Delirium

Medical Emergencies SeriesInternal Medicine – July 2011

Royal Victoria Hospital – McGill U

J Verdon MD MSc FRCPC

Scenario …NIGHT FLOAT

You are called at 5 am

82 y.o. women admitted for pneumonia

Nurse found her all a sudden agitated

Pulled her iv out

Not keeping her O2 on

What do you do???

Confusion is not always Delirium!

ALL confused Older patients

Do NOT

NECESSARILY

have

DELIRIUM

Confusion is not always Delirium!

It could be a

SHOCK Stroke Encephalitis / meningitis Seizure & Post ictal Dementia with behavior disturbance Speech or hearing impairment

Delirium in NOT normal ….

URBAN LEGEND: It is normal to be confused

when you are older…

They won’t remember anyways

The Problem with delirium…

it is often missed • BUT easy to screen

there is no ‘deliriumin’ level• BUT excellent criteria!

it is hard to treat • BUT treatable!

it is reversible anyways• BUT NOT ALWAYS!

It is mostly preventable• BUT prevention measures not taken!

What you may learn about delirium..

Update on Management

Drugs & Delirium in ED

Delirium and Prognosis

Delirium is a lethal condition that needs attention

Delirium Management

Delirium is ……….?

A) problem with memory mainly

B) problem of agitation, tremor, hallucinations mainly

C) problem with attention mainly

Delirium is ... ?

The A.D.D.

of older persons

Disturbance of consciousness with ATTENTION DEFICIT

Change in cognition or perceptual disturbance Develop over a short period Evidence that related to medical condition

• DSM IV -

Delirium & neurochemical explanation:Cholinergic Buzz Theory

Cholinergic deficiency is most plausible

Dopaminergic and/or Noradrenergic imbalance may give different types of delirium

Delirium: Who is at risk?

Patients with , severe illness, cognitive

impairment, Dehydration, impaired vision

are more likely to develop delirium

Delirium: What triggers it!

Metabolic derangement

Change in environment, use of restraints & catheter

Rx, Rx, Rx

Who is at risk x what we do = DELIRIUM or NO DELIRIUM

Delirium: think about it! look for it!

THE MORE

YOU’LL LOOK,

THE MORE

YOU’LL FIND!!!

How could I manage delirium

What about getting the history for delirium….

History limited with patient ASK for PAIN ASK the nurse or room mates

History hard to get from family 90% undiagnosed MCI or mild dementia Look for change from baseline

Concentrate on the Rx history New, change, accidental overdose, compliance

How do I assess someone with delirium ?

The ABC of Delirium Assessment

A - Airway B - Breathing C - Circulation

The ABC of Delirium assessment

A - Airway aspiration, obstruction, O2 non compliant

B - Breathing pneumonia, pulm oed, PE

C - Circulation MI, tachy, low BP, shock

and DEF of Delirium!

A - Airway B - Breathing C - Circulation

in DELIRIUM D - Drugs new, d/c, error, anticholinergic E - Electrolytes dehydration,glycemia,Na,Ca F - For the rest INFECTION, acute ischemia,

neurological problem

Assessment of patient with delirium: DIFFICULT!

Exam limited and

often impossible

THINK ABOUT YOUR SAFETY & Get some help

Delirium - STOP and OBSERVE !!!

HANDS OFF !

Before

The patient get their

HANDS ON YOU!

Delirium - STOP and OBSERVE

Observe for

- Agitation – anxiety - Apathy- lethargy- Hallucination –

delusions- Main physical findings

Focus your physical exam

Focus on

Vitals Sensorium, attention ask about PAIN! …….

Focus your physical exam

then ; Lungs (& heart) Abdo (urin retention,

gallbladder, rebound) Limbs (swelling, skin, dvt) then, neuro if possible and

SAFE for you!

What work-up to be done?

CBC SMA7 Glucose O2sat urine MINIMAL

CBC SMA7 Glucose LFT Trops Rx serum level Urine c&s ECG O2sat CXR

URGENT

CBC SMA7 Glucose LFT Trops Druglevel Urine c&s ECG O2sat CXR Ca Mg TSH B12 Folate

CT-head COMPLETE

How do I treat Delirium?

1- Tx acute conditions

REMEMBER:

There is USUALLY more than 1 acute condition causing delirium: If you only have 1 cause, you are missing 2 others! Look for and treat them ALL!

Try limiting the LINES: be inventive!

Don ’t forget retention, infection!

2- Review and Simplify all Rx

Discontinue or taper all anticholinergic Rx

Substitute if necessary

3- Institute the non pharmacological treatment

Sleep enhancement Reorientation Early mobilisation Compensation for

hearing, visual impairment

Hydration Safe environment

• Inouye, Cole

DRUGS & DELIRIUM

Rx are acommonly missed cause of delirium

A good internist MUST look for this!

Famously unfamous delirium related prescriptions!

Drug withdrawal• Benzos, Rivotril,

Drug intoxication• Dilantin, Digoxin

Drug interaction

Over the counter• Benadryl• Gravol• Ranitidine

Rx adjustmentare needed in delirium

A good internist knows this!

Individualize the prescription!

STOP what needs to be stopped anticholinergic

RESTART what should not have been stopped Benzos,

ADJUST doses for WEIGHT and Renal Fx USE P.O. route, to avoid lines AVOID possible Rx interaction

Delirium and Rx for symptoms

The internist survival kit!

The urgent prescription!

Different options

Haldol 0.25-0.5mg po or im q6h prn + regular seroquel 12.5-25 mg po qHS

Or

Haldol 0.25-0.5mg po or im q6h prn + regular risperdal 0.25 mg bid po

Treat Delirium symptoms

For Rx Tx as Tx for acute pain

REGULAR doses with some prn x 72 hours and r/a

Tx symptoms (psychosis, hallucin, or anxiety) with most appropriate PSYCH Rx

Tx small dose short acting benzos occasionnally

ALSO Tx PAIN with regular analgesics IMPORTANT

Atypical Antipsychotics

Olanzapine(zyprexa) 2.5 mg qD ( also ZYDIS) up to 10 mg tot /day

Quietapine (seroquel) 12.5mg qHS to bid - up to 150 mg tot/day

Risperidone (risperdal) 0.25 mg daily up to 2 mg tot/day

Delirium & Prognosis

Delirium is lethal…

Delirium associated risk of mortality/ nursing home up to 3 months after discharge is…. increased by 2-3

O.R. for death/nursing home,adjusted for age, gender, apache score, functional status, dementia

at discharge; 2.1 (1.4-4)at 3 months; 2.6 (1.4-4.5)

Delirium is a Medical Emergency!

Delirium can be easily diagnosed The more you’ll look, The more you’ll find

Look and Treat all causes and symptoms

Always think Rx!

Multidisciplinary approach makes a difference!

References.

N Engl J Med Volume 340:669–676 1999. A multicomponent intervention to prevent delirium in hospitalized older patients. Inouye SK et al.

J Am Geriatr Soc Volume 48:1697–1706, 2000.The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in hospitalized older patients. Inouye SK et al

Cleveland Clinic Journal of medicine Volume 71(11): 890-896, 2004. A practical program for preventing delirium in hospitalized elderly patients. Inouye SK et al.

Journal of Psychosomatic Research Volume 65; 273–282, 2008. Drug treatment of delirium: Past, present and future.

Age and Ageing 2011; 40: 23–29. Which medications to avoid in people at risk of delirium: a systematic review.

JAMA. 2010;304(4):443-451. Dementia: A Meta-analysis Ann Intern Med. 2011;154:746-751. Guideline for Prevention of Delirium

THANK YOU