Mini CHAMP Delirium in the Hospitalized Elder

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Mini CHAMP Delirium in the Hospitalized Elder

• Shellie Williams, M.D.
• Assistant Professor of Medicine
• Section of Geriatric Medicine
• University of Chicago

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Objectives

• Increase recognition of delirium in hospitalized
  elders.
• Identify a risk stratification for delirium in
  hospitalized elder.
• Gain understanding of prevention for delirium.
• Enhance ability to evaluate patients for
  deliriumassessment.
• Develop a strategy for treatment of delirium from
  a non-pharmacologic and pharmacologic focus.

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Mrs. Fleming

• 75yo female admitted from ER with generalized
  weakness, UTI and pre-renal azotemia.
• She is admitted to 5NE with IVF cipro
• RN calls post-admit day1 She pulled out her
  IV this morning and ordered me out of her home.
  She is upsetting her roommate and refused another
  IV. Shall I initiate a sitter?

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Delirium The Data

• Prevalence 15-70
• (20) 12.5 million elderly admits
• Admission Onset 20-33
• Post surgical 30-59

Rockwood 1990 Francis 1992
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Defining Delirium

• Disturbance of consciousness and reduced ability
  to focus, sustain or shift attention.
• Change in cognition (decline memory, orientation,
  language, motor) not accounted for by preexisting
  dementia.
• Disturbance that develops over short time and
  fluctuates.
• Direct physiologic consequences of a specific
  medical condition, substance intoxication,
  withdrawal, or multiple causes.

Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV)
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Delirium Pathophysiology

• Neurotransmitter Theory
• Cholinergic deficits benadryl, scopalmine
• Norephinephrine excess antidepressants
• Dopamine excess Parkinson meds
• Cytokines-IL1, IL2, TNF (Infection)
• Cerebral Hypoxia
• Stress related hormonal fluctuation

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Why Focus on Delirium? Risk

• Increased LOS (2x)
• Increased Mortality (2-7x)
• 38 51 mortality 1yr/5yr post-hosp
• Increased ADL dependence (2x)
• Increased instituitionalization (2-3x)

Dolan J of Ger 2000 Leslie Arch In Med 2005.
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Why Focus on Delirium? Cost
Leslie, D.L. Arch In Med, 2008 168 27-32.
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Why Focus on Delirium? Cognition

• 60 persistent impairment from baseline
• 40 Progression dementia 1yr
• Premorbid Cognitive Impaired
• 4 complete resolution prior d/c
• 20 complete resolution 3-6mo s/p d/c

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ObstaclesUnder-recognition

• Poor recognition
• Nurse recognition lt50
• Physician recognition 20

Inouye 2001
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Recognize Delirium Fluctuating Faces

• Hyperactive 30
• Tremor
• Agitation
• Picking/Pacing
• Vivid hallucinations
• Irritability
• Aggression
• Hyperactive 30

• Hypoactive 70
• Sedate
• Psychomotor retardation
• Poverty speech
• Diminished awareness

Spiller, JA. Pall Med 2006 20 17-23.
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Delirium Prevention Pre-hospital Risk
Inouye,SK. Arch Int Med 1993, 119 474-81.
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Risk Stratification Based on Pre-hospital risk
Inouye,SK. Arch Int Med 1993, 119 474-81.
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Risk Stratification In-Hospital Risk

• Use of Physical Restraints (RR 4.4, CI 2.5-7.9)
• Malnutrition (RR 4.0, CI 2.2-7.4)
• gt3 Medications added (RR 2.9, CI 1.2-4.7)
• Use of Bladder Cath (RR 2.4, CI 1.2-4.7)
• Any Iatrogenic Event (RR 1.9, CI 1.1-3.2)

Inouye, SK. JAMA. 1996 275 (11) 852-7.
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Risk Stratification Delirium at Discharge
Inouye, SK. Arch Intern Med 167 (13) 1406-12.
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Prevention Elder Life Program

• Elder Life Program
• Targeted protocols
• Cognitive impairment
• Sleep deprivation
• Immobility
• Visual impairment
• Hearing impairment
• Dehydration

Inouye, SK. NEJM 1999 (340) 9 669-675.
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Delirium Prevention

• Decreased incidence of delirium
• (9.9 vs 15.0) p0.02
• Decreased days of delirium
• (105d vs 161d) p0.02
• No statistically significant change in severity
  or recurrence of delirium

Inouye, SK. NEJM 1999 (340) 9 669-675.
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Evaluation of Delirium

• MULTIFACTORIAL is the rule of thumb (2.8/pt)
• Focused, patient-centered investigation
• History guides diagnostics
• Examination guides diagnostics

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Evaluation Algorithm to Recall

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DOCUMENT DELIRIUM!

