managing delirium in the emergency department. introduction not a talk about the agitated patient...
TRANSCRIPT
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Managing Delirium in the Emergency Department
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Introduction
• Not a talk about the agitated patient
• They’re easy and there is lots of literature
- sedate, intubate and let ICU sort it out
Talk about delirium
- emphasis on the emergency department
- very little literature
- big management problem
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Introduction
• Managing a patient with delirium is difficult and labour intensive
• A bigger problem is actually recognising that the patient has a delirium
• The 2 groups where we need to have a high index of suspicion are the elderly and the (first presentation) psych patient
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Delirium
• Neuropsychiatric Syndrome
- multiple causes
- produce a similar constellation of
symptoms
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Delirium Definitions
• A sudden and significant decline in mental functioning not better accounted for by a preexisting or evolving dementia
• Disturbance of consciousness with reduced ability to focus, sustain, and shift attention
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DSM-IV Diagnosis • DSM-IV
– A. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.
– B. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia.
– C. The disturbance develops over a short period of time and tends to fluctuate during the course of the day
– D. There is evidence from the history, PE, or labs that the disturbance is caused by the direct physiologic consequences of a general medical condition
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Introduction
• Simplest definition of delirium is “acute brain failure” with a combination of
- behavioural symptoms
- psychological symptoms
- cognitive symptoms
- neurological symptoms
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Introduction
• Common presenting problem
> 40% of patients over 65
• Frequently develops during an admission
• Frequently misdiagnosed as psych or dementia
- overlap of symptoms
- dementia predisposes to delirium
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Introduction
• Frequently missed all together
• We forget that there are a range of presentations
- agitated delirium
- quiet delirium
- mixed
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Why Does Delirium Matter?
• Increased morbidity and mortality
• Increased length of stay
• Increases rate of cognitive decline
• Increased distress to patient and family
- may believe delusions and hallucinations
really happened even after delirium
resolved
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Behavioural Symptoms
• Aggressive or agitated
• Quiet and withdrawn
• Screaming / calling out
• Wandering
• Disinhibited
• Altered sleep-wake cycle
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Behavioural Symptoms
• Constant questioning
• Hide things / hoarding objects
• Frontal lobe release
- picking at the air / bed clothes
- pulling on IVC or IDC
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Psychological Symptoms
• Anxiety
• Paranoid
• Delusions (usually persecutory)
• Hallucinations (usually visual)
- auditory hallucinations: think psych
- visual delusions: think delirium
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Cognitive Symptoms
• Can’t focus / inattention
- beware of the “vague historian”
• Can’t shift focus
• Can’t solve problems
• Trouble with abstract thought
• Impaired recent and remote memory
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Neurological Symptoms
• Dysphasia
• Dysarthria
• Tremor
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Psychiatry and Delirium
• Many of the symptoms of delirium also can occur in a psychiatric illness
- easy to see why there is confusion
• Liason psych are often called to review patients whose delirium has been missed by the treating team
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“Psychiatric Symptoms”
• Altered mood
• Altered behaviour
• Altered thought or cognition
• Altered perception
If patients are triaged with these problems,
we jump to the conclusion that is a psych
illness
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“Psychiatric Symptoms”
• May be caused by or aggravated by a medical illness (organic illness)
• Incidence is unclear - 10 to 75% range quoted in A&E literature Medical illness is a significant cause of
“psychiatric symptoms”
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“Psychiatric Symptoms”
• Unfortunately, medical illnesses often go unrecognized due to inadequate and poorly documented medical assessment in A&E
Tintinelli (1994)
- assessment of: mental state 40 – 80%
LOC 80 – 95%
orientation 70 – 90%
full motor exam 50 - 60%
cranial nerves 20 – 55%
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“Psychiatric Symptoms”
• Reeves (2000): still the same problem
• 64 patients with medical illness admitted inappropriately to a psychiatric unit
- full history 66%
- vital signs 90%
- full physical exam 65%
- full mental state exam 0%
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“Psychiatric Symptoms”
• Problems with medical assessment are not due to a lack of imaging or esoteric blood tests.
