Delirium

1
Delirium

• John Puxty
• Queens university

2
Delirum Learning Objectives (1)

• Define Delirium based on DSM IV and describe the
  main diagnostic criteria
• Describe common clinical symptoms and signs
  associated with it
• Appreciate frequency with which it is seen in
  different clinical settings
• Describe the immediate and long term impact on
  common outcome
• Appreciate the theoretic models for the
  mechanisms of delirium
• Appreciate the risk factors which predispose the
  elderly to delirium

3
Delirum Learning Objectives (2)

• Describe common causes and main differential
  diagnoses
• Appreciate the need a structured clinical
  assessment
• Describe appropriate investigation including role
  of neurodiagnostics
• Appreciate the role of standardized assessments
  tools such as the CAM and Neecham
• Appreciate importance of treatment of underlying
  causes
• Appreciate the role of pharmacological and
  non-pharmacological strategies to modify the
  natural history of delirium

4
Delirum Learning Objectives

• Define Delirium based on DSM IV and describe the
  main diagnostic criteria

5
DSM-IV Criteria for Delirium

• Disturbance of consciousness with reduced ability
  to focus, sustain or shift attention
• A change in cognition or development of a
  perceptual change not accounted for by
  pre-existing, established or developing dementia
• The disturbance fluctuates over a short period of
  time and tends to fluctuate during the course of
  the day
• Evidence in history, examination or investigation
  of an organic cause
• (Diagnostic and Statistical Manual of Mental
  Disorders, 4th ed Text Revision (DSM-IV-TR).
  American Psychiatric Association 2000)

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Delirum Learning Objectives

• Describe common clinical symptoms and signs
  associated with it

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Operationally defining Delirium

• Altered level of consciousness may include
  drowsiness, agitation, poor attention span,
  wandering, disrupted sleep cycles and easy
  distractibility
• May see disorientation, memory deficits and
  hallucinations
• Motor signs includes agitation, myoclonus,
  asterixis and picking at non-existent objects
• Possible to demonstrate predisposing and
  precipitating factors

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Spectrum of Psychomotor Activity

• HYPOACTIVE delirium (lethargy, excess somnolence,
  sluggish). Individuals often not recognized as
  they may not cause a disturbance so they dont
  get ATTENTION.
• HYPERACTIVE delirium (agitated, hallucinating,
  inappropriateness)
• MIXED - combination of both

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Case Study of delirium post hip
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Delirum Learning Objectives

• Appreciate frequency with which it is seen in
  different clinical settings

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Significance of Delirium

• 10-18 admissions to acute care
• 10-40 exhibit delirium during admission
• Seen 10-85 post-surgery
• 20 discharges post-hip fracture still had
  evidence of delirium
• LOS doubled in presence of delirium
• Mortality increased 3-5 times

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Delirum Learning Objectives

• Describe the immediate and long term impact on
  common outcome

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Delirium Prognosis
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Delirium Prognosis

• Increased institutionalization rate
• Delirium may serve as a marker for future
  cognitive decline
• Patients need to be FOLLOWED for the development
  of dementia.
• Following recovery, annual incidence of dementia
  20

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Delirum Learning Objectives

• Appreciate the theoretic models for the
  mechanisms of delirium

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Mechanisms of Delirium

• Abnormalities of cholinergic neurotransmission
• Impaired cerebral oxidative mechanisms (also
  disrupts Ach synthesis)
• CNS effects of lymphokines
• Stress induced cortisol hypersecretion, and
  changes in endorphin and biogenic amines

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Delirum Learning Objectives

• Appreciate the risk factors which predispose the
  elderly to delirium
• Describe common causes and main differential
  diagnoses

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General Causes of Delirium

• Usually multifactorial
• Individual often predisposed by poor
  vision/hearing, recent relocation, premorbid
  cognitive problems, multiple chronic disease and
  use of multiple medications
• Vision impairment RR3.5 (1.2-10.7)
• Severe illness RR3.5 (1.5-8.2)
• Cognitive impairment RR2.8 (1.2-6.7)
• High Urea/Creatinine RR 2.0 (0.9-4.6)
• (Inouye S. Ann Intern Med 1983 119-474)

