delirium in the ed sheldon jacobson md, facep, facp chairman, emergency medicine mount sinai school...
TRANSCRIPT
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Delirium In the EDDelirium In the ED
Sheldon Jacobson MD, FACEP, FACP
Chairman, Emergency Medicine
Mount Sinai School of Medicine
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Sheldon Jacobson, MD
DeliriumDelirium
• Case Presentation• Case Presentation
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Sheldon Jacobson, MD
Case presentationCase presentation
• A sixty year old woman is brought to the ED for evaluation of a change in mental status. She has metastatic breast cancer and is receiving chemotherapy. She is lethargic confused and alternatively agitated and somnolent. On physical exam. VS- T-37.5º, P-104, BP-100/67, POX 95%
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Sheldon Jacobson, MD
Case cont.
• She is dehydrated, disoriented, does not pay attention to the examiner. She is pale, mildly icteric and her liver is enlarged and irregular. Neuro-nonfocal exam. Bilat. snout, grasp and Babinski reflexes. There was no tremor, asterixis or myoclonic jerks
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Sheldon Jacobson, MD
Case Presentation-Mental Status Case Presentation-Mental Status ExaminationExamination
The patient was oriented as to person and place but did not know the date. She was lethargic and would doze off in the midst of a sentence. She would answer questions with a simple yes, no I don’t know answers. She did not interact with her family who were at the bedside.
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Sheldon Jacobson, MD
Case Presentation-Mental Case Presentation-Mental Status ExaminationStatus Examination
• Mini-mental status examination–score 20/30 (positive test)
• CAM score 4/4 (positive test)
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Sheldon Jacobson, MD
Further Evaluation of Our CaseFurther Evaluation of Our Case
• What is the working diagnosis here?
Brain met? Psychosis? Delirium?
Dementia? Malingering?
• What other information would you like to have?
• What lab tests do you need?
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Sheldon Jacobson, MD
DeliriumDelirium
• AKA
•Acute Confusional State
• Toxic Psychosis
•Delirium Tremens
•Metabolic Encephalopathy
•Acute organic psychosis
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Sheldon Jacobson, MD
Delirium-DefinitionDelirium-Definition
An acute reversible diffuse neuronal dysfunction usually due to a toxi-metabolic derangement, characterized by inattention, disorientation, misperceptions, agitation and/or somnolence, hallucinations, acute memory disturbances and paranoid ideation
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Sheldon Jacobson, MD
Delirium-VariantsDelirium-Variants
• Agitated delirium e.g. delirium tremens- autonomic hyperactivity and instability
• Quiet delirium-withdrawn, clouded sensorium, inattentive
• Alternating
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Sheldon Jacobson, MD
Delirium-PathophysiologyDelirium-Pathophysiology
• Reversible neuronal dysfunction often due to toxic or metabolic disturbances but in other cases causal process is as yet unknown e.g. ICU and post-op delirium
• Sensory deprivation
• Sleep deprivation
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Sheldon Jacobson, MD
Delirium-Pathophysiologic Delirium-Pathophysiologic CorrelatesCorrelates
• Underlying dementia• Central anticholingeric states or
decreased Ach prod.• Diffuse slowing of the EEG• Decreased A-V O2 difference across the
brain
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Sheldon Jacobson, MD
Causes of Delirium-Systemic Causes of Delirium-Systemic DiseasesDiseases
• Hepatic failure
• Uremia
• Ventilatory failure
• Sepsis
• Hypertensive Crisis
• Heart failure, dysrhythmia,
• Heat stroke, hypothermia
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Sheldon Jacobson, MD
Delirium-Metabolic CausesDelirium-Metabolic Causes
• Electrolyte Abnormalities
• Hyper and hypoglycemia
• Acidosis/alkalosis
• Osmolar Crises, hyper and hypo
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Sheldon Jacobson, MD
Delirium-Toxic CausesDelirium-Toxic Causes
• Ethical Drug Intoxication/Effect, Polypharmacy
• Recreational Drug Effect/Toxicity
• Drug withdrawal
• Nutrient Deficiency- B6, B1, B12 , Niacin
• Environmental- Poisoning- CO, CN, Bites, Dysbarism, Toxic Plants
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Sheldon Jacobson, MD
Delirium-HistoryDelirium-History
• Acute change in mental status• Frequently underlying dementia• Polypharmacy• Exacerbation of systemic illness or other
concurrent stressors e.g. surgery, ICU• Hallucinations, delusions, paranoia,
liability
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Sheldon Jacobson, MD
Delirium-Physical ExaminationDelirium-Physical Examination • Abnormal vital signs, inattention
• Toxidromes-cholinergic, anticholinergic, adrenergic, opiod, hallucinogen, sedative
