Terminology
• Acute mental status change
• Reversible dementia
• Altered mental status
• Organic brain syndrome (OBS)
• Toxic or metabolic encephalopathy
• Acute brain failure
• Acute confusional state
Differential Diagnosis
Delirium
• Acute onset
• Brief duration
• Impaired attention
• Reduced LOC
• Disorganized speech
• Fluctuating course
Dementia
• Insidious onset
• Progressive course
• Normal attention span
• No change in LOC
• Speech organized
• Persistent deficits
INCIDENCE OF DELIRIUM AMONG OLDER PATIENTS
• ⅓ of older patients presenting to the ED
• ⅓ of inpatients aged 70+ on general medical units (half of these are delirious on admission)
MORBIDITY ASSOCIATED WITH DELIRIUM
• 10‐fold risk of death in hospital
• 3‐ to 5‐fold risk of nosocomial complications, prolonged stay, post‐acute nursing‐home placement
• Poor functional recovery and risk of death up to 2 years following discharge
• Persistence of delirium with poor long‐term outcomes
RECOGNIZING DELIRIUM
• Nurses recognize and document <50% of cases
• Physicians recognize and document only 20%
DIAGNOSING DELIRIUM
• DSM‐5 criteria
– Precise
– Field‐tested
– High inter‐rater reliability
– Not meant as a scale
– Delirium has an ICD‐9 code (293.00)
DIAGNOSING DELIRIUM
• Confusion Assessment Method (CAM) is a practical tool to identify delirium
– Evidence based and validated
– Clinically useful
– Sensitivity 94‐100%
– Specificity 90‐95%
CONFUSION ASSESSMENT METHOD
1. Acute change in mental status and fluctuating course
2. Inattention 3. Disorganized speech 4. Altered level of consciousness
Requires features 1 and 2 and either 3 or 4
DELIRIUM TAKES VARIOUS FORMS
• Hyperactive or agitated delirium = 25% of all cases
• Mixed
• Hypoactive delirium = 50% of all cases, but less recognized and appropriately treated
• Additional features include emotional lability, psychosis, hallucinations
PREDISPOSING FACTORS
• Advanced age
• Dementia
• Functional impairment in ADLs
• Medical comorbidity
• History of alcohol abuse
• Male sex
• Sensory impairment (vision, hearing)
PRECIPITATING FACTORS 1 • Acute cardiac events
• Acute pulmonary events
• Bed rest
• Drug withdrawal (sedatives, alcohol)
• Fecal impaction
• Sleep deprivation
• Fluid or electrolyte disturbances
PRECIPITATING FACTORS 2 • Indwelling devices
• Infections (esp. respiratory & urinary)
• Medications
• Restraints
• Severe anemia
• Uncontrolled pain
• Urinary retention
EVALUATION 1
• HISTORY & PHYSICAL
• Emphasis on– Medication review
– Vital signs
– Mental status
– Neurostatus
EVALUATION 2
• LABORATORY TESTING – CBC
– BMP (electrolytes, BS, LFTs, renal function tests)
– UA and urine toxicology screen
– (Serum drug levels)
– chest x‐ray
– EKG
– Cultures
EVALUATION 3
• RARELY NEEDED
• Cerebral imaging (except with head trauma or new focal neurologic findings)
• EEG and CSF (except with associated seizure activity or signs of meningitis)
PREVENTION
1. It is estimated that 30‐40% of cases of delirium are preventable.
2. Prevention is the most effective strategy for minimizing the adverse outcomes of delirium
PREVENTION
Hospital Elder Life Program (HELP)
– To prevent delirium in older, hospitalized adults by systematically identifying and intervening to reduce delirium
– Interventions are carried out by a skilled interdisciplinary team and trained volunteers
Yale University School of Medicine
GOALS OF HELP
• Maintain cognitive and physical functioning of high‐risk older adults throughout hospitalization
• Maximize patients' independence at discharge
• Assist patients with the transition from hospital to home
• Prevent unplanned hospital readmissions
STANDARDIZED PROTOCOLS
• Cognitive impairment
• Sleep deprivation
• Immobility
• Visual impairment
• Hearing impairment
• Dehydration
RESULTS OF HELP• Incidence of delirium was reduced by 40%
• Fewer days and episodes of delirium
• No significant effect on the severity of delirium (NB: primary prevention of delirium is the most effective treatment strategy)
MANAGEMENT
• DRUGS TO REDUCE OR ELIMINATE– Alcohol – Anticholinergics – Anticonvulsants – Tricyclic antidepressants– Antihistamines (anticholinergic only) – Antiparkinsonian agents – Antipsychotics – Barbiturates – Benzodiazepines – H2‐blocking agents – Opioid analgesics (esp. meperidine)
MANAGEMENT
• BEHAVIORAL PROBLEMS
• “Social” restraints: consider a sitter or allow family to stay in room
• Avoid physical or pharmacologic restraints
MANAGEMENT
• BEHAVIORAL PROBLEMS
• If absolutely necessary, use antipsychotic
• Haloperidol is the most widely used
MANAGEMENT: HALOPERIDOL
• Advantages
– Can be given PO, IM or IV
– Little sedation
– Low anticholinergic potency
– No respiratory suppression
– No active metabolites
MANAGEMENT: HALOPERIDOL
• Disadvantages
– Extrapyramidal symptoms (dystonias, Parkinsonian symptoms)
– Neuroleptic malignant syndrome
– Prolonged QT interval
– Torsade de pointes esp. when given IV
MANAGEMENT: HALOPERIDOL
• Dosing– Mild delirium: 0.25–0.5 mg PO or 0.125–0.25 mg IV/IM
– Severe delirium: 0.5–2 mg IV/IM – Additional dosing q 60 min, as required
• Caveats– Assess for akathisia and extrapyramidal effects – Monitor for QT interval prolongation– Do not exceed 10 mg of haloperidol in a 24 hour period (5 mg in the older patient )
NON PHARMACOLOGIC MANAGEMENT
• Orienting stimuli (clocks, calendar, radio)
• Provide adequate socialization
• Use eyeglasses and hearing aids appropriately
• Mobilize patient as soon as possible
• Ensure adequate intake of nutrition and fluids, by hand feeding if necessary
• Educate and support the patient and family
SUMMARY
• Delirium is common and associated with substantial morbidity
• Delirium can be diagnosed with high sensitivity and specificity using the CAM
• A thorough history, physical, and focused labs will lead to the underlying cause(s) of delirium
SUMMARY
• Discontinue meds likely to contribute to delirium
• Managing delirium involves treating the primary disease, avoiding complications, managing behavioral problems, providing rehabilitation
• The best treatment for delirium is prevention
MANAGEMENT
• GENERAL PRINCIPLES– Interdisciplinary effort
– Multifactorial approach is most successful because multiple factors contribute to delirium
– Failure to diagnose and manage delirium .. costly, life‐threatening complications; loss of function
KEYS TO EFFECTIVE MANAGEMENT
• Treat the underlying disease
• Address contributing factors
• Optimize medication regimen
• Treat the underlying disease
• Address contributing factors
• Optimize medication regimen
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