• Confusion Assessment Method CAM

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Evaluation CAMConfusion Assessment Method
DELIRIUM
Inouye SK et al. Ann Intern Med
1990113941-948.
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Evaluation R/o Dementia

• Hx of dementia?
• Need hx of sundowning to dx it!
• Agitated dementia delirium
• Understand delirium-dementia relationship
• DEMENTIA DELIRIUM

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Distinguishing the 3 Ds
DELIRIUM DEMENTIA DEPRESSION
ONSET Sudden (days) Insidious (yrs) Insidious (wks)
ATTN/LOC Persistent Abnormal Normal Normal
COURSE Fluctuates Stable, slow decline Slow
HALLUCINS Us. Visual Absent until late Us. Absent
INVOL MVMNTS Tremors, picking, asterixis Absent until late Absent
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Evaluation Physical Exam

• Head to toe
• Vitals (temp, HR, RR, BP, pulse ox)
• CNS (CVA, bleed, meningitis, sz, blind, deaf)
• Pulm (pneumonia, PE, CHF)
• CVS (ischemia, CHF, arrhythmia)
• GI (ischemia, impaction, bleed)
• GU (UTI, retention)
• Extrem (pain, volume status, CVA)
• Skin (pressure ulcer, volume status)

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Evaluation Most common causes of delirium

1. Medications 30
2. Infections 40
3. Fluid/Electrolyte imbalance 40

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Evaluation Medications (30)

• Too little (alcohol or other drug withdrawal) 6
• Too much
• narcotics
• neuroleptics
• anti-cholinergics
• anti-emetics
• gt3 new medications introduced

Francis 1990, Schor 1999, Lawlor 2002
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Evaluation Medications

• Antibiotics (aminogly, PCN, ceph, sulfa)
• Benadryl
• Benzodiazepines (triazolam, alprazolam, diazepam)
• Digoxin
• GI (Reglan, Bentyl)
• Lithium
• Narcotics
• Neuroleptics
• Steroids
• NSAIDs (Indocin)
• H2 Blockers (Cimetidine,)
• Parkinsons drugs (Levodopa, Benztropine,
  Amantadine)
• Tricyclics

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Evaluation Anti-cholinergic Medications

• Fecal/urine impacted, confused, flushed, dry, low
  bp
• Elavil (amitriptyline) Flexeril
  (cyclobenzaprine)
• Cogentin (benztropine) Atarax/Vistaril(hydroxyzin
  e)
• Bentyl (dicyclomine) Welbutrin/Zyban
  (bupropion)
• Ditropan (oxybutynin) Antivert
  (meclizine)
• Detrol (tolterodine) Ipratropium (atrovent)
• Benadryl (diphenhydramine) Phenergan
  (promethazine)
• Zyprexa (olanzapine) Atropine
• Levsin (hyoscyamine) Belladonna
  Alkoloids

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Evaluation Brain CT?

• Controversy on routine ordering
• Low yield if lack focal neuro findings
• Documented head trauma with new neuro findings or
  high risk bleed

Francis, J. Clin Res 1991 (abstract) 39 103.
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Evaluation Additional tests

• Labs
• CBC, lytes, liver, renal
• Consider TSH, B12
• Drug levels (digoxin, valproic, phenytoin)
• Urine tox, UA/culture
• CXR
• EKG
• EEG

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Management Plan before Pills

• Prevention of delirium
• Correction underlying causes
• Non-pharmacologic intensify
• Pharmacologic (agitation)

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Management Non-pharmacologicHELP Prevention

• Cognition orientation board (carry pen!), (day)
  open drapes, clock, calendar, family photos
• Sleep min deprivation (d/c 2am labs o/n
  BD/vitals meds when awake) warm drink limited
  pm awake
• Mobility Early OOB?chair PT/OT no
  foley/restraints
• Vision glasses
• HOH get aids adapt environment (stethoscope!)
• Dehydration po fluids observe at mealtime
• Feeding assist with meals
• Activity Involve family (rotate members) or get
  sitter move pt to room close to RN station,
  current events

Inouye, SK. JAGS 2006 54 1492-1499.
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Management Non-pharmacologicRestraint Use

• AVOID!
• 4x increased risk protracted delirium
• Increase risk of falls, injury, delirium
• Use only in emergency, for as short a duration as
  possible with frequent re-evaluations, and d/c
  asap
• Absolutely no sheeting

Inouye, SK. Arch Intern Med 167 (13) 1406-12.
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Management Pharmacologic

• 30/244 AIDS patients admitted to hospital with
  AIDS related illness, developed delirium
• Double blind randomization to lorazepam,
  chlorpromazine or haloperidol
• Early cessation of lorazepam arm due to worsening
  sedation, confusion ataxia
• Chlorpromazine haldoperidol arm improvement in
  delirium per DRS score, limited EPS and improved
  MMSE in chlorpromazine group _at_ 2d

Breitbart, W. Am J. Psych, 1996 153 231-237.
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Management Pharmacologic Anti-psychotics

• Typical Haldol
• Advantages min sed
• Disadvantages lower sz thrshld more EPS (even
  at low dose) not FDA-app for IV can incr QTc
  Torsades
• Dose 0.25-0.5mg po, IM, IV can repeat in 30
  mins x1 then dose q4h
• t1/221h (10-38)
• 
  APA 1999

