Mini CHAMPMini CHAMP

Delirium in the Hospitalized ElderDelirium in the Hospitalized Elder

Shellie Williams, M.D.Shellie Williams, M.D.Assistant Professor of Assistant Professor of

MedicineMedicineSection of Geriatric Section of Geriatric

Medicine Medicine University of ChicagoUniversity of Chicago

Objectives:Objectives:

• Increase recognition of delirium in Increase recognition of delirium in hospitalized elders.hospitalized elders.

• Identify a risk stratification for delirium in Identify a risk stratification for delirium in hospitalized elder.hospitalized elder.

• Gain understanding of prevention for Gain understanding of prevention for delirium.delirium.

• Enhance ability to evaluate patients for Enhance ability to evaluate patients for delirium—assessment.delirium—assessment.

• Develop a strategy for treatment of Develop a strategy for treatment of delirium from a non-pharmacologic and delirium from a non-pharmacologic and pharmacologic focus.pharmacologic focus.

Mrs. Fleming:Mrs. Fleming:

• 75yo female admitted from ER with 75yo female admitted from ER with generalized weakness, UTI and pre-generalized weakness, UTI and pre-renal azotemia.renal azotemia.

• She is admitted to 5NE with IVF & She is admitted to 5NE with IVF & ciprocipro

• RN calls post-admit day#1: “She RN calls post-admit day#1: “She pulled out her IV this morning and pulled out her IV this morning and ordered me out of her home. She is ordered me out of her home. She is upsetting her roommate and refused upsetting her roommate and refused another IV. Shall I initiate a sitter?”another IV. Shall I initiate a sitter?”

Delirium: The DataDelirium: The Data

• Prevalence: 15-70%Prevalence: 15-70%• (20%) 12.5 million elderly admits(20%) 12.5 million elderly admits• Admission Onset: 20-33% Admission Onset: 20-33% • Post surgical: 30-59% Post surgical: 30-59%

Rockwood 1990; Francis 1992Rockwood 1990; Francis 1992

Defining Delirium:Defining Delirium:

• Disturbance of Disturbance of consciousnessconsciousness and reduced and reduced ability to ability to focusfocus, sustain or shift attention., sustain or shift attention.

• Change in cognitionChange in cognition (decline memory, (decline memory, orientation, language, motor) not accounted orientation, language, motor) not accounted for by preexisting dementia.for by preexisting dementia.

• Disturbance that develops over Disturbance that develops over short timeshort time and and fluctuatesfluctuates..

• Direct physiologic consequences of a specific Direct physiologic consequences of a specific medical condition, substance intoxication, medical condition, substance intoxication, withdrawal, or withdrawal, or multiplemultiple causes. causes.

Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition (DSM-IV)

Delirium: PathophysiologyDelirium: Pathophysiology

• Neurotransmitter Theory:Neurotransmitter Theory:• Cholinergic deficits: benadryl, Cholinergic deficits: benadryl,

scopalminescopalmine• Norephinephrine excess: Norephinephrine excess:

antidepressantsantidepressants• Dopamine excess: Parkinson medsDopamine excess: Parkinson meds• Cytokines-IL1, IL2, TNF (Infection)Cytokines-IL1, IL2, TNF (Infection)• Cerebral HypoxiaCerebral Hypoxia• Stress related Stress related hormonalhormonal fluctuation fluctuation

Why Focus on Delirium? RiskWhy Focus on Delirium? Risk

• Increased LOS (2x)Increased LOS (2x)• Increased Mortality (2-7x) Increased Mortality (2-7x) • 38% & 51% mortality 1yr/5yr post-38% & 51% mortality 1yr/5yr post-

hosphosp• Increased ADL dependence (2x)Increased ADL dependence (2x)• Increased instituitionalization (2-3x)Increased instituitionalization (2-3x)

Dolan J of Ger 2000;Leslie Arch In Med 2005.

Why Focus on Delirium? CostWhy Focus on Delirium? Cost

Leslie, D.L. Arch In Med, 2008; 168: 27-32.

