Delirium in the Elderly

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Delirium in the Elderly

• Kirsten M. Wilkins, MD
• Assistant Professor of Psychiatry
• Yale School of Medicine
• VA CT Healthcare System

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Case 1

• A 79 year old man with dementia, DMII, CAD, COPD,
  and acute renal failure but no other psychiatric
  history was admitted for pneumonia. After a 3
  week hospital course complicated by delirium,
  hyponatremia, and UTI, he has been less agitated,
  more cooperative and more oriented for 2 days in
  association with decreased wbc and lessened
  oxygen requirements. You are consulted for acute
  suicidal ideation.
• What initial plan would be best?
• a. Assign a sitter (11), evaluate patient for
  antidepressant, provide supportive psychotherapy
  to address prolonged hospitalization
• b. Assign a sitter (11), check urinalysis, do a
  chest x-ray, begin SSRI
• c. Transfer to psychiatry for further care
• d. Evaluate for a sitter (11), check
  urinalysis, do a chest x-ray, discuss with
  primary team

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Case 1 - Discussion

• Answer D Evaluate for a sitter (11), check
  urinalysis, do a chest x-ray, discuss with
  primary team
• Delirium must be ruled out first in this caseit
  offers more morbidity than depression in this
  setting and this patient is at higher risk for
  having delirium. Suicidal ideation is common in
  delirium. Adding an antidepressant may worsen the
  picturebetter to wait 2-3 days to rule out
  delirium, as that delay will not greatly impact
  treatment of depression but, misdiagnosing as
  depression may result in failing to search for
  the cause of the delirium.

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Delirium

• DSM-IV-TR Criteria
• Disturbance of consciousness with reduced ability
  to focus, sustain, or shift attention.
• A change in cognition (memory deficit,
  disorientation, language disturbance) or the
  development of a perceptual disturbance (i.e.
  auditory or visual hallucinations) that is not
  better accounted for by a preexisting dementia.

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Delirium

• DSM-IV-TR Criteria, cont.
• The disturbance develops over a short time
  (hours to days) and fluctuates during the day.
• There is evidence that the disturbance is caused
  by the direct physiological consequences of a
  general medical condition or substance.

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Delirium

• DELIRIUM IS ALSO KNOWN AS.
• acute confusional state
• acute mental status change
• altered mental status
• brain failure
• hepatic encephalopathy
• organic brain syndrome
• toxic or metabolic encephalopathy

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Delirium Epidemiology

• Prevalence depends on population
• Greater in med/surg population
• Community 0.4 - 2
• General hospital admissions 20
• On admission 10 15 elders
• During hospitalization up to 40
• At end of life up to 83
• Trzepacz and Meagher 2005
• Saxena and Lawley 2009
• Fong et al 2009

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Delirium Epidemiology

• Higher rates seen with
• Post-op (ortho, cardiothoracic, vascular)
• ICU admission
• Poor functional recovery
• Increased hospital lengths of stay
• Increased likelihood of NH placement
• Up to 60 NH pts have delirium
• Trzepacz and Meagher 2005
• Mittal et al 2011

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Delirium - Impact

• Increased morbidity
• Poorer recovery from medical illness
• Increased need for walking devices
• 6x increased risk of decubitus ulcers or
  aspiration pneumonia
• Increased risk of future cognitive decline
• 10-33 mortality rate in hospital
• Increased risk of mortality even months after d/c
  Fong
  et al 2009
• Siddiqi et al 2006

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Case 2

• Consult requested for 85 yo female with h/o
  dementia recently admitted to SNF, following
  hospitalization for hip fracture/repair ,
  complicated by post-op infection. Pt noted by
  staff to be disoriented, sundowning, and
  resistant to care and PT. Per staff, family
  concerned that her dementia is much worse than
  before her surgery despite apparently successful
  surgery and resolution of her infection. Which
  of the following may explain her symptoms?
• A) Opioid pain medications
• B) Ongoing symptoms of delirium
• C) New cognitive baseline
• D) Old age
• E) A, B, and C