• The problem is a failure to do a thorough history, examination and mental state examination
ie we aren’t doing the basics
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Psych Vrs Delirium
• First presentation of a psych illness is rare over 45 years of age
• Auditory hallucinations are more common
• Even floridly psychotic patients tend to remain orientated to time and place
• Memory is usually intact
• Does not fluctuate over the course of a day
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Delirium Vrs Dementia
• Memory deficits, language disturbances and disorganized thinking are common to both diagnoses
• Need to know the patients baseline, what has changed and how quickly it has changed
• Need a good history from multiple sources
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Delirium versus Dementia
• DeliriumRapid onsetPrimary defect in attentionFluctuates during the
course of a dayVisual hallucinations
commonOften cannot attend to
MMSE or clock draw
• Dementia
Insidious onsetPrimary defect in short
term memoryAttention often normalDoes not fluctuate during
dayVisual hallucinations less
commonCan attend to MMSE or
clock draw, but cannot perform well
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Pathophysiology of Delirium
• Systemic pathology leading to a local inflammatory response in the brain with subsequent changes in neurotransmission
- we don’t care
• It involves predisposing factors and precipitating factors
- we do care
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Pathophysiology of Delirium
Can use predisposing factors to predict who
is at risk of developing delirium
Can use precipitating factors to guide our
management strategies
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Pathophysiology of Delirium
Predisposing factors- Children and elderly (<10 & > 65)- history of brain disease (dementia, CVA)- history of delirium- impaired vision or hearing- medications (benzo’s; anti-cholinergics)- alcohol dependance- psych history
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• Precipitating factors
- lots
• The main ones are
- underlying medical condition
- substance intoxication
- substance withdrawal
- combination of any or all of these
Pathophysiology of Delirium
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Pathophysiology of Delirium
Other Precipitating Factors- new medications- invasive procedures (IVC; IDC; NG)- fluid and electrolyte abnormalities
- metabolic disturbances
- change of environment (ED is bad!)
- nutritional deficiencies
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Pathophysiology of Delirium
• The more precipitants, the greater the chance of developing a delirium
• The more predisposing factors, the fewer precipitating factors are needed to trigger delirium
- In the frail elderly, constipation alone
can trigger delirium
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Making the Diagnosis
• Delirium is common
• Delirium is important
• Delirium seems really complicated
• How can I make the diagnosis?
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Medical Assessment
• Stable / Unstable
• Danger to Self or Others
• Detailed History
- medical & psychiatric
- from multiple sources
- baseline ADL, cognition, behaviour etc
eg family, ambo’s, bystanders, NH
GP, old notes, CMH team
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Clues for an Organic Cause
• Age less than 12 or greater than 40 • Sudden onset (hours to days)• Fluctuating course• Disorientation• Decreased consciousness• Visual hallucinations• No psychiatric history• Emotional lability• Abnormal vitals / physical examination findings • History of substance abuse or toxin exposure
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Clues for a Functional Cause
• Age 13 to 40 years• Gradual onset (weeks to months)• Continuous course• Awake and alert• Auditory hallucinations• Psychiatric history• Flat affect• Normal physical examination findings (including
vital signs)
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Medical Assessment
• Full physical Examination
- head to toe
eg head / neck / CVS / lungs / abdo
neuro / periphery / skin
- includes vital signs
eg BP, HR, RR, Temp, BSL, RAIR sats
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Medical Assessment
• Bedside tests
- mental state exam
- mini mental exam
- EEG
- CAM
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Making the Diagnosis
Mini Mental- Useful at separating “normal” from “abnormal”- Not specific for distinguishing delirium from dementia- May be useful as change from baseline- Suggestive if score varies during or between days
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Making the Diagnosis
• Mini mental does include tests of attention
- serial 7’s
- spell “world” backwards
Other simple tests
- counting backwards from 20
- days of week backwards
- month of year backwards
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EEG
• Can be diagnostic
- generalised slowing of brain activity
• Significant false positive and negative rate
• Is done on the wards
- but is it useful?
• Not done in A&E
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Confusion Assessment Method
Is there evidence of:1) Acute onset and fluctuating course2) Inattention3) Disorganized thinking4) Altered LOC (increased or decreased)
1 and 2 and either 3 or 4 Sens = 95% spec = 90%
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Confusion Assessment Method
1) Acute onset & fluctuating course
- is there an acute change from the patient’s baseline?
What are they normally like, what has
changed and when did it change
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Confusion Assessment Method
2) Inattention
- did the patient have difficulty keeping track of what was being said?
- can’t focus
- can’t shift focus
- Serial 7’s
- World backwards etc
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Confusion Assessment Method
3) Disorganized thinking- rambling conversation- unclear or illogical flow of ideas- Interpret a proverb- “Will a stone float on water?”