Why Focus on Delirium?: Why Focus on Delirium?: CognitionCognition

• 60% persistent impairment from 60% persistent impairment from baselinebaseline

• 40% Progression dementia 1yr 40% Progression dementia 1yr • Premorbid Cognitive Impaired:Premorbid Cognitive Impaired:• 4% complete resolution prior d/c4% complete resolution prior d/c• 20% complete resolution 3-6mo s/p 20% complete resolution 3-6mo s/p

d/cd/c

Obstacles:Obstacles:Under-recognitionUnder-recognition

• Poor recognition:Poor recognition:Nurse recognition <50%Nurse recognition <50%Physician recognition 20%Physician recognition 20%

Inouye 2001

Recognize Delirium Fluctuating Recognize Delirium Fluctuating Faces:Faces:

• Hyperactive: 30%Hyperactive: 30%• TremorTremor• AgitationAgitation• Picking/PacingPicking/Pacing• Vivid hallucinationsVivid hallucinations• IrritabilityIrritability• AggressionAggression• Hyperactive: 30%Hyperactive: 30%

• Hypoactive: 70%Hypoactive: 70%• SedateSedate• Psychomotor Psychomotor

retardationretardation• Poverty speechPoverty speech• Diminished Diminished

awarenessawareness

Spiller, JA. Pall Med 2006; 20: 17-23.

Delirium Prevention: Delirium Prevention: Pre-hospital RiskPre-hospital Risk

Inouye,SK. Arch Int Med; 1993, 119: 474-81.

Risk Stratification Based on Risk Stratification Based on Pre-hospital risk:Pre-hospital risk:

Inouye,SK. Arch Int Med; 1993, 119: 474-81.

Risk Stratification: In-Risk Stratification: In-Hospital RiskHospital Risk

• Use of Physical Restraints (RR 4.4, CI Use of Physical Restraints (RR 4.4, CI 2.5-7.9)2.5-7.9)

• Malnutrition (RR 4.0, CI 2.2-7.4)Malnutrition (RR 4.0, CI 2.2-7.4)• >3 Medications added (RR 2.9, CI 1.2->3 Medications added (RR 2.9, CI 1.2-

4.7)4.7)• Use of Bladder Cath (RR 2.4, CI 1.2-Use of Bladder Cath (RR 2.4, CI 1.2-

4.7)4.7)• Any Iatrogenic Event (RR 1.9, CI 1.1-Any Iatrogenic Event (RR 1.9, CI 1.1-

3.2)3.2)Inouye, SK. JAMA. 1996; 275 (11): 852-7.

Risk Stratification: Risk Stratification: Delirium at Discharge Delirium at Discharge

Inouye, SK. Arch Intern Med 167 (13): 1406-12.

Prevention: Elder Life Prevention: Elder Life ProgramProgram

• Elder Life ProgramElder Life Program• Targeted protocols:Targeted protocols:

– Cognitive impairmentCognitive impairment– Sleep deprivationSleep deprivation– ImmobilityImmobility– Visual impairmentVisual impairment– Hearing impairmentHearing impairment– DehydrationDehydration

Inouye, SK. NEJM 1999; (340) 9: 669-675.

Delirium Prevention Delirium Prevention

• Decreased incidence of delirium Decreased incidence of delirium

(9.9% vs 15.0%)(9.9% vs 15.0%) p=0.02p=0.02• Decreased days of delirium Decreased days of delirium

(105d vs 161d)(105d vs 161d) p=0.02p=0.02• No statistically significant change in No statistically significant change in

severity or recurrence of deliriumseverity or recurrence of delirium

Inouye, SK. NEJM 1999; (340) 9: 669-675.

Evaluation of DeliriumEvaluation of Delirium

• MULTIFACTORIAL is the rule of thumb MULTIFACTORIAL is the rule of thumb (2.8/pt)(2.8/pt)

• Focused, patient-centered Focused, patient-centered investigationinvestigation

• History guides diagnosticsHistory guides diagnostics• Examination guides diagnosticsExamination guides diagnostics

fo ca l exam n on-focal n on -a gitated a gitated

T rea t F ind in gs

D o a p pro pr ia te ne x t s tep(e g , fev er - -> cx;

n eu ro a bn l- -> head CT )

T rea t F ind in gs

Review m edsOrder addn'l tests

H isto ry(h /o dementia?)