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Delirium Risk Factors

• Age
• Preexisting dementia
• Recent surgery
• Bone fractures
• Infections
• Hypoalbuminemia
• Preexisting CNS structural abnormalities

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Delirium Risk Factors

• Abnormal sodium
• Severe illness
• AIDS, Cancer
• Polypharmacy
• Dehydration
• Visual/hearing impairment

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Delirium Risk Factors

• Substance Abuse
• Alcohol
• Prescription drugs
• Illicit drugs
• You must ask!
• Collateral informant

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Delirium Presentation

• Three types
• Hyperactive
• Better recognized
• More attention to treatment
• Associated with improved outcome
• Hypoactive
• Little recognized
• Depression is primary differential
• Associated with poor outcomes
• Mixed

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Delirium Presentation

• Cognitive Symptoms
• Inattention
• Memory impairment
• Disorientation
• Behavioral Symptoms
• Agitation or hypoactivity
• Resistance to care
• Sleep-wake disturbance
• Psychiatric Symptoms
• Paranoia, delusions
• Hallucinations (often visual), illusions
• Affective lability

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Disrupted Sleep-wake Cycle

• Insomnia
• Napping
• Being awake at night, limited light and external
  cues leads to disorientation and paranoia which
  may cause agitation
• Caution with sedative medications due to concerns
  of worsening delirium

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Affective Lability

• Mood may fluctuate widely in a very short period
  of time (minutes/hours)
• Anxiety/panic/fear/anger
• Apathy/sadness - commonly mistaken for depression
• Euphoria (esp. if steroid-induced)

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DeliriumDifferential Diagnosis

• Dementia with Behavioral Disturbance
• Psychotic Disorder (Schizophrenia)
• Mood Disorder (Depression, Mania)
• Catatonia
• Others

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Delirium versus Dementia

• DELIRIUM
• impaired memory
• impaired thinking
• clouding of consciousness
• major attention deficit
• fluctuation of course/day
• disorientation
• vivid perceptual disturbance
• incoherent speech
• disrupt sleep/wake cycle
• nocturnal exacerbation
• lack of insight
• acute or sub acute onset
• impaired judgment

• DEMENTIA
• -
• -

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Delirium

• Generally divided into 4 major types
• Delirium secondary to general medical condition
• Delirium secondary to substance intoxication
• Delirium secondary to substance withdrawal
• Delirium secondary to multiple etiologies

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Delirium

• Rarely is delirium caused by a single factor
  rather, it is a multifactorial syndrome,
  resulting from the interaction of the
  vulnerability on the part of the patient (ie,
  predisposing conditionscognitive impairment,
  severe illness, visual impairment) and
  hospital-related insults (ie, medications and
  procedures). Inouye et al 2007

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Source Matrix Advocare Network wesite
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Case 2

• Consult requested for 85 yo female with h/o
  dementia recently admitted to the SNF, following
  hospitalization for hip fracture/repair ,
  complicated by post-op infection. Pt noted by
  staff to be disoriented, sundowning, and
  resistant to care and PT. Per staff, family
  concerned that her dementia is much worse than
  before her surgery despite apparently successful
  surgery and resolution of her infection.
• What initial plan would be best?
• A) Send her to the ER
• B) Review chart including medication list, talk
  to staff/family, physical and mental status exams
• C) Begin routine haloperidol 0.5 mg TID for
  agitation
• D) Begin lorazepam 1 mg with dinner for
  sundowning behaviors

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Etiologies of Delirium

• Urgent recognition
• Wernickes
• Hypoxia
• Hypoglycemia
• Hypertensive encephalopathy
• Intracerebral hemorrhage
• Meningitis/encephalitis
• Poisoning/medications

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Etiologies - I WATCH DEATH

• I Infection
• W Withdrawal
• A Acute Metabolic
• T Trauma
• C CNS Pathology
• H Hypoxia

• D Deficiencies (especially vitamin)
• E Endocrinopathies
• A Acute Vascular
• T Toxins
• H Heavy metals

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Etiologies of Delirium

• General Medical Conditions
• HIV/AIDS
• Orthopedic procedures (50)
• Infectious (UTI, Pneumonia, Sepsis)
• Metabolic derangement
• Cancer (PLE, brain metsL, B, M)
• Impaction, constipation, dehydration, many, many
  others