• Focal findings seen in some intoxications• Myoclonic jerks, asterixis, tremor, seizure,
frontal release• Fluctuating signs• Evidence of systemic disease-
dehydration, hypoxia, liver or renal failure, CHF, COPD
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Sheldon Jacobson, MD
Delirium-Laboratory Work-upDelirium-Laboratory Work-up
• Metabolic panel include lactate and ABG• LFTS, Tox Screen, Carboxy Hb• Sepsis work-up• EEG• Brain imaging/ LP
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Sheldon Jacobson, MD
Delirium-Memory TestingDelirium-Memory TestingA)Primary memory (immediate recall)
stored in reticular activating system tested by serial digits
B)Secondary (recent) memory stored in the limbic system, tested by 3 objects in 3 minutes
C)Tertiary memory (remote events) stored in the association areas of cortex, tested by asking about verifiable remote events
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Sheldon Jacobson, MD
Primary Memory TestingPrimary Memory Testing
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Sheldon Jacobson, MD
Modified Mini-mental Status Exam.Modified Mini-mental Status Exam.(used to diagnose cognitive impairment)(used to diagnose cognitive impairment)
5-Time Orientation- date, day, season5-Place Orientation-City, State, Building5-Attention-serial 7s3-Registration of 3 objects (instant memory)3-Recall-3 objects in 3 min. (recent memory)9-Language-name 2 objects, repeat “no ifs
ands buts, 3 stage command, write sentence, copy design (23 or less=cognitive abnormal.)
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Sheldon Jacobson, MD
Confusion Assessment Confusion Assessment Method-CAM ScoreMethod-CAM Score
• Feature 1-Acute onset and fluctuating course of cognitive/behavioral impairment
• Feature 2-Inattention (distractibility)• Feature 3-Disorganized thinking• Feature 4-Altered level of
consciousness Positive test- 1&2 + 3 or 4
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Sheldon Jacobson, MD
Orientation-Memory-Concentration Orientation-Memory-Concentration TestTest
• What is the Year, Month, Time? • Count backwards from 20 and name the
months in reverse order• Repeat: John Brown, 42 Market Street,
Chicago• Remember the phrase @ 3 min.
Am Jl. Psych. Vol. 140, pg 734, ‘83Am Jl. Psych. Vol. 140, pg 734, ‘83
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Sheldon Jacobson, MD
EDED Prevalence and Documentation of Prevalence and Documentation of Impaired Mental Status in ElderlyImpaired Mental Status in Elderly
• 26%(78/297) of patients had altered mental status
• 10%(30/297) had delirium
• 70% of patients discharged home with cognitive impairment had no evidence available that the mental status abnormal was chronic
Hustey Annals vol. 39 No. 3 March ‘02Hustey Annals vol. 39 No. 3 March ‘02
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Sheldon Jacobson, MD
Delirium and Other Cognitive Impairments Delirium and Other Cognitive Impairments in Adults in the EDin Adults in the ED
Using GCS, MMSE & CAM test on patients 70 or older
• 40%: altered mental status• 8.5%: delirium• 9.6%: dementia• 21%: cognitive impairment without
delirium
Naughton et al. Annals 25, No. 6, June ‘95Naughton et al. Annals 25, No. 6, June ‘95
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Sheldon Jacobson, MD
Delirium in the Emergency Department Delirium in the Emergency Department Older PatientsOlder Patients
• 26-40% are cognitively impaired• 25% of these have delirium• 50% of these have dementia• Prevalence increases with age• Patients with delirium have higher Apache
scores and short term mortality• Retrospectively, 25-40% cases not
diagnosed and 38% of delirious patients discharged
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Sheldon Jacobson, MD
Delirium-Differential DiagnosisDelirium-Differential Diagnosis CNS Diseases CNS Diseases
• Nonconvulsive status, (post ictal)
• Stroke, Meningitis, Encephalitis, SAH, Trauma, Hydrocephalous
• Dementia
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Sheldon Jacobson, MD
Differential Diagnosis-Differential Diagnosis-Psychiatric IllnessPsychiatric Illness
• Depression
• Psychotic episode
• Malingering
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Sheldon Jacobson, MD
Consequences of Missing Consequences of Missing Delirium In EDDelirium In ED
Short term mortality- missing the treatment window
• Inappropriate treatment
• Unreliable history
• Poor compliance
• Falls
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Sheldon Jacobson, MD
Delirium- Immediate PrognosisDelirium- Immediate Prognosis
• Prognosis varies with the underlying reversible cause
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Sheldon Jacobson, MD
Delirium-Back to Our CaseDelirium-Back to Our Case
The patient was found to be using both Fentanyl patches and Oxycontin
She improved markedly with Narcan
The head CT was unchanged and her Ca++ was 10.8
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Questions?Questions?