ACUTE CONFUSION IN THE ELDERLY

Dr. Barbara PowerApril, 2010

Major Objectives

1. Describe common causes of delirium

2. Recognize risk factors, and means of prevention of delirium

3. Work up and treatment of delirium when it does occur, and management of behavioral problems

Synonyms for Delirium

• Acute confusional state• Organic brain syndrome• Toxic/metabolic

encephalopathy• Out of it• Uncooperative

Epidemiology in ElderlyPrevalence :• On Admission 10 - 30%• ER 10 -18%

Incidence:

• In Hospital 10 - 56%• Post-operatively 15 - 53%• Cardiac Surgery 17 - 73%• ICU 70 - 87%

So What?Why is Delirium Important?

3 criteria:

Common, Morbidity & Costly!

•on admit? 15-24%

•in hospital?14-31%

•Ortho? 25-65%

•ICU: 70%!

•Death ~20-35%

•Cognitive drop in 40%

•Premature institutionalization

•LOS doubles

• ++ hospital $

•Caregiver burden

Recognition of Delirium

• Previous studies 32%-66% of cases unrecognized

by MD’s

• Yale- New Haven study

– 65% unrecognized by Physicians

– 43 % unrecognized by nurses

Case - Delirium

Mrs G. 79 year old lady• lives alone, manages own

apartment• slightly forgetful (according to

daughter)• PMed Hx: HTN; Insomnia• Meds:

– Hydrochlorothiazide 25 mg OD– Amitriptyline 50 mg qhs– Oxazepam 15-30 mg qhs– Occasional alcohol use

Case - Delirium

Admisssion to Hospital

• Tripped on rug, sustained a hip

fracture

• Brought to hospital. Spends 12

hours in ER waiting for bed

1) What are the risk factors that make Mrs. F vulnerable to developing delirium?

2) Suggest actions that could be initiated to reduce her risk of developing delirium

Case - Delirium

Admisssion to Hospital

• ORIF the following day

• 1st POD– climbing over bedrails– shouting all night– sleeping in day– pulling out her IV’s

3. What are the key features of delirium that the MD should elicit in Mrs. G?

The First Question –What is this?

Is this Delirium?

Dementia??

Or something else???

All Confusion is Not Dementia

Always Consider Delirium

Delirium

Delirium

Definition:

• a disturbance of consciousness with inattention that develops over a short time & fluctuates

Delirium (DSM-IV)A: Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attentionB: Change in cognition (eg. memory deficit, disorientation, language disturbance) or development of a perceptual disturbance not due to pre-existing, established or developing dementiaC: The disturbance develops over a short period of time (hours to days) and tends to fluctuate during the course of the day.D. Evidence of aetiology

Delirium versus Dementia?

DELIRIUM• Acute • Inattention• AbN LOC• Fluctuations/minutes• Reversible• Hallucinations

common

DEMENTIA• Gradual• Memory disturbance• N LOC• None/days• Irreversible• Hallucinations

common only in advanced disease

It is common for Delirium to be superimposed on Dementia!

Confusion Assessment Method (CAM)

1. History of acute onset of change in patient’s normal mental status & fluctuating course?

AND2. Lack of attention?

AND EITHER

3. Disorganized thinking?4. Altered Level of Consciousness?

Inouye SK: Ann Intern Med 1990;113(12):941-8

Arch Intern Med. 1995; 155:301

Sensitivity: 94-100%Specificity: 90-95%Kappa: 0.81

Testing Attention

• Formal methods:– MMSE: Serial 7’s, WORLD backwards– Digit Span: 5 forwards, 4 backwards– Days of Week, Months of Year backwards

• Affects all other areas of cognition

Delirium: Cognitive Evaluation

• MMSE:– inaccurate tool to diagnose delirium as the patient:

• fluctuates• has poor attention/concentration

– helpful tool to demonstrate improvement in cognitive status when following patient.

Psychomotor Variants of Delirium :

• Hyperactive ("wild man!"); 25%

• Hypoactive ("out of it!“, “pleasantly confused”); 50% - Individuals often not recognized as they may not cause a disturbance so they don’t get ATTENTION

• Mixed delirium (features of both), with reversal of normal day-night cycle (“sundowning”)

Case – Delirium: CAM• Acute /Fluctuating Course• Altered level of

Consciousness• Inattention• Disorganized Thinking

9 am

1 pm

Top 4 Independent Risk Factors for Delirium

Vision impairment: RR=3.5 (1.2-10.7)

Any severe illness: RR=3.5 (1.5-8.2)

Cognitive impairment: RR=2.8 (1.2-6.7)

High Urea/Creatinine: RR= 2.0 (0.9-4.6)

Inouye S. Ann Intern Med 1993: 119-474

What causes delirium:Inouye Delirium Model

Fit 65 y.o. who plays senior’s hockey Frail 89 y.o. with baseline dementia

Strong or repeated precipitant needed

Minimal precipitant needed

Added Independent Precipitating Factors in Hospital For Delirium(i.e.. bad things WE do to elderly

patients):

• Restraints (RR 4.4)• NPO status (RR 4.0)• 3+ new med/24 hr (RR

2.9)• Foley catheter (RR 2.4)• Any iatrogenic event

(RR 1.9)

Inouye SK, Charpentier PA, Precipitating Factors for Delirium in Hospitalized Elderly Persons. JAMA. 1996;275:852-857

Causes of Delirium?

• brain’s way of demonstrating “acute organ dysfunction”

• Anything that hurts the brain or impairs its proper functioning can provoke a delirium!

