Delirious you or the patient

1
Delirious you or the patient?

• November 2004

2
Questions to ponder

• What risk factors are associated with delirium?
• What tools are available to assess for delirium?
• What is the importance of diagnosing delirium?
• What is the appropriate workup?
• What medications are associated with confusion in
  the hospitalized older patient?
• Can delirium be prevented?
• Is delirium a marker for bad outcomes?
• Once delirium occurs, can multitargeted
  strategies change the outcome?
• Are medications useful for the management of
  patients with hyperactive or agitated delirium?
• Is preventing delirium cost effective?

3
Overview

• Background and definition
• Risk factors
• Screening tools
• Workup
• Preventing delirium
• Delirium as a marker of bad things to come
• Treating delirium
• Multitargeted strategies
• Medications

4
Definition and background

• DSM IV reversible state of confusion with
  reduced level of consciousness manifest as
  inability to focus, sustain or shift attention
• Acute confusional state
• Acute onset, fluctuating course
• Attention impairment
• Up to 60 hospitalized elders
• Often iatrogenic, often misdiagnosed

5
Risk Factors

• Advanced age
• Underlying dementia/cognitive impairment
• Acute medical illness
• Alcohol abuse
• Male gender
• Depression
• Malnutrition
• Terminal illness
• ICU stay (up to 80)

6
Iatrogenic Risk Factors

• The things we do
• Physical restraints
• Polypharmacy
• Malnutrition
• Other restraints
• Foley catheters
• IV lines
• Telemetry boxes
• Oxygen tubing

7
Screening or Assessment Tools

• DSM IV definition
• Serial MMSE
• Confusion Assessment Method (CAM)
• CAM-ICU

8
DSM IV definition

• Acute confusional state associated with
• Disturbance of consciousness with reduced ability
  to focus, sustain, or shift attention
• Change in cognition (memory impairment,
  disorientation, language deficits) or development
  of perceptual disturbance that is not due to
  underlying/established dementia
• Development during hours/days with fluctuating
  course

9
MMSE

• Pro familiarity
• Con not specific (deficits may be due to
  underlying dementia, limitations due to low
  literacy level)
• How to use serial MMSE during hospital course
  change in performance suggests delirium

10
Confusion Assessment Method

• Quick and easy
• Sensitivity 94-100, specificity 90-95

11
CAM

• 1. Acute onset and fluctuating course (history
  can be obtained from family/friends or staff)
• 2. Inattention (did the patient have difficulty
  keeping track of conversation?)
• 3. Disorganized thinking (was conversation
  rambling or incoherent, unclear, illogical or
  unpredictable?)
• 4. Altered level of consciousness (vigilant,
  lethargic, stupor, coma anything other than
  alert)

12
Disorganized thinking

• Set A
• 1. Will a stone float on water
• 2. Are there fish in the sea?
• 3. Does 1 lb weigh more than 2 lbs
• 4. Can you use a hammer to pound a nail?

• Set B
• 1. will a leaf float on water?
• 2. Are there elephants in the sea?
• 3. Do 2 lbs weigh more than 1 lb?
• 4. Can you use a hammer to cut wood?

13
Workup Delirium is a Marker!

• Medication review
• Labs Na, glucose, ca, creat/BUN
• Infection (UTI, pneumonia)
• Hypoxemia
• Neuroimaging for subdural
• EEG
• Sleep apnea
• Pain (skin, urinary retention)
• Myocardial ischemia
• Alcohol or benzo withdrawal
• Consider LP (arboviral infections/encephalitis in
  elderly!)
• Review for underlying dementia

14
Medications associated with delirium First Think
Drugs!

• General anticholinergics and benzodiazepines!
• Opioids (especially meperidine)
• Tricyclic antidepressants
• Antihistamines (NO BENADRYL FOR SLEEP!!!!)
• Antiparkinsonian meds levodopa/carbidopa,
  amantadine, bromocriptine)
• H2 receptor blockers
• Antibiotics (ciprofloxacin)
• Anticonvulsants
• Prednisone
• Clonidine

15
Perioperative Delirium

• Orthopedic and vascular surgeries 40-50
  incidence
• Vascular surgeries associated with underlying
  hyperlipidemia, amputation, age over 65,
  depression