P h ys ica l exa m ( "h ea d to toe ")

E va lua tion

Non Pharm acologic Non Pharm acologic& Pharmacolgic

T rea t F ind in gs(R ea ssu re ,

d /c re stra in ts)

M an a ge m e nt

D e lirium

Evaluation: Algorithm to Evaluation: Algorithm to RecallRecall

DOCUMENT DELIRIUM!DOCUMENT DELIRIUM!

Confusion Assessment Method: Confusion Assessment Method: CAMCAM

Evaluation: CAMEvaluation: CAMConfusion Assessment MethodConfusion Assessment Method

DELIRIUMDELIRIUM

Acute Onset & Fluctuating Course

ANDAND Inattention

plus either

Disorganized Thinking

Altered LOC

Inouye SK et al. Ann Intern Med 1990;113:941-948.

Evaluation: R/o Dementia Evaluation: R/o Dementia

• Hx of dementia?Hx of dementia?• Need hx of sundowning to dx it!Need hx of sundowning to dx it!• Agitated dementia = deliriumAgitated dementia = delirium• Understand delirium-dementia Understand delirium-dementia

relationshiprelationship

DEMENTIA DELIRIUMDEMENTIA DELIRIUM

Distinguishing the 3 Ds:Distinguishing the 3 Ds:DELIRIUMDELIRIUM DEMENTIADEMENTIA DEPRESSIODEPRESSIO

NN

ONSETONSET SuddenSudden(days)(days)

Insidious Insidious (yrs)(yrs)

InsidiousInsidious(wks)(wks)

ATTN/LOCATTN/LOC Persistent Persistent AbnormalAbnormal

NormalNormal NormalNormal

COURSECOURSE FluctuatesFluctuates Stable, Stable, slow slow declinedecline

SlowSlow

HALLUCINSHALLUCINS Us. VisualUs. Visual Absent Absent until lateuntil late

Us. Us. AbsentAbsent

INVOL INVOL MVMNTSMVMNTS

Tremors, Tremors, picking, picking, asterixisasterixis

Absent Absent until lateuntil late

AbsentAbsent

Evaluation: Physical ExamEvaluation: Physical Exam

• ““Head to toe”Head to toe”– Vitals Vitals (temp, HR, RR, BP, pulse ox)(temp, HR, RR, BP, pulse ox)– CNSCNS (CVA, bleed, meningitis, sz, blind, deaf)(CVA, bleed, meningitis, sz, blind, deaf)– PulmPulm (pneumonia, PE, CHF)(pneumonia, PE, CHF)– CVSCVS (ischemia, CHF, arrhythmia)(ischemia, CHF, arrhythmia)– GIGI (ischemia, impaction, bleed)(ischemia, impaction, bleed)– GUGU (UTI, retention)(UTI, retention)– Extrem (pain, volume status, CVA)Extrem (pain, volume status, CVA)– SkinSkin (pressure ulcer, volume status)(pressure ulcer, volume status)

Evaluation: Evaluation: Most common causes of deliriumMost common causes of delirium

1.1. Medications 30%Medications 30%

2.2. Infections 40%Infections 40%

3.3. Fluid/Electrolyte imbalance 40%Fluid/Electrolyte imbalance 40%

Evaluation: Medications (30%)Evaluation: Medications (30%)

• Too little (alcohol or other drug Too little (alcohol or other drug withdrawal) 6%withdrawal) 6%

• Too muchToo muchnarcoticsnarcoticsneurolepticsneurolepticsanti-cholinergicsanti-cholinergicsanti-emeticsanti-emetics

