Morning ReportSteve Hart4/19/2006

Case Presentation77 y/o AAF with ESRD presents to ED with lower extremity weakness x 1-2 days and elevated blood pressure.Feeling generally weak, now unable to ambulateOff BP meds for about a weekBP controlled with DialysisHeadachesPoor visionSome SOB and coughingPer social worker and daughter, mental status changed from baseline

PMHxHTNGlaucomaCataractAnemiaRecent AV graft infection

Social HxLives at home with daughterQuit smoking in 50s

Allergies noneMedsLisinoprilAranespXalatin eye dropsPhosloNephrocapsZocorAspirin

VitalsT 97.1 HR 79 R 14 BP 175/69 Pox 98% 2L

Physical ExamGen Alert, oriented? Female, HEENT PERRLA, EOMI, MMMNeck JVD, nl thyroidChest bilateral rhonciCV RRR, nl S1 and S2, no edema, no bruitsAbd soft, NT/ND, no HSMExt no E/C/CNeuro equal/symetric +1 reflexes., CN intact, nl cerebellar signs, +5 strength in UE, -5 in LE Neg Rhomberg

Labs138 96 73.7 33 2.5 90 13.6 5.3 218 41.5 Ca 9.7CKMB 1.8Trop I 0.05

EKG NSR, No ST changesCXR NADUA: 1.006, 8.5, prot 100, occ bact, LE large, 27 WBCDiff: N65 L20 M10

ImagingHead CTSmall vessel disease with age indeterminate infarcts in internal capsule. Possible subacute on old?

MRI Headmoderate deep and sub-cortical ischemic white matter changes non acuteBilateral patchy ischemic foci in the lentiform nucleus and pons. No intracranial mass lesionremote micro hemorrhage in the right posterior inferior aspect of the thalamus

Problem ListGeriatricWeakness, ambulatory only with assistance - newRecent decline in mental statusHTN, uncontrolledESRDUTIImpaired visionSOB, hypoxicSmall vessel disease, lacunar infarcts

Hospital CourseDay 1Started on routine SQ heparin and pepcid on admissionMI ruled out with serial enzymes and EKGsCultures negative, no empiric antibioticsRemained afebrileSOB and hypoxia relieved with dialysisBlood pressure poorly controlledNeurology consulted for mental status changes

Hospital CourseMental Status quickly deterioratedHallucinationsFluctuating mental statusAlert but not oriented at timesUnable to concentrateTangential thoughtsundowning Patient placed in restraints

Delirium

DeliriumDefinitionreduced ability to focus, sustain, or shift attention change in cognition or the development of a perceptual disturbance Acute onset (hours to days)Identifiable cause

EpidemiologyAt admission prevalence 14-24% Hospitalization incidence 6 to 56%15-53% geriatric patients post-op70-80% older patients in ICU60% nursing home will have at some time83% of geriatric patients prior to death

Delirium.Why should I care?Mortality rate in hospitalized patients 22-76% One year mortality rate is 35-40%Prolongs hospital courseIncreased cost of care in hospitalIncreases likelihood of disposition to nursing home, functional decline and loss of independence

More reasons to careStrong association with underlying dementiaFrequently, patient may never return to baseline or take months to over a year to do soDelirium is often the sole manifestation of serious underlying disease

PathophysEEG shows diffuse cortical slowingNeuropsyc and imagingDisruption of higher cortical functionPrefrontal cortexSubcortical structuresThalamusBasal gangliaFrontal and temporoparietal cortex fusiform cortexLingual gyriEffect greatest on non-dominant side.

InvolvesNeurotransmissionInflammationChronic stressPathogenesis

NeurotransmissionCholinergic deficiencyAnticholinergics can precipitate deliriumSerum anticholinergic activity increased in those with deliriumCholinesterase inhibitors can reverse this effectDopaminergic excessNeuropeptides, endorphins, serotonin, NE, GABA may play a role.Pathogenesis

PathogensisCytokinesInterleukins and interferonsOften elevated in DeliriumHave known strong CNS effectsPrimary role sepsis, bypass surgeries, dialysis, cancers

PathogensisChronic stressUntreated pain / analgesia are strong risk factorsElevated cortisol assoc with delirium

Risk FactorsUnderlying brain diseaseDementiaStrokeParkinsonsAdvanced AgeSensory ImpairmentBladder Caths

DifferentialPsychiatric IllnessDepressionmaniaDementiasNonconvulsive status epilepticusEspecially in ICUWernickes aphasiaOccipital lesions(cortical lesions and confabulations)Bifrontal lesions (tumors or trauma)

DiagnosisClinical

Step #1 Recongnize the disorder

Step #2 - Uncover underlying medical illness

RecognizeOften unrecongnized, >70% of cases

Behavioral or cognitive issues often wrongly attributed to age, dementia or other mental disorders

determine acuity of change in mental status.if no historian available, one should assume acute and delirious until proven otherwise

RecognizeDisturbance in consciousness and alterned congnitionConsciousnessAttention poorSubtle loss of mental clarity initiallyPatient isnt acting rightDistractabilityTangential or disorganized thoughtAcute/subacute onsetFluctuating course throughout a day

RecongnitionCongitionMemory lossDisorientationDifficulty with language and speechPerceptual disturbancesDelusionsHallucination

AssessmentFormal mental status evaluation in all geriatric patients (ie. MMSE or CAM)

Arouse all older patients daily to evaluate hypoactive form of delirium

Search for causes of delirium

D Drugs, Drugs and toxins, tooE Eyes, earsL Low O2 states (MI, ARDS, PE, CHF, COPD, stroke, shock)I InfectionR Retention (of urine or stool). RestraintsI IctalU Underhydration, UndernutritionM Metabolic (hypo/hyper glycemia, calcemia, uremia, liver failure, thyroid disorders)Causes

Other CausesFoley catheterInvasive procedureSleep deprivationPain

DrugsAccounts for 30% of all casesCommon culpritsAnti-histaminesAnti-cholinergicsAntibioticsSome antidepressantsDopamine agonistsHypoglycemicsBenzosOpiates

PatientPoor visionEvidence of old and recent strokesInfection - UTIRestraintedMultiple medicationsPepcid started on admissionESRDHypoxia

TreatmentCorrect all identifiable causesDelirium is usually multifactorialCorrection of multiple causes is often necessary for recoveryPharmacologic if neededAntipsychoticsAvoid benzos except with ETOH withdrawlOrient Patients Provide clocks, calenders, windows, structured activitiesHearing aides, glasses

The End Questions/Comments?