delirium ashley duckett, md pamela pride, md medical university of south carolina 2012
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DeliriumDelirium
Ashley Duckett, MDAshley Duckett, MD
Pamela Pride, MDPamela Pride, MD
Medical University of South CarolinaMedical University of South Carolina
20122012
CAM Definition of CAM Definition of DeliriumDeliriumAcute onset or fluctuating courseAcute onset or fluctuating course
ANDANDInattention (decreased ability to focus, shift Inattention (decreased ability to focus, shift
or sustain attention)or sustain attention)PLUS EITHERPLUS EITHER
Disorganized thinking (incoherent or Disorganized thinking (incoherent or illogical speech (illogical speech (questions – does a stone float on questions – does a stone float on water, etc)water, etc)
ORORAltered Level of Consiousness (anything Altered Level of Consiousness (anything
other than alert and calm) – RASS other other than alert and calm) – RASS other than 0than 0
Confusion Assessment Method- Inouye, Ann Intern Med 1990
-INATTTENTION is the cardinal feature for diagnosis-INATTTENTION is the cardinal feature for diagnosis-Can use serial 7’s, WORLD, reciting days or months -Can use serial 7’s, WORLD, reciting days or months in reverse, etc; ICU uses letter test (SAVEAHAART)in reverse, etc; ICU uses letter test (SAVEAHAART)
-SUBTYPES -SUBTYPES -Hyperactive – agitated, hyperalert-Hyperactive – agitated, hyperalert-Hypoactive – calm and confused, lethargic-Hypoactive – calm and confused, lethargic-Mixed – features of both-Mixed – features of both
*no difference in etiology or outcomes among the *no difference in etiology or outcomes among the subtypessubtypes
*hypoactive pts commonly missed without formal screen*hypoactive pts commonly missed without formal screen
The 3 D’sDepression - Dementia - Delirium
Delirium Dementia Depression
Onset Abrupt Slow, insidious Recent, may be associated with loss
Duration Hours to days Months to years Stable, may be worse in the morning
Attention Impaired Normal, except severe cases Usually normal
Consciousness Reduced, fluctuating
Clear Clear
Silverstein & Maslow, 2006
Why do we care?Why do we care?
VERY common (esp if older, had VERY common (esp if older, had ICU stay) although underdetectedICU stay) although underdetected
Increased morbidity and mortalityIncreased morbidity and mortality– Higher risk for falls, decubs, pnaHigher risk for falls, decubs, pna– Higher risk of functional decline and Higher risk of functional decline and
institutional careinstitutional care– Longer LOSLonger LOS– Predictor of 12 mo mortalityPredictor of 12 mo mortality
Risk factors Risk factors (far from an exhaustive (far from an exhaustive
list)list)
Age >70Age >70 Dementia or underlying brain Dementia or underlying brain
dysfunctiondysfunction Alcohol abuseAlcohol abuse Hearing or visual impairmentHearing or visual impairment History of deliriumHistory of delirium
Inouye et al, Multicomponent Intervention of Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76)
Modifiable risk factorsModifiable risk factors
Medications Medications Polypharmacy (>3 new inpt meds)Polypharmacy (>3 new inpt meds) Physical restraints and catheters Physical restraints and catheters Sleep deprivation Sleep deprivation ImmobilityImmobility Uncontrolled painUncontrolled pain Medical illness (organ failure, Medical illness (organ failure,
electrolytes, etc)electrolytes, etc)
Antiparkinson drugs Corticosteroids UI drugs Theophylline Emptying drugs (motility
drugs) Cardiovascular Drugs H2 blockers Antimicrobials NSAIDs Geropsychiatric drugs ENT drugs
Insomnia drugs Narcotics
Muscle relaxants Seizures Drugs
Look to these medications if there is
an ACUTE CHANGE IN MS
http://www.geronurseonline.org; Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): 101-27.
Mini-Cog
Recall 0 Recall 1-2 Recall 3
Abnormal Clock Normal Clock
Impaired
Not ImpairedImpaired
Not Impaired
Borson S et al. (2000), Int J Geriatr Psychiatry 15(11):1021-1027
Serial administration of a modified RASS for Serial administration of a modified RASS for delirium screeningdelirium screening
Chester, JG et al. J Hosp Med 2012 May-June 7 (5) 450-3.