• >3 new medications introduced>3 new medications introduced

Francis 1990, Schor 1999, Lawlor 2002

Evaluation: MedicationsEvaluation: Medications

• Antibiotics (aminogly, PCN, ceph, sulfa)Antibiotics (aminogly, PCN, ceph, sulfa)• BenadrylBenadryl• BenzodiazepinesBenzodiazepines (triazolam, alprazolam, diazepam) (triazolam, alprazolam, diazepam)• DigoxinDigoxin• GI (Reglan, Bentyl)GI (Reglan, Bentyl)• LithiumLithium• NarcoticsNarcotics• NeurolepticsNeuroleptics• SteroidsSteroids• NSAIDs (Indocin)NSAIDs (Indocin)• H2 Blockers (Cimetidine,…)H2 Blockers (Cimetidine,…)• Parkinsons drugs (Levodopa, Benztropine, Parkinsons drugs (Levodopa, Benztropine,

Amantadine)Amantadine)• TricyclicsTricyclics

Evaluation: Anti-cholinergic Evaluation: Anti-cholinergic MedicationsMedications

Fecal/urine impacted, confused, flushed, dry, low Fecal/urine impacted, confused, flushed, dry, low bpbp

Elavil Elavil (amitriptyline)(amitriptyline) Flexeril Flexeril (cyclobenzaprine)(cyclobenzaprine)

Cogentin Cogentin (benztropine)(benztropine) Atarax/VistarilAtarax/Vistaril(hydroxyzine)(hydroxyzine) Bentyl Bentyl (dicyclomine)(dicyclomine) Welbutrin/Zyban Welbutrin/Zyban (bupropion)(bupropion) Ditropan Ditropan (oxybutynin)(oxybutynin) Antivert Antivert (meclizine)(meclizine)

Detrol Detrol (tolterodine)(tolterodine) Ipratropium Ipratropium (atrovent)(atrovent)

Benadryl Benadryl (diphenhydramine)(diphenhydramine) Phenergan Phenergan (promethazine)(promethazine)

Zyprexa Zyprexa (olanzapine)(olanzapine) Atropine AtropineLevsin Levsin (hyoscyamine)(hyoscyamine) Belladonna Alkoloids Belladonna Alkoloids

Evaluation: Brain CT?Evaluation: Brain CT?

• Controversy on routine orderingControversy on routine ordering• Low yield if lack focal neuro findingsLow yield if lack focal neuro findings• Documented head trauma with new Documented head trauma with new

neuro findings or high risk bleedneuro findings or high risk bleed

Francis, J. Clin Res 1991 (abstract); 39: 103.

Evaluation: Additional testsEvaluation: Additional tests

• Labs Labs – CBC, lytes, liver, renalCBC, lytes, liver, renal– Consider TSH, B12Consider TSH, B12

• Drug levels (digoxin, valproic, Drug levels (digoxin, valproic, phenytoin)phenytoin)

• Urine tox, Urine tox, UA/cultureUA/culture• CXRCXR• EKGEKG • EEG**EEG**

Management: Plan before Management: Plan before PillsPills

• Prevention of deliriumPrevention of delirium• Correction underlying causesCorrection underlying causes• Non-pharmacologic intensifyNon-pharmacologic intensify• Pharmacologic (agitation)Pharmacologic (agitation)

Management: Non-Management: Non-pharmacologicpharmacologicHELP PreventionHELP Prevention

• CognitionCognition: orientation board (carry pen!), (day) : orientation board (carry pen!), (day) open drapes, clock, calendar, family photosopen drapes, clock, calendar, family photos

• SleepSleep: min deprivation (d/c 2am labs & o/n : min deprivation (d/c 2am labs & o/n BD/vitals; meds when awake); warm drink; limited BD/vitals; meds when awake); warm drink; limited pm awakepm awake

• MobilityMobility: Early OOB: Early OOBchair ; PT/OT; no chair ; PT/OT; no foley/restraintsfoley/restraints

• VisionVision: glasses: glasses• HOHHOH: get aids; adapt environment (stethoscope!): get aids; adapt environment (stethoscope!)• DehydrationDehydration: po fluids; observe at mealtime: po fluids; observe at mealtime• Feeding:Feeding: assist with meals assist with meals• ActivityActivity: Involve family (rotate members) or get : Involve family (rotate members) or get

sitter; move pt to room close to RN station, current sitter; move pt to room close to RN station, current eventsevents Inouye, SK. JAGS 2006; 54: 1492-1499.