I WATCH DEATHMnemonic

• I  Infection:   Most common are pneumonias & UTI in elderly, but sepsis, cellulitis, SBE and meningitis can also occur

I WATCH DEATH

• I  Infection 

• W  Withdrawal: benzodiazapines, ETOH,

I WATCH DEATH

• I  Infection 

• W  Withdrawal• A  Acute metabolic:

electrolytes, renal failure, acid-base disorders, abnormal glycemic control, Calcium

I WATCH DEATH

• I  Infection 

• W  Withdrawal• A  Acute metabolic• T Trauma: head injury

(SDH, SAH), pain, vertebral or hip fracture, urinary retention, fecal impaction

I WATCH DEATH

• I  Infection 

• W  Withdrawal• A  Acute metabolic• T Trauma• C  CNS pathology• H  Hypoxia from COPD

exacerbation, CHF

Medication review:

• Look at all prescriptions• include PRNs, regular,

ETOH and OTC meds• Ask if anything has been

added, changed or stopped• Watch for sleeping meds ie

Gravol; Nytol,

Miscellaneous Causes of Delirium

• Pain

• Fecal Impaction

• Urinary Retention

In other words, anything that makes an older person very

very sick…

…can cause a delirium in a vulnerable older person!

Delirium Workup

• On History: – time course of

mental status changes?

– association with other events (i.e.. meds, illness)?

– Pre-existing impairments of cognition or sensory modalities?

How to find out more? One of the most useful and underused medical

tools:

Physical Exam

– Vitals: normal range of BP, HR Spo2, Temp? – Good physical exam: particular emphasis on

Cardiac, pulmonary and neurologic systems

– Hydration status ? (dry axilla=dehyd!; + LR ~3)

– Also rule out • fecal impaction (DRE) • urinary retention (bladder U/S, in-and-out catheter)• Infected decubatis ulcer

Delirium workup: Lab testing

• Basic labs most helpful!– CBC, lytes, BUN/Cr,

glucose– TSH, B-12, LFTs

Calcium, & albumin

• Infection workup (Urinalysis, CXR) +/- blood cultures

• Other investigations based on Hx- EKG/CT Scan/Drug levels

Case - Delirium

Admisssion to Hospital

• ORIF the following day

• 1st POD– climbing over bedrails– shouting all night– sleeping in day– pulling out her IV’s

5. What are the main immediate treatments you would initiate?

Helping to improve Delirium

Once it starts, needs to ride its course; but you can make a difference!

Delirium Reduction:• You can get

improvement of delirium with such simple measures as:– Glasses– Using hearing aids– Fluids/nutrition– reducing noise– Early mobility– Familiar faces

S Inouye A multicomponent intervention to prevent delirium in hospitalized older patients.

N Engl J Med. 1999 Mar 4;340(9):669-76.

Can We Prevent of Delirium

• Multi component intervention strategy

targeted to 6 delirium risk factors

Ref: Inouye SK, NEJM. 1999;340:669-676

Yale Delirium Prevention Trial Risk Factors Intervention

Cognitive Impairment Reality orientation / therapeutic activities program

Vision/Hearing impairment Vision / hearing aids / adaptive equipment

Immobilization Early mobilization / Reduce immobilizing equipment

Psychoactive medication Non pharmacologic approaches to sleep / anxiety / Restricted use of

sleeping medicationDehydration Early recognition / Volume

expansionSleep deprivation Noise reduction strategies/sleep

enhancement programRef: Inouye SK, NEJM. 1999;340:669-676

Yale Delirium Prevention TrialSignificance

• Practical intervention towards evidence based risk factors

• Significant reduction in risk of delirium

( 9.9% in intervention group vs 15% in usual care)

• Significant reduction in total delirium days

Pharmacological Rx: Goals

• Reverse psychotic signs and symptoms

• stop dangerous or potentially dangerous behavior

• To calm the patient sufficiently to conduct the necessary evaluation and treatment

Drug Treatment of Agitation• Only 4 RCTs (largest N=73):

– Neuroleptics preferable to benzodiazepines in most cases (except: PD, DLBD, ETOH)

– Low dose high potency neuroleptics (e.g., starting at haloperidol 0.25-1 mg)

– Newer “atypical” agents: no better than haloperidol

• Avoid Combination Drugs – SINGLE Drug is better

Lacasse et. al., Ann Pharm, 2006

IF SEVERE AGITATION consider Rx w/ high potency antipsychotic:

• Haloperidol: po/IM/(IV short acting):

– start with 0.5 - 1 mg initial dose – Repeat dose of 0.25-0.5 mg Q30 minutes if patient remains

unmanageable without adverse events until sedation achieved and continue monitoring

– repeat cycle until acceptable response or adverse events occur– max suggested Haldol dose in frail elderly 3-4mg/24 hr

• Maintenance: 50% loading dose in divided doses over next 24 hrs

• Taper the dose as soon as possible• Avoid in individuals with Parkinson’s Disease

Benzodiazepines

1. Avoid use in combination with

antipsychotics - SINGLE drug is better.

2. May cause distribution/increased agitation.

3. Best reserved for Delirium 2o to alcohol /

Benzodiazepine withdrawal.

4. Relatively contraindicated in Delirium from

Hepatic Encephalopathy.

Summary - Recognition of Delirium

• Delirium is Common

• Yale- New Haven study

– 65% of cases unrecognized by Physicians

• Don’t be part of that group!

Now! …That should clear up a Now! …That should clear up a few things around here!few things around here!