EvaluationEvaluation
Vital signs, pulse ox, volume statusVital signs, pulse ox, volume status Focused exam including determining Focused exam including determining
baseline cognition, urine output, last BMbaseline cognition, urine output, last BM Blood glucoseBlood glucose Review medicationsReview medications Consider withdrawal as a causeConsider withdrawal as a cause Testing – CBC, BMP, UA, CXR, EKGTesting – CBC, BMP, UA, CXR, EKG Additional testing if clinically indicatedAdditional testing if clinically indicated
ManagementManagement
Try to identify underlying causeTry to identify underlying cause Prevent complications and provide Prevent complications and provide
supportive caresupportive care– Avoid bed rest, catheters, mobilize Avoid bed rest, catheters, mobilize
patientpatient– Sleep at night, awake during daySleep at night, awake during day– Monitor nutrition status and outputMonitor nutrition status and output– Consider aspiration precautionsConsider aspiration precautions– Enlist the help of familyEnlist the help of family
ManagementManagement
Antipsychotics are drug of choice for Antipsychotics are drug of choice for treating agitationtreating agitation– Can consider treating hypoactive delirium to Can consider treating hypoactive delirium to
treat subjective stress (paranoia, treat subjective stress (paranoia, hallucinations)hallucinations)
Haldol – cheap, can be given PO, IV, IMHaldol – cheap, can be given PO, IV, IM– CAN’T be used in Parkinson’s, Lewy body CAN’T be used in Parkinson’s, Lewy body
dementia, prolonged QTdementia, prolonged QT DON’T USE BENZOs UNLESS YOU’RE DON’T USE BENZOs UNLESS YOU’RE
TREATING WITHDRAWAL or NMS!!!TREATING WITHDRAWAL or NMS!!!
What’s the evidence?What’s the evidence?
Best drug? Haldol v Atypicals Best drug? Haldol v Atypicals ((Risperidone, Olanzipine, Quetipine)Risperidone, Olanzipine, Quetipine)
– Systematic reviews show similar efficacy, Systematic reviews show similar efficacy, question of fewer side effects question of fewer side effects
– NEED larger and better studies NEED larger and better studies
2005 FDA warning re risk of death 2005 FDA warning re risk of death – Use for shortest duration, with cautionUse for shortest duration, with caution– NEED larger and better studiesNEED larger and better studies
Haldol and EKGs?Haldol and EKGs?
Concern for prolonged QTc and Concern for prolonged QTc and torsades or polymorphic VTtorsades or polymorphic VT
Review showed that most conduction Review showed that most conduction disturbances involve heart disease and disturbances involve heart disease and high doses (50mg/24 hrs) high doses (50mg/24 hrs)
More recent review – heart dz, >65, More recent review – heart dz, >65, female, hypokalemiafemale, hypokalemia
Stop if QTc>500Stop if QTc>500 Don’t wait to give Haldol until after Don’t wait to give Haldol until after
EKGEKGLawrence, Pharmacotherapy 1997; 17(3);531-537
Screening InpatientsScreening Inpatients
Delirium task forceDelirium task force Goal should be prevention; cutting Goal should be prevention; cutting
back on physical restraints back on physical restraints Nurses will screen each shift with Nurses will screen each shift with
RASSRASS Delirium protocol - order set with Delirium protocol - order set with
suggested workup and drug dosing suggested workup and drug dosing based on patient factorsbased on patient factors
ReferencesReferences DSM-IV TR, 2000DSM-IV TR, 2000
Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76)Older Patients, NEJM; 1999 (340) 9:669-76)
Borson S et al. (2000), Borson S et al. (2000), The mini-cog: a cognitive 'vital signs' measure for The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry Int J Geriatr Psychiatry 15(11):1021-102715(11):1021-1027
Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): 101-27.Geriatric Medicine, 14(1): 101-27.
http://www.geronurseonline.orghttp://www.geronurseonline.org Lawrence, Conduction Disturbances Associated with Administration of Lawrence, Conduction Disturbances Associated with Administration of
Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Pharmacotherapy 1997; 17(3);531-537Pharmacotherapy 1997; 17(3);531-537
Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): 687-93Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): 687-93
Delirium. Updates in Hospital Medicine 2012. Harvard Medical SchoolDelirium. Updates in Hospital Medicine 2012. Harvard Medical School Antipsychotics for delirium. Cochrane reviewAntipsychotics for delirium. Cochrane review