Management: Non-Management: Non-pharmacologicpharmacologicRestraint UseRestraint Use

• AVOID!AVOID!• 4x increased risk protracted delirium4x increased risk protracted delirium• Increase risk of falls, injury, & Increase risk of falls, injury, &

deliriumdelirium• Use only in emergency, for as short a Use only in emergency, for as short a

duration as possible with frequent re-duration as possible with frequent re-evaluations, and d/c asapevaluations, and d/c asap

• Absolutely no “sheeting”Absolutely no “sheeting”Inouye, SK. Arch Intern Med 167 (13): 1406-12.

Management: PharmacologicManagement: Pharmacologic

• 30/244 AIDS patients admitted to hospital 30/244 AIDS patients admitted to hospital with AIDS related illness, developed with AIDS related illness, developed delirium delirium

• Double blind randomization to lorazepam, Double blind randomization to lorazepam, chlorpromazine or haloperidolchlorpromazine or haloperidol

• Early cessation of lorazepam arm due to Early cessation of lorazepam arm due to worsening sedation, confusion & ataxiaworsening sedation, confusion & ataxia

• Chlorpromazine & haldoperidol arm Chlorpromazine & haldoperidol arm improvement in delirium per DRS score, improvement in delirium per DRS score, limited EPS and improved MMSE in limited EPS and improved MMSE in chlorpromazine group @ 2dchlorpromazine group @ 2d

Breitbart, W. Am J. Psych, 1996; 153: 231-237.

Management: Management: Pharmacologic Anti-psychoticsPharmacologic Anti-psychotics

Typical: HaldolTypical: HaldolAdvantagesAdvantages: : min sedmin sedDisadvantages: lower sz thrshld; more EPS (even at Disadvantages: lower sz thrshld; more EPS (even at low dose); not FDA-app for IV; can incr QTc; low dose); not FDA-app for IV; can incr QTc; TorsadesTorsades

Dose: 0.25-0.5mg po, IM, IV; can repeat in 30 mins Dose: 0.25-0.5mg po, IM, IV; can repeat in 30 mins x1; then dose q4hx1; then dose q4h

tt1/21/2=21h (10-38)=21h (10-38)

APA 1999APA 1999

Management:Management:Pharmacologic AntipsychoticsPharmacologic Antipsychotics

Atypical:Atypical:Advantages: min sed, less EPS, hyperglycemiaAdvantages: min sed, less EPS, hyperglycemia

Disadvantages: take time to work, no evidence in Disadvantages: take time to work, no evidence in short-term; short-term; recent Black Box warning: vascular recent Black Box warning: vascular events!events!

Risperidone 0.25-0.5mg po bid Risperidone 0.25-0.5mg po bid tt1/21/2=20-30h =20-30h

EPS with high doseEPS with high dose

Olanzapine (Zyprexa) 2.5-5mg po qd Olanzapine (Zyprexa) 2.5-5mg po qd tt1/21/2=30 (21-54h) =30 (21-54h)

more anticholinergicmore anticholinergic

Quetiapine (Seroquel) 12.5-25mg po bid Quetiapine (Seroquel) 12.5-25mg po bid t ½=6ht ½=6h

less EPS riskless EPS risk

Van Zyl. Geriatrics 2006; 61(3): 18-21.

Management: PharmacologicManagement: PharmacologicBenzodiazepinesBenzodiazepines

Used best in w/dUsed best in w/d

Lorazepam 0.5-1mg po, IM, IV q6-8Lorazepam 0.5-1mg po, IM, IV q6-8(no first-pass, no renal adjustment)(no first-pass, no renal adjustment)

tt1/21/2=12h=12h

Conclusion:Conclusion:

1.1. Prevent delirium.Prevent delirium.– Evaluate risk factors pre-admit, during Evaluate risk factors pre-admit, during

and post hospitalization.and post hospitalization.– Adjust admit ordersAdjust admit orders

2.2. It is important to develop a systematic It is important to develop a systematic approach for diagnosis of delirium, approach for diagnosis of delirium, THEN (DOCUMENT!).THEN (DOCUMENT!).

