common)

Surgery

Uncontrolled Pain

Low Hb

Bed rest

Physical restraints

D Drugs (BNZ, H2 blockers, Opioids, Anticholinergics,

antidepressants, Antipsychotics)

E Electrolyte imbalance (Na and Ca), Eyes & Ears

L Liver disease

I Infection/Intoxication/Insomnia/Intracranial tumor

R Retention (urinary or fecal)

I Ischemia (MI, CVA, PAD, CAD)

U Urea/ARF

MMetabolic (thyroid, B12, cortisol, blood sugar,

hypoxia)

Agent Adverse Events

Agent AE

Agent AE

The incidence is 15% after elective non-cardiac surgery and up

to 50% after high risk procedures such as hip fracture repair,

AAA repair and CABG.

Total dose of anesthetics used during the procedure also play

an important route.

It is important to note that high levels of pain have also been

associated with delirium.

Strategies to provide adequate analgesia with minimally

effective doses of opioids should be used.

Low post-op Hb level (<30%) has also been associated with

delirium, although transfusions have not been shown to reduce

delirium.

• Eight strong recommendations: benefitsclearlyoutweighedtherisks,ortherisksclearlyoutweighedthebenefits.

• Multicomponentnonpharmacologic interventionsdeliveredbyaninterprofessionalteamshouldbeadministeredtoat‐riskolderadultstopreventdelirium.

• Ongoingeducationalprogramsregardingdeliriumshouldbeprovidedforhealthcareprofessionals.

• Amedicalevaluationshouldbeperformedtoidentifyandmanageunderlyingcontributorstodelirium.

• Painmanagement(preferablywithnonopioid medications)shouldbeoptimizedtopreventpostoperativedelirium.

• Medicationswithhighriskofprecipitatingdeliriumshouldbeavoided.• Cholinesteraseinhibitorsshouldnotbenewlyprescribedtopreventortreat

postoperativedelirium.• Benzodiazepinesshouldnotbeusedasfirst‐linetreatmentofagitationassociatedwith

delirium.• Antipsychoticsandbenzodiazepinesshouldbeavoidedfortreatmentofhypoactive

delirium.

Step Key Issues Proposed Treatment

Target for Prevention Intervention

Cognitive impairment Orientation, board with names, daily schedule, reorientatingcommunication

Sleep deprivation Nonpharm: warm milk/herbal tea, music, massage, noise reduction; melatonin or ramelteon

Immobility Early mobilization, ambulation or range of motion 3x/d

Visual impairment Visual aids and adaptiveequipment

Hearing impairment Amplification, cerumen disimpaction, special communication techniques

Dehydration Early recognition and repletion

Urinary catheters should be avoided unless absolutely

required for monitoring fluids or treating urinary retention.

Bowel stimulants and stool softeners can be used to prevent

obstipation, particularly in those taking opioids.

Complete bed rest should be avoided because it can lead to

increasing disability through disuse of muscles and

development of pressure ulcers and atelectasis in the lungs.

Malnutrition can be prevented through use of nutritional

supplements and careful attention to intake of food and fluids.

Ensure safety

Use families or sitters as first line

Physical restraints can lead to serious injury or death and may worsen agitation and delirium. Use soft restraints or mitts only as a last resort to maintain pt safety (eg to prevent pt from pulling out tubes or catheters)

The lowest dose of the least toxic agent should be used for

the shortest time possible.

Except in unusual cases (alcohol withdrawal), antipsychotics

have a more risk:benefit ratio than BNZ or other sedatives.

Use of antipsychotics for delirium is off-label – there are no

FDA-approved drugs for the indication of delirium.

Haloperidol and Risperidone have the least sedation but the greatest risk of EPS. Quetiapine is most sedating and has the least EPS effects.

It is important to point that many cognitive deficits associated

with delirium can continue, abating weeks and even months

after the illness.

Careful monitoring of mental status and providing adequate

functional supports during this period are necessary to give

the patient maximal chance of returning to his or her

baseline level.

The first key step in delirium management is accurate diagnosis; several brief diagnostic assessments are available that operationalize the Confusion Assessment Method diagnostic algorithm after administration of a brief mental status examination that includes testing attention

All delirious patients require a thorough evaluation for reversible causes; all correctable contributing factors should be addressed.

In addition to the established associations of delirium with death, functional decline, and nursing home placement, new evidence shows that patients with delirium are at increased risk of prolonged cognitive decline and dementia.

Pharmacologic intervention should be reserved for key target symptoms that cannot be adequately managed with nonpharmacologic interventions; low-dose, high-potency antipsychotics are usually the treatment of choice.