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CAM Diagnostic Algorithm
4) Altered level of consciousness - alert (normal), - vigilant (hyperalert), - lethargic (drowsy, easily aroused), - stupor (difficulty to arouse)
Any answer other than “alert” is abnormal
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Management
• The key is to identify and treat the underlying causes
Also need to:
- minimise patient anxiety
- prevent harm to the patient
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Management: Investigations
• Not to make the diagnosis
• To help guide our treatment
• Often use a “shotgun” approach
• EUC, FBC, LFT, MSU, blood cultures, cardiac biomarkers, CT brain, ABG, ECG, CXR, PR, etc etc etc
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Management: Treatment
• Can treat against their will using the mental health act
• Non-pharmacological Strategies
• Pharmacological Strategies
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Soapbox Moment
• We used to have a CNC for dementia and delirium but admin in their wisdom has terminated the position
• Each speciality has a CNC who should be involved early in the management of admitted patients with a delirium
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Non-pharmacological Treatment
• “A calm, quiet atmosphere, frequent prompts concerning orientation, clear precise communications and a night light are helpful in the management of delirium”
Some dude who has never stepped foot inside an Emergency Department
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Non-pharmacological Treatment
• Numerous strategies that aren’t practical in ED (or wards either?)
1)Providing support and orientation
2)Providing an unabiguous environment
3)Maintaining Competence
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Non-pharmacological Treatment
In English- Frequent reminders about time and place- Constant reassurance- Staff to wear name tags and indentify
themselves often- Minimise stimuli (noise, lights, procedures)- Place familiar objects in room- Minimise the number of staff involved in care
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Non-pharmacological Treatment
• Patients with delirium are unpredictable.
• Unpredictability = bad things happen
- fall; pull out vascaths; abscond; ride
around naked in elevators
• They need a special.
• If none available, place the bed where they can be seen at all times
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Pharmacological Treatment
• Not Indications
- calling out
- wandering
- convenience of staff
No drug will stop a patient from wandering.
Drugs will help a wandering patient fall
Consider sedating the nurse
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Pharmacological Treatment
Indications for drug therapy
- relieve patient anxiety
- behaviour putting patient or others at risk
- agitation distressing to patient
Not aiming to sedate the patient
Trying to calm them down
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Pharmacological Treatment
• No good evidence based studies
• Large range of treatment guidelines
• Are now Australian Best Practice Guideines
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Pharmacological Treatment
• Aim to use one drug
• Keep doses to a minimum
• Avoid escalating doses
• Seek expert advice early
• Review medications daily
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Benzodiazepines
• Don’t use as a first line agent
- long half life & easy to over sedate
- respiratory depression
- may worsen delirium
- no anti-psychotic actions
- role in alcohol withdrawal & terminal
delirium
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Haloperidol
• Haloperidol
- first line in the Australian Guidelines
- widely used (outside of Westmead ED)
- oral, IM or IV
- no agreement in dosing strategy
- “start low, go slow”
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Haloperidol Dosing
• 0.5 to 1 mg initially
• repeat in 30 mins to 2 hours if needed
• Maximum 2 to 4 mg / 24 hours
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Haloperidol
• Haloperidol in ICU
- 1 , 2 or 5 mg IV
- double dose every 30 minutes till settled
- then give total 24 hr dose as qid on
subsequent days
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Second Line Agents
• If after haloperidol, there are prominent psychotic features
- risperidone
- olanzepine
• If after haloperidol, agitation is prominent
- lorazepam
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Resperidone
• 0.25 to 0.5 mg PO, Q4 hourly, PRN, maximum 2 mg / day
• Maximum 4 mg / 24 hours
• Side effects include hypotension and sedation
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Olanzapine
• Tablets, wafer, IM
• 2.5mg If needed repeat in 4 hours
• Maximum 10 mg / 24 hours
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Lorazepam
• 0.5 – 1 mg initially
• If needed repeat in 4 hours
• Maximum 3 mg / 24 hours
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Conclusions
• Maintain a high index of suspicion for delirium in elderly patients and possible psych patients
• Remember the red flags for organic & functional illness
• Thorough exam & clear documentation
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Conclusions
• Remember the CAM
• Try to avoid drug therapy
• Calling out and wandering are not indications for drug treatment
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