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Susan Cox, DO Chief Resident July 2014 Delirium Slide 2 Goals Understand the different presentations of delirium Know the