Proactive, multifactorial interventions have reduced the incidence, severity, and duration of delirium.

GRS 9th Edition

AGS Expert Panel on Postoperative Delirium. Clinical Practice Guidelines for Postoperative Delirium in Older Adults. New York: American Geriatrics Society; 2014.

Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. 2015;175(4):512–520.

Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383(9920):911–922.

Marcantonio ER, Ngo LH, O’Connor M, et al. 3D-CAM: derivation and validation of a 3-minute diagnostic interview for CAM-defined delirium. Ann Intern Med. 2014;161(8):554–561.

Mrs. Tufts is 75 year old retired school teacher who comes to the hospital for acute confusion. she lives in a small, older home. She has HTN, DM, hyperlipidemia, CAD s/p stent in 2000, CHF, atrial fibrillation, CKD , GERD, migraines, osteoarthritis, COPD, & hypothyroidism.

PMH.

• Amitriptyline25mgpo qhs

• Ibuprofen400mgpo tid

• Meloxicam7.5mgpo bid

• Naproxen250mgpo bid

• Citalopram20mgpo qday

• Sertraline25mgpo qday

• Furosemide20mgpo qday

• KCL20meq po qday

• Clopidogrel 75mgpo qday

• Atrovent 17mcg/actuation1puffbid

• Combivent 1puffevery6hrsprn

• Advair250/50mcg1puffbid

• Ambien10mgoqhs

• Levothyroxine50mcgpoqhs.

M E D I C A T I O N S : • L i s i n o p r i l 4 0 m g p o

q d a y

• M e t o p r o l o l t a r t r a t e 5 0 m g p o q d a y

• A t o r v a s t a t i n 4 0 m g p oq d a y

• A s p i r i n 3 2 5 m g p o q d a y

• C o u m a d i n 3 m g p o q h s

• O m e p r a z o l e 4 0 m g p oq d a y

• G l y b u r i d e 1 0 m g p oq d a y

• M e t f o r m i n 1 0 0 0 m g p ob i d

• P i o g l i t a z o n e 4 5 m g p oq d a y

• N t g 0 . 4 m g S C p r n c h e s t p a i n

• D i g o x i n 0 . 2 5 m g p oq d a i l y

MEDS.

• Amitriptyline25mgpo qhs

• Ibuprofen400mgpo tid

• Meloxicam7.5mgpo bid

• Naproxen250mgpo bid

• Citalopram20mgpo qday

• Sertraline25mgpo qday

• Furosemide20mgpo qday

• KCL20meq po qday

• Clopidogrel 75mgpo qday

• Atrovent 17mcg/actuation1puffbid

• Combivent 1puffevery6hrsprn

• Advair250/50mcg1puffbid

• Ambien10mgoqhs

• Levothyroxine 50mcgpo qhs.

M E D I C A T I O N S :

• L i s i n o p r i l 4 0 m g p oq d a y

• M e t o p r o l o l t a r t r a t e 5 0 m g p o q d a y

• A t o r v a s t a t i n 4 0 m g p oq d a y

• A s p i r i n 3 2 5 m g p o q d a y• C o u m a d i n 3 m g p o q h s• O m e p r a z o l e 4 0 m g p o

q d a y• G l y b u r i d e 1 0 m g p o

q d a y• M e t f o r m i n 1 0 0 0 m g p o

b i d• P i o g l i t a z o n e 4 5 m g p o

q d a y• N t g 0 . 4 m g S C p r n c h e s t

p a i n• D i g o x i n 0 . 2 5 m g p o

q d a i l y

MEDS that can cause delirium.

Allergies: Latex, sulfas

SOCIAL : 30 pack year, quit 5 years back. No alcohol or illicit drug use

Surgeries: Cholecystectomy

Stents

VITALS:

BP 110/70 mm Hg Pulse :60 RR:14 Temp 98 F Standing up 100/70 mm Hg

Which one of the following is the most appropriate next step in her care?

A. Obtain computed tomography of the head with contrast.

B. Administer a high-potency, low-dose antipsychotic agent.

C. Perform physical examination and order laboratory tests.

D. Transfer to ICU for observation.

E. Obtain psychiatric consultation.

Which one of the following classes of medication is the most common cause of delirium in hospitalized older adults?

A. Angiotensin-receptor blockers

B. H2-receptor antagonists

C. Selective serotonin-reuptake inhibitors

D. H1-receptor antagonists

E. HMG-CoA reductase inhibitors

Strong evidence suggests that delirium is an important, independent predictor of all of the following EXCEPT:

A. Death

B. New institutionalization

C. Dementia

D. Functional decline

E. Delusional disorder

division of geriatrics & palliative medicine department of

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