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Etiologies of Delirium

• Iatrogenic and polypharmacy
• Anticholinergic medications
• Opioids
• Benzodiazepines
• Steroids
• Antihistamines
• Antibiotics
• Many, many others

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Delirium Neurobiology

• Best established neurotransmitter dysfunction
  reduced cholinergic activity
• Increased dopamine may also play a role
• Low and excessive serotonin
• Low and excessive GABA
• Trzepacz and Meagher 2005

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Delirium Neurobiology

• Direct injury to the neurons
• Metabolic
• Ischemic
• Alters synthesis/release of neurotransmitters
• Stress response
• Trauma, surgery, infection ? release of
  proinflammatory cytokines, elevated cortisol
• Direct neurotoxic effects
• Alters neurotransmitter levels
• Mittal et al 2011

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Diagnosis of Delirium

• Delirium is a clinical diagnosis
• History and physical examination (attention to
  VS)
• Mental Status Exam
• Rating Scales-consider on admission
• Confusion Assessment Method
• Delirium Rating Scale
• MMSE/Clock

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Diagnosis of Delirium

• Lab tests cannot diagnose delirium but may
  support dx
• CBC, CMP, UA, urine tox, TSH, B12, ammonia
• CXR, EKG, LP if indicated
• Neuroimaging
• EEG
• Generalized slowing in delirium, nonspecific
• Triphasic waves in hepatic encephalopathy
• Low voltage fast activity in EtOH or BZD w/d

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Delirium Management

• Identification and reversal of cause is the
  definitive treatment
• The search must be thorough, as in the diagnosis
  and treatment of any other organ system failure.
  
• Delirium is brain failure!

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Delirium Management

• Monitor VS and I/O
• Ensure good oxygenation
• D/C nonessential medications
• Minimize opioids, benzos, etc
• Repeat PE, further lab, radiologic studies if
  cause not yet identified

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Delirium Management

• Behavioral/Environmental Strategies
• Reorientation, calendars, clocks
• Room near nursing station
• Lights on/off during day/night
• Windows
• Family/familiarity
• Hearing aids, glasses
• Avoid restraints

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Delirium Management

• Pharmacological Therapy
• Nothing FDA-approved
• Antipsychotics are treatment of choice for
  agitation compromising care or safety
• Haloperidol best studied, widely used
• Virtually no anticholinergic effects
• Virtually no hypotensive effects
• Risk of EPS (akathisia), rare with IV route

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Delirium Management

• Pharmacological Therapy
• Haloperidol
• EPS rare when IV route used, however, IV route
  carries risk of QTc prolongation?risk of TdP
• Risk greatest with higher doses over shorter
  periods of time, in pts with QTc gt450
• Monitor EKG and electrolytes (K, Mg)
• Monitor for akathisia

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Delirium Management

• Antipsychotic Dosing in Elderly
• Use clinical judgment depending on severity of
  symptoms for starting dose
• Haloperidol
• 0.5mg mild
• 1mg moderate
• 2mg severe
• Assess response to initial dose and repeat as
  needed, monitoring for effectiveness and adverse
  effects
• Day one order prn
• Day two and beyond assess total drug needed
  previous day and schedule that amount over the
  next day. Reassess daily continuing process
  until delirium resolves.
• Once symptoms have remitted, continue effective
  dose for 48 hours, then slowly taper and
  discontinue over 1-5 days, depending on severity
  and duration of delirium up to that point. Avoid
  abrupt discontinuation after first day or two of
  mental clarity to avoid risk of rebound symptoms

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Delirium Management

• Atypical Antipsychotics
• Risperidone 0.25-0.5 po bid prn
• ODT available
• Olanzapine 2.5 mg qhs
• IM/ODT available
• Caution sedating, anticholinergic
• Quetiapine 25 mg po bid prn
• Limited data on aripiprazole, ziprasidone
  (concern for QTc prolongation)