3.3. First use non-pharmacologic First use non-pharmacologic measures, then pharmacologic, to measures, then pharmacologic, to treat delirium.treat delirium.

Case Revisited:Case Revisited:

• Mrs. Fleming is a 75 year old female with Mrs. Fleming is a 75 year old female with htn, OA, dm, cri (1.3) baseline and chronic htn, OA, dm, cri (1.3) baseline and chronic AF. She lives alone in a 3 story home.AF. She lives alone in a 3 story home.

• Meds: Meds: (Home)(Home) Lisinopril 20mg qamLisinopril 20mg qamAsa 81 mgAsa 81 mgCelebrex 200mg qamCelebrex 200mg qamMetformin 500mg bidMetformin 500mg bidHctz 25mg qamHctz 25mg qamElavil 50 mg qhsElavil 50 mg qhs

Medicines In-hospital:Medicines In-hospital:

• Lisinopril 10mg Lisinopril 10mg qamqam

• Hctz 25mg qamHctz 25mg qam• Regular Insulin SSRegular Insulin SS• 0.9NS 150 cc/hr x 0.9NS 150 cc/hr x

36hr36hr• Elavil 50mg qhsElavil 50mg qhs• ASA 81mg qamASA 81mg qam• Darvocet N 1 q 6hrDarvocet N 1 q 6hr

• Prosom 15mg qhs Prosom 15mg qhs prnprn

• Benadryl 25mg q Benadryl 25mg q 6hr itching, sleep6hr itching, sleep

• Vicodin 5/500mg q Vicodin 5/500mg q 4hr prn4hr prn

• Morphine 2-4 mg iv Morphine 2-4 mg iv q 4hrq 4hr

• Zofran 4mg q 6hr Zofran 4mg q 6hr prn n/vprn n/v

Case revisited:Case revisited:

• Currently, pt is quietly sitting in chair, Currently, pt is quietly sitting in chair, picking at skin.picking at skin.

• When asked what is she doing she notes, “ When asked what is she doing she notes, “ It is a shame you can’t afford extermination It is a shame you can’t afford extermination in this place!” in this place!”

• She then returns to her activity.She then returns to her activity.• Her daughter notes she has not slept in 3 Her daughter notes she has not slept in 3

days and was incontinent of urine 2 days days and was incontinent of urine 2 days PTA.PTA.

• Roommate notes she was lethargic and not Roommate notes she was lethargic and not answering questions a few moments ago.answering questions a few moments ago.

CAM Assessment: Is she CAM Assessment: Is she Delirious?Delirious?

• Acute/fluctuating?Acute/fluctuating?

• Inattentive?Inattentive?

• Disorganized thinking?Disorganized thinking?

• Decreased level of consciousness? Decreased level of consciousness?

fo ca l exam n on-focal n on -a gitated a gitated

T rea t F ind in gs

D o a p pro pr ia te ne x t s tep(e g , fev er - -> cx;

n eu ro a bn l- -> head CT )

T rea t F ind in gs

Review m edsOrder addn'l tests

H isto ry(h /o dementia?)

P h ys ica l exa m ( "h ea d to toe ")

E va lua tion

Non Pharm acologic Non Pharm acologic& Pharmacolgic

T rea t F ind in gs(R ea ssu re ,

d /c re stra in ts)

M an a ge m e nt

D e lirium

An Algorithm to Remember!

Review Dementia?Review Dementia?