16
Cardiac Surgery and Delirium

• Associated with delirium and persistent memory
  impairment
• Microembolism, hypoperfusion, inflammatory
  responses
• Highest risk history of cerebrovascular disease,
  PVD, diabetes, cardiomyopathy, urgent operation,
  long surgery time, high transfusion requirement
• CABG with beating heart/off pump technique
  associated with less delirium

17
Preventing delirium, can it be done?

• Inouye NEJM 1999
• Randomized trial of 852 patients
• Multicomponent intervention plan
• Delirium developed in 9.9 intervention group vs
  15 usual care group
• Total number days with delirium 62 intervention
  group, 90 in control group
• NO DIFFERENCE in severity or recurrence of
  delirium once it developed KEY IS PREVENTION

18
Preventing Delirium

• Recognizing patients at risk (screening high risk
  patient)
• Avoiding risky medications
• Close observation for infection
• Family/friend involvement
• Decrease isolation hearing aids, glasses
• Decrease sleep disturbances
• Environmental cues (opening blinds)
• Avoiding restraints
• Avoiding restraints (foley catheters, oxygen,
  IV fluids, telemetry boxes) that are not needed
• Vigilance for withdrawal syndromes (benzo, ETOH,
  SSRI)

19
Delirium, Bad Things to Come?

• Observational data suggests that delirium
  associated with adverse outcomes including loss
  of independence, need for placement, cognitive
  decline, increased mortality
• Problem confounding (those at highest risk for
  delirium are also the oldest and the sickest)

20
Prognostic Significance of Delirium

• Prospective studies do demonstrate delirium and
  dementia being associated with decline in
  cognitive and functional status, even up to 12
  months after hospital stay
• Highest decline in patients with both dementia
  and delirium

21
Can multitargeted strategies change outcomes of
patients with delirium?

• Lack of data
• Several studies have failed to demonstrate a
  difference in patients with delirium treated with
  various strategies compared to usual care
• Problem Hawthorne Effect
• Studies randomized, but usual care group likely
  benefited from presence of study itself

22
Antipsychotic use

• Commonly used
• Care to ensure not missing underlying pain,
  urinary retention, psychiatric disorder,
  withdrawal syndrome, infection!
• If used, use atypicals in very, very low dose!
• Remember, no great data to support this use so
  use care
• Avoid benzodiazepine use (unless for withdrawal)

23
Typical antipychotics

• Haloperidol
• Try to avoid
• High risk of tardive diskinesia and EPS with long
  term use (over 50 in elderly)
• If used, use low dose (0.5 mg), and limit to 1-3
  days
• Newer routes of atypical agents (IV, sublingual,
  IM) should make use of haloperidol in this
  setting obsolete

24
General risks of antipyschotics

• Much less risk of EPS and TD
• Orthostasis
• Sedation
• Cardiovascular effects (QT prolongation)
• Weight gain
• Edema

25
Risperidone (risperdal)

• Emerging (although small studies) to support use
  with agitated delirium
• Begin 0.25 mg 0.5 mg, 1-2 times/day
• Effectiveness at low doses in elderly (max 1-3
  mg/day)
• Limited in past by only oral route new routes
  soon to be available

26
Olanzepine (zyprexa)

• 2.5- 5 mg
• Sedation (usually started at night) with more
  anticholinergic side effects
• Routes PO or rapidly dissolving tablet (Zydis)
• Link with weight gain and diabetes

27
Quetiapine (seroquel)

• Start at 25 mg
• Can rapidly increase up
• Sedating, use at night
• More commonly used longer term for behavior
  problems with dementia (limited EPS and TD
  effects)

28
Ziprasidone (geodon)

• Restricted use at UNC
• IV form
• 20-80 mg
• Contraindicated with acute CV disease (nondose
  dependent QT prolongation)

29
Clozapine

• Great with underlying parkinsonian symptoms due
  to little risk of increasing tremor
• Significant rate of agranulocytosis
• Restricted use

30
Anticholinesterase inhibitors??

• Agents such as donepezil being studied
• Observational data suggest benefit with
  behavioral disturbances with dementia

31
Is preventing delirium cost effective?

• Probably cost neutral

32
Take Home Points

• Delirium is very common and often missed in
  hospitalized older patients (15 on a general
  medical unit, up to 50 undergoing surgeries)
• Think drugs, lines, sleep deprivation, pain,
  infection
• Think prevention!