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General Causes of Delirium

• Usually multifactorial
• Individual often predisposed by poor
  vision/hearing, recent relocation, premorbid
  cognitive problems, multiple chronic disease and
  use of multiple medications
• Common causes are fluid/electrolyte disturbance,
  drug toxicity/withdrawal, infections, metabolic
  disturbances, hypoxia and hypotension

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Common causes of Delirium

• Infection Commonly UTI, Pneumonia, Skin and
  Ulcer sepsis. Less common but important SBE and
  Meningits

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Common causes of Delirium

• Infection
• Withdrawal of drugs eg benzodiazpines,
  barbituates, alcohol (common denial of alcohol
  abuse).

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Common causes of Delirium

• Infection
• Withdrawal
• Acute metabolic eg hypoglycaemia, hypercalcemia,
  hyponatremia

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Common causes of Delirium

• Infection
• Withdrawal
• Acute metabolic
• Trauma - consider pain, fractures, subdural,
  concealed haemorrhage

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Common causes of Delirium

• Infection
• Withdrawal
• Acute metabolic
• Trauma
• CNS pathology - Subdural, SOL, CVA, Encephalitis,
  Abscess

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Common causes of Delirium

• Infection
• Withdrawal
• Acute metabolic
• Trauma
• CNS pathology
• Hypoxia
• Deficiencies
• Endocrine
• Acute vascular

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Common causes of Delirium

• Infection
• Withdrawal
• Acute metabolic
• Trauma
• CNS pathology
• Hypoxia
• Deficiencies
• Endocrine
• Acute vascular
• Toxin/Drugs - Benzodiazepine, Anticholinergics,
  L-Dopa Anticonvulsants, H2 Blockers, Analgeics ,
  NSAIs

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Medications Associated With Delirium

• Any drug can potentially cause confusion.
• Take a careful history of any new drug STARTED or
  any old drug STOPPED recently.

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Medications Associated with Delirium

• Sedatives- hypnotics Benzodiazepines - toxicity
  or withdrawal
• Narcotics- especially Demerol
• Anticolinergics
• Tricyclic Antidepressants
• e.g. Amitriptyline, Doxepin, Imipramine
• Dimenhydrinate (Gravol)
• Ditropan
• Cogentin
• Anti-Parkinsonian Drugs
• e.g. Artane/Kemedrin

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Medications Associated with Delirium

• Sedatives- hypnotics Benzodiazepines - toxicity
  or withdrawal
• Narcotics- especially Demerol
• Anticolinergics
• Antiparkinsonian agents
• Cardiac e.g. Digitalis
• Miscellaneous
• H2 blockers
• Lithium
• Steroids
• Anticonvulsants
• Metoclopramide
• NSAIDs e.g. Indocid

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Medications Associated with Delirium

• Sedatives- hypnotics Benzodiazepines - toxicity
  or withdrawal
• Narcotics- especially Demerol
• Anticolinergics
• Cardiac e.g. Digitalis
• Miscellaneous
• Herbal/over the counter drugs
• Cimetidine
• Cough/Cold Remedies
• Gravol
• Sleeping medications e.g. Nytol...

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Common causes of Delirium

• Infection
• Withdrawal
• Acute metabolic
• Trauma
• CNS pathology
• Hypoxia
• Deficiencies
• Endocrine
• Acute vascular
• Toxin/Drugs
• Heavy metal

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Differential Diagnosis of Delirium

• Communication Problem (patient or staff!)
• Mood disorder (depression and severe anxiety)
• Psychosis
• CVA
• Post-ictal
• OBS
• Dementia

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Delirium vs Dementia
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General clues to distinguish dementia and delirium

• Relatively abrupt decline in cognition, function
  and behaviour
• Change in level of consciousness
• Presence of hallucinations
• Presence of potential causal agent(s)
• Neurological deficits other than above

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Delirum Learning Objectives

• Appreciate the need a structured clinical
  assessment
• Describe appropriate investigation including role
  of neurodiagnostics

36
How well do we detect Delirium?

• Only 30-50 have symptoms/signs documented by
  MDs
• RNs document 60-90
• Even if symptoms/signs noted commonly
  misdiagnosed for dementia or depression