• DementiaDementia– Get further hx from family of baseline Get further hx from family of baseline – Was dx missed or never made? Was dx missed or never made? – Prior hx of delirium during Prior hx of delirium during

hospitalization?hospitalization?– Do serial cognitive assessment: MMSEDo serial cognitive assessment: MMSE

Review Other Risks for Review Other Risks for Delirium:Delirium:

• Recent physical symptoms? Cough, Recent physical symptoms? Cough, chills, SOBchills, SOB

• Psychiatric symptoms? NonePsychiatric symptoms? None• Alcohol/Illicit drug use? 1 Highball Alcohol/Illicit drug use? 1 Highball

nightlynightly• Recent CNS trauma? No trauma Recent CNS trauma? No trauma

other than hipother than hip• Recent stroke symptoms? NoRecent stroke symptoms? No

Case Revisited: ExamCase Revisited: Exam

• Sat 88% ra, rr 28, p 100, bp 100/50, pain grimaceSat 88% ra, rr 28, p 100, bp 100/50, pain grimace• HEENT: Dry mucosa, no evidence cns contusionHEENT: Dry mucosa, no evidence cns contusion• Neck: No adenopathy or thyromegaly or jvdNeck: No adenopathy or thyromegaly or jvd• Lungs: Increase fremitus and percussion dullness Lungs: Increase fremitus and percussion dullness

rt. base no use acc musclesrt. base no use acc muscles• Heart: Irregular rhythm, rate 100, no murmur, Heart: Irregular rhythm, rate 100, no murmur,

rub or galloprub or gallop• Abdomen: +bs, soft non distended, non tenderAbdomen: +bs, soft non distended, non tender• GU: +foley, no evidence retentionGU: +foley, no evidence retention• Neuro: Inattentive, disoriented, poor recall of Neuro: Inattentive, disoriented, poor recall of

hospital events, hyperalert at times, motor hospital events, hyperalert at times, motor strength symmetric, normal sensory function, no strength symmetric, normal sensory function, no hyper-reflexia, antalgic gaithyper-reflexia, antalgic gait

Case, cont’dCase, cont’d

• Labs: 10.5Labs: 10.5 13.2 19213.2 192

33.033.0

148 110 56 128148 110 56 128 5.2 30 1.85.2 30 1.8

UA: +LE, nitrite, 1.025, bacteria, rbcUA: +LE, nitrite, 1.025, bacteria, rbcECG: A. Fib rate 60s, no acute ST ECG: A. Fib rate 60s, no acute ST changeschanges

CXR:CXR:

Case Revisited: Case Revisited: What factors What factors predisposed this patient for predisposed this patient for delirium?delirium?

FoleyFoley Poor po intakePoor po intake Poor visionPoor vision > 3 new > 3 new

medicationsmedications Sensory Sensory

impairmentimpairment Use of restraintsUse of restraints Bed bound statusBed bound status

>30 bun/creatinine >30 bun/creatinine ratioratio

Baseline cognitive Baseline cognitive deficitsdeficits

Lack of pain controlLack of pain controlPoor sleepPoor sleep

Case Revisited: Case Revisited: What factors precipitated What factors precipitated delirium?delirium?

StrokeStrokeUTIUTIPneumoniaPneumoniaAnti-cholinergicsAnti-cholinergicsDehydrationDehydrationHypoxiaHypoxiaAnemiaAnemia

HypotensionHypotensionMetabolic Metabolic

derangementsderangementsAlcoholismAlcoholism Illicit drugsIllicit drugsCardiac ischemiaCardiac ischemia

Case Revisited: Case Revisited: How should we treat this How should we treat this patient?patient?

Add lorazepamAdd lorazepam Initiate sleep ordersInitiate sleep ordersStop elavilStop elavilStop lisinoprilStop lisinoprilSchedule tylenolSchedule tylenolAdd vicodin Add vicodin

schedulescheduleStop combo Stop combo

analgesicanalgesicExplain condition to Explain condition to

daughterdaughter

Zosyn 3.25 mg q Zosyn 3.25 mg q 6h6h

Initiate oral Initiate oral hydration protocolhydration protocol

Start IVFStart IVFReorientation Reorientation

protocolprotocolRemove foleyRemove foleyOxygen therapyOxygen therapy

THANK YOUTHANK YOU