Delirium in the Elderly
Kirsten M. Wilkins, MDAssistant Professor of PsychiatryYale School of MedicineVA CT Healthcare System
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 (1:1), evaluate patient for antidepressant, provide
supportive psychotherapy to address prolonged hospitalizationb. Assign a sitter (1:1), check urinalysis, do a chest x-ray, begin
SSRIc. Transfer to psychiatry for further cared. Evaluate for a sitter (1:1), check urinalysis, do a chest x-ray,
discuss with primary team
Case 1 - Discussion
Answer = D: Evaluate for a sitter (1:1), check urinalysis, do a chest x-ray, discuss with primary team
Delirium must be ruled out first in this case…it 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 picture—better 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.
Delirium
DSM-IV-TR CriteriaDisturbance 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.
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.
Delirium
DELIRIUM IS ALSO KNOWN AS….acute confusional stateacute mental status changealtered mental statusbrain failurehepatic encephalopathyorganic brain syndrome toxic or metabolic encephalopathy
Delirium: Epidemiology
Prevalence depends on populationGreater 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
Delirium: Epidemiology
Higher rates seen with…Post-op (ortho, cardiothoracic, vascular) ICU admission
Poor functional recovery Increased hospital lengths of stayIncreased likelihood of NH placement
Up to 60% NH pts have deliriumTrzepacz and Meagher 2005
Mittal et al 2011
Delirium - Impact
Increased morbidityPoorer recovery from medical illness Increased need for walking devices6x increased risk of decubitus ulcers or
aspiration pneumoniaIncreased risk of future cognitive decline10-33% mortality rate in hospitalIncreased risk of mortality even months
after d/c Fong et al
2009
Siddiqi et al 2006
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
Delirium Risk Factors
AgePreexisting dementiaRecent surgeryBone fracturesInfectionsHypoalbuminemiaPreexisting CNS structural abnormalities
Delirium Risk Factors
Abnormal sodiumSevere illness
AIDS, CancerPolypharmacyDehydrationVisual/hearing impairment
Delirium Risk Factors
Substance AbuseAlcoholPrescription drugs Illicit drugs
You must ask!Collateral informant
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
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
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
Affective Lability
Mood may fluctuate widely in a very short period of time (minutes/hours)
Anxiety/panic/fear/angerApathy/sadness - commonly mistaken
for depressionEuphoria (esp. if steroid-induced)
Delirium:Differential Diagnosis
Dementia with Behavioral DisturbancePsychotic Disorder (Schizophrenia)Mood Disorder (Depression, Mania)CatatoniaOthers
Delirium versus Dementia
DELIRIUMimpaired 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
+++
+++
-
+
+
++
+
+
+
+
+
-
+++
Delirium
Generally divided into 4 major types:Delirium secondary to general medical
conditionDelirium secondary to substance
intoxicationDelirium secondary to substance withdrawalDelirium secondary to multiple etiologies
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 conditions—cognitive impairment, severe illness, visual impairment) and hospital-related insults (ie, medications and procedures).” –Inouye et al 2007
Source: Matrix Advocare Network wesite
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
Etiologies of Delirium
Urgent recognitionWernicke’sHypoxiaHypoglycemiaHypertensive encephalopathy Intracerebral hemorrhageMeningitis/encephalitisPoisoning/medications
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
Etiologies of Delirium
General Medical ConditionsHIV/AIDS Orthopedic procedures (50%) Infectious (UTI, Pneumonia, Sepsis)Metabolic derangementCancer (PLE, brain mets—L, B, M) Impaction, constipation, dehydration, many,
many others…
Etiologies of Delirium
Iatrogenic and polypharmacy Anticholinergic medications Opioids Benzodiazepines Steroids Antihistamines Antibiotics Many, many others…
Delirium: Neurobiology
Best established neurotransmitter dysfunction: reduced cholinergic activity
Increased dopamine may also play a roleLow and excessive serotoninLow and excessive GABA
Trzepacz and Meagher 2005
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
Diagnosis of Delirium
Delirium is a clinical diagnosisHistory and physical examination
(attention to VS)Mental Status ExamRating Scales-consider on admission
Confusion Assessment MethodDelirium Rating ScaleMMSE/Clock
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
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!
Delirium: Management
Monitor VS and I/O Ensure good oxygenationD/C nonessential medications
Minimize opioids, benzos, etcRepeat PE, further lab, radiologic studies
if cause not yet identified
Delirium: Management
Behavioral/Environmental StrategiesReorientation, calendars, clocksRoom near nursing stationLights on/off during day/nightWindowsFamily/familiarityHearing aids, glassesAvoid restraints
Delirium: Management
Pharmacological TherapyNothing FDA-approvedAntipsychotics are treatment of choice for
agitation compromising care or safetyHaloperidol best studied, widely used
Virtually no anticholinergic effectsVirtually no hypotensive effectsRisk of EPS (akathisia), rare with IV route
Delirium: Management
Pharmacological TherapyHaloperidol
EPS rare when IV route used, however, IV route carries risk of QTc prolongationrisk of TdP
Risk greatest with higher doses over shorter periods of time, in pts with QTc >450
Monitor EKG and electrolytes (K, Mg)Monitor for akathisia
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
Delirium: Management
Atypical AntipsychoticsRisperidone 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 prnLimited data on aripiprazole, ziprasidone
(concern for QTc prolongation)
Delirium: Management
Cochrane Review 2007Meta-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 (>4.5 mg/d) greater incidence of SE, mainly EPS
Lonergan 2007
Delirium: Management
AntipsychoticsBlack box warning Increased risk of death/CVAE’s in pts with
dementiaUse judiciously, continue to reassess R/B
ratio, taper when appropriate
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
Delirium: Management
Pharmacological TherapyBenzodiazepines
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
Prognosis
VariableFull 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)
Prevention
30-40% cases preventableRisk factor intervention (Inouye 1999)
Standardized protocols for 6 risk factors:Reduced incidence of deliriumDecreased total # of days and # of episodes
No difference in:Severity of deliriumRecurrence of delirium
Fong 2009
Inouye et al1999
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.
References
Trzepacz PT, Meagher DJ. Delirium. In: Levenson JL, ed. Textbook of Psychosomatic Medicine. Arlington, VA: American Psychiatric Publishing, 2005:91-130.
Saxena S, Lawley D. Delirium in the Elderly: a clinical review. Postgrad Med J. 2009;85(1006):405-413.
Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol. 2009;5(4):210-220.
Mittal V, Muralee S, Williamson D, et al. Delirium in the elderly: a comprehensive review. Am J Alzheimer’s Dis Other Dement. 2011 Mar;26(2):97-109.
Siddiqui N, House AO, Holmes JD. Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age Ageing. 2006;35(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. 1999;340(9):669-676.