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Clinicians approach to delirium (1) Diagnostic

• Consider possibility
• Often need multiple assessments over period of
  time
• Priority to clarify pre-morbid status and
  sequence of events
• Exclude important differential diagnosis
• Identify all predisposing and precipitating
  factors

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Clinicians approach to delirium (1) Diagnostic

• Good Physical Exam
• Assess Hydration Status
• ? New Localizing Neurological Findings
• ? CHF/Pneumonia
• Rectal Exam to R/O Impaction
• ? Distended Bladder
• ? Infected Ulcer

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Clinicians approach to delirium (1) Diagnostic

• Review medication list
• Measurement of serum levels of medications e.g.
  Digoxin/phenytoin
• Metabolic work up
• CBC
• lytes/BUN/creat/glucose
• Ca, albumin
• liver function tests
• 02 saturation/ABGs to R/O ? pCO2

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Clinicians approach to delirium (1) Diagnostic

• ECG to R/O silent MI
• CXR to R/O pneumonia as physical exam often
  difficult/inaccurate
• CNS work-up (if indicated) i.e. CT Head
• Positive urine cultures
• Common in the elderly
• Should only be used as the cause for a delirium
  when patient has new urinary symptoms.

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Delirum Learning Objectives

• Appreciate the role of standardized assessments
  tools such as the CAM and Neecham

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Clinicians approach to Delirium (2)
Standardized Assessment Tools

• Assess impact of change in conscious level,
  attention, cognition and perception
• Interpret in terms of function and behaviour
• Appreciate impact of environment and staff on
  behaviours
• Neecham Scale
• (Chapter 27 p278-288 in Key Aspects of Elder
  Care Managing Falls, Incontinence and Cognitive
  Impairment (1992) S.G. Funk, E.M. Tournquist,
  M.T. Champangne R.A. Wiese)
• Confusion Assessment Method (CAM)
• (Inouye et al Ann Int. Med. 1990 113 941-48)

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Confusion Assessment Method

• Acute Change in mental status
• AND
• Inattention/fluctuation
• PLUS
• Disorganized thinking
• OR
• Altered level of consciousness
• Sensitivity 94 - 100
• Specificity 90 - 95
• Ann Intern Med 1990 113941
• Arch Intern Med. 1995 155301

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Confusion Assessment Method

• Most important
• Least Important

• 1. Acute change in mental status?
• 2. Disorganized thinking?
• 3. Altered level of consciousness?
• 4. Inattention/fluctuation?
• 5. Psychomotor agitation/retardation?
• 6. Perceptual disturbance?
• 7. Disorientation?
• 8. Sleep wake cycle altered?
• 9. Memory impairment?
• Ann Intern Med. 1990 113-941

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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.

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Delirum Learning Objectives

• Appreciate importance of treatment of underlying
  causes
• Appreciate the role of pharmacological and
  non-pharmacological strategies to modify the
  natural history of delirium

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Clinicians approach to delirium (3a)
Non-Pharmacological Therapeutic

• Treat all precipitating causes including pain!
• Optimise physiological status (hydration,
  nutrition etc)
• Inform and educate staff and family
• Minimise predisposing factors (lighting, hearing
  etc)
• Stabilise environment and re-orientate
• Encourage familiar faces for reassurance e.g.
  family members
• Low stimulation - avoid excessive noise
• Avoid restraints

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Preventing Delirium
Cognitive impairment Orientation protocol Sleep
deprivation Non-pharmacological sleep
protocol noise reduction Immobility
Early mobilization Reduce
immobilizing Aides/Adaptations Visual
impairment Visual aids (clean) Hearing
impairment Wax removal
Amplification Dehydration Volume
repletion (Inouye SK et al. N Engl J Med.
1999 340 669)
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Hospital Elder Life Program (HELP)

• Hospital wide Delirium Prevention Protocols
• (n1507)
• Program interventions
• . Geriatric nursing assessment
• . Interdisciplinary rounds
• . Education Program
• . Community linkage, telephone follow-up
• . Geriatric consultation
• . Interdisciplinary consultation

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Hospital Elder Life Program (HELP)