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ManagementPharmacologic Antipsychotics

• Atypical
• Advantages min sed, less EPS, hyperglycemia
• Disadvantages take time to work, no evidence in
  short-term recent Black Box warning vascular
  events!
• Risperidone 0.25-0.5mg po bid
  t1/220-30h
• EPS with high dose
• Olanzapine (Zyprexa) 2.5-5mg po qd t1/230
  (21-54h)
• more anticholinergic
• Quetiapine (Seroquel) 12.5-25mg po bid t ½6h
• less EPS risk

Van Zyl. Geriatrics 2006 61(3) 18-21.
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Management PharmacologicBenzodiazepines

• Used best in w/d
• Lorazepam 0.5-1mg po, IM, IV q6-8
• (no first-pass, no renal adjustment)
• t1/212h

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Conclusion

• Prevent delirium.
• Evaluate risk factors pre-admit, during and post
  hospitalization.
• Adjust admit orders
• It is important to develop a systematic approach
  for diagnosis of delirium, THEN (DOCUMENT!).
• First use non-pharmacologic measures, then
  pharmacologic, to treat delirium.

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Case Revisited

• Mrs. Fleming is a 75 year old female with htn,
  OA, dm, cri (1.3) baseline and chronic AF. She
  lives alone in a 3 story home.
• Meds (Home)
• Lisinopril 20mg qam
• Asa 81 mg
• Celebrex 200mg qam
• Metformin 500mg bid
• Hctz 25mg qam
• Elavil 50 mg qhs

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Medicines In-hospital

• Lisinopril 10mg qam
• Hctz 25mg qam
• Regular Insulin SS
• 0.9NS 150 cc/hr x 36hr
• Elavil 50mg qhs
• ASA 81mg qam
• Darvocet N 1 q 6hr

• Prosom 15mg qhs prn
• Benadryl 25mg q 6hr itching, sleep
• Vicodin 5/500mg q 4hr prn
• Morphine 2-4 mg iv q 4hr
• Zofran 4mg q 6hr prn n/v

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Case revisited

• Currently, pt is quietly sitting in chair,
  picking at skin.
• When asked what is she doing she notes, It is a
  shame you cant afford extermination in this
  place!
• She then returns to her activity.
• Her daughter notes she has not slept in 3 days
  and was incontinent of urine 2 days PTA.
• Roommate notes she was lethargic and not
  answering questions a few moments ago.

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CAM Assessment Is she Delirious?

• Acute/fluctuating?
• Inattentive?
• Disorganized thinking?
• Decreased level of consciousness?

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An Algorithm to Remember!

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Review Dementia?

• Dementia
• Get further hx from family of baseline
• Was dx missed or never made?
• Prior hx of delirium during hospitalization?
• Do serial cognitive assessment MMSE

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Review Other Risks for Delirium

• Recent physical symptoms? Cough, chills, SOB
• Psychiatric symptoms? None
• Alcohol/Illicit drug use? 1 Highball nightly
• Recent CNS trauma? No trauma other than hip
• Recent stroke symptoms? No

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Case Revisited Exam

• Sat 88 ra, rr 28, p 100, bp 100/50, pain grimace
• HEENT Dry mucosa, no evidence cns contusion
• Neck No adenopathy or thyromegaly or jvd
• Lungs Increase fremitus and percussion dullness
  rt. base no use acc muscles
• Heart Irregular rhythm, rate 100, no murmur,
  rub or gallop
• Abdomen bs, soft non distended, non tender
• GU foley, no evidence retention
• Neuro Inattentive, disoriented, poor recall of
  hospital events, hyperalert at times, motor
  strength symmetric, normal sensory function, no
  hyper-reflexia, antalgic gait

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Case, contd

• Labs 10.5
• 13.2 192
• 33.0
• 148 110 56
  128
• 5.2 30 1.8
• UA LE, nitrite, 1.025, bacteria, rbc
• ECG A. Fib rate 60s, no acute ST changes

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CXR
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Case Revisited What factors predisposed this
patient for delirium?

• Foley
• Poor po intake
• Poor vision
• gt 3 new medications
• Sensory impairment
• Use of restraints
• Bed bound status

• gt30 bun/creatinine ratio
• Baseline cognitive deficits
• Lack of pain control
• Poor sleep

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Case Revisited What factors precipitated
delirium?

• Stroke
• UTI
• Pneumonia
• Anti-cholinergics
• Dehydration
• Hypoxia
• Anemia

• Hypotension
• Metabolic derangements
• Alcoholism
• Illicit drugs
• Cardiac ischemia

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Case Revisited How should we treat this
patient?

• Add lorazepam
• Initiate sleep orders
• Stop elavil
• Stop lisinopril
• Schedule tylenol
• Add vicodin schedule
• Stop combo analgesic
• Explain condition to daughter

• Zosyn 3.25 mg q 6h
• Initiate oral hydration protocol
• Start IVF
• Reorientation protocol
• Remove foley
• Oxygen therapy

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THANK YOU