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Delirium Management

• Cochrane Review 2007
• Meta-analysis compared efficacy and adverse
  effects (3 trials included)
• No difference in efficacy or adverse effects
  between low dose haloperidol and risperidone and
  olanzapine
• High dose haloperidol (gt4.5 mg/d) greater
  incidence of SE, mainly EPS
• Lonergan 2007

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Delirium Management

• Antipsychotics
• Black box warning
• Increased risk of death/CVAEs in pts with
  dementia
• Use judiciously, continue to reassess R/B ratio,
  taper when appropriate

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Case 3

• 70 yo male with no reported psychiatric history
  admitted for elective surgery. Doing well post-op
  until development of acute confusion, agitation,
  paranoia, trying to pull out lines and demanding
  to leave AMA. Exam reveals a diaphoretic,
  tremulous man with tachycardia and elevated BP.
  Which are part of the initial treatment plan?
• A) Begin olanzapine 5 mg q4h routine for
  agitation
• B) Transfer directly to psychiatry
• C) Ensure safety of patient/staff
• D) Obtain collateral information and history
  from family, review chart/meds, complete physical
  and mental status examinations
• E) Initiate alcohol detox protocol with
  lorazepam
• F) Check CMP, CBC, UA, urine tox, ammonia

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Delirium Management

• Pharmacological Therapy
• Benzodiazepines
• Primarily indicated in EtOH or benzodiazepine
  withdrawal delirium
• Adjunct to neuroleptics in treatment of severe
  agitation
• Lorazepam preferred given its reliable absorption
  from po/IM/IV routes
• Generally avoided as may WORSEN
  delirium--especially hepatic encephalopathy

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Prognosis

• Variable
• Full recovery (unlikely at time of hospital d/c
  in the elderly, may take several weeks)
• Persistent cognitive deficits (new baseline)
• Stupor, coma, death (the presence of delirium
  indicates a more serious medical illness,
  affecting the central nervous system)

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Prevention

• 30-40 cases preventable
• Risk factor intervention (Inouye 1999)
• Standardized protocols for 6 risk factors
• Reduced incidence of delirium
• Decreased total of days and of episodes
• No difference in
• Severity of delirium
• Recurrence of delirium
• Fong 2009
• Inouye et al1999

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Conclusion

• Delirium is common in the geriatric population
• Dementia is a risk factor for delirium patients
  frequently have both
• Recognizing delirium, and distinguishing the
  syndrome from primary psychiatric conditions is
  critical
• Delirium can present in a variety of ways and can
  be a result of a number of etiologies
• Awareness of the hypoactive subtype of delirium
  is important avoid confusing it with depression
• Antipsychotic medications are useful in the
  management of symptoms of delirium
  benzodiazepines are useful in cases of alcohol or
  benzodiazepine withdrawal, only.

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References

• Trzepacz PT, Meagher DJ. Delirium. In Levenson
  JL, ed. Textbook of Psychosomatic Medicine.
  Arlington, VA American Psychiatric Publishing,
  200591-130.
• Saxena S, Lawley D. Delirium in the Elderly a
  clinical review. Postgrad Med J.
  200985(1006)405-413.
• Fong TG, Tulebaev SR, Inouye SK. Delirium in
  elderly adults diagnosis, prevention and
  treatment. Nat Rev Neurol. 20095(4)210-220.
• Mittal V, Muralee S, Williamson D, et al.
  Delirium in the elderly a comprehensive review.
  Am J Alzheimers Dis Other Dement. 2011
  Mar26(2)97-109.
• Siddiqui N, House AO, Holmes JD. Occurrence and
  outcome of delirium in medical in-patients a
  systematic literature review. Age Ageing.
  200635(4)350-364.
• Lonergan E, Britton AM, Luxenberg J.
  Antipsychotics for delirium. Cochrane Database of
  Systematic Reviews 2007, Issue 2. Art. No.
  CD005594. DOI 10.1002/14651858.CD005594.pub2
• Inouye SK, Bogardus ST Jt, Charpentier PA, et al.
  A multicomponent intervention to prevent delirium
  in hospitalized older patients. N Engl J Med.
  1999340(9)669-676.