• Cognitive decline (2 points MMSE) 8 vs 26
• Functional decline (2 points ADL) 14 vs 33
• (Inouye et al. J Am Geriatr Soc. 2000 48
  1697)

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Clinicians approach to delirium (3b)
Pharmacological Principles

• Avoid physical and chemical restraints if
  possible
• Minimise medication use
• Use sedation only if severely agitated and
  restless and real concern of risk
• Avoid prn use of medication if possible

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Clinicians approach to delirium (3b)
Pharmacological Principles

• 1. Use a SINGLE medication rather than two to
  decrease the potential for side effects/drug
  interactions.
• 2. Start with a low dose
• 3. Choose a drug with low anticholinergic
  activity.
• 4. Try to stop the medication as soon as
  possible, focusing on correcting the underlying
  cause for the delirium.
• 5. Continue to use Non-Pharmacological
  Interventions.

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Possible Pharmacotherapy for Symtomatic
Management

• Benzodiazepines (oxazepam, lorazepam)
• Buspirone
• Neuroleptics (haldol, loxapine, rispiridone,
  olanzapine)
• Anticonvulsants (carbamazipine, valporate)
• Serotinergic agents (trazdone, 5 HT uptake
  blockers)
• Lithium
• B-blockers
• Selegiline

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Clinicians approach to delirium (3b)
Pharmacological Principles

• Haldol
• try to only use for SEVERE agitation
• lowest anticholinergic activity of all major
  neuroleptics
• high potency
• can use used IM/IV
• start with 0.5 - 1 mg initial dose, gradually
  titrating to a maximum of 4 mg/day
• once initial dose is given, wait approximately
  2-4 hours before repeating the dose
• taper the dose as soon as possible
• avoid in individuals with Parkinson's Disease

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Clinicians approach to delirium (3b)
Pharmacological Principles

• Benzodiazepines-
• Avoid use in combination with antipsychotics
  unless severe agitation and safety concern -
  SINGLE drug is better.
• May cause distribution/increased agitation.
• Best reserved for Delirium 2 to Alcohol or
  Benzodiazepine withdrawal.
• Relatively contraindicated in Delirium from
  Hepatic Encephalopathy.

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Clinicians approach to delirium (3b)
Pharmacological Principles

• Atypical Antipsychotics
• (Risperidone, Olanzepine, Quetiapine)
• No controlled studies at present of their use in
  delirium (just case reports)
• MAY TRY
• low dose Risperidone starting at .25 mg BID
• Olanzapine - 2.5 mg/d as starting dose
• Quetiapine - 12.5 mg/d starting dose

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Delirium - Conclusions

• A medical emergency!!
• Common but under-recognized
• Treatment Address the underlying cause.
  Non-Pharmacological approaches are essential.
  Pharmacological treatments are largely symptoms
  based.

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Suggested Readings

• Cole MG, McCusker J., Dendukuri N, Han L.
  Symptoms of delirium among elderly medical
  inpatients with or without dementia. J.
  Neuropsychiatry Clin Neurosci 2002 14(2)167-75.
• Francis J. Martin D, Kkapoor WN. A prospective
  study of delirium in hospitalized elderly. JAMA
  1990263(8)1097-101.
• Pompei P, Foreman M, Rudberg MA, Inouye SK,
  Braund V, Cassel CK. Delirium in hospitalized
  older persons Outcomes and predictors. J Am
  Geriatr Soc 1994 2(8)809-15.
• Inouye SK. The dilemma of delirium Clinical and
  research controversies regarding diagnosis and
  evaluation of delirium in hospitalized elderly
  medical patients. AM J Med 199497(3)278-88.

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Suggested Readings

• Inouye, SK, van Dyck CH, Alessi CA, Balkin S,
  Siegal AP, Horwitz RI. Clarifying confusion
  The confusion assessment method. A new method for
  detection of delirium. Ann Intern Med
  1990113(12)941-8.
• Inouye SK, Charpentier PA, Precipitating Factors
  for Delirium in Hospitalized Elderly Persons.
  JAMA. 1996275852-857.
• Inouye SK, A Multicomponent Intervention to
  Prevention Delirium in Hospitalized Older
  Patients. NEJM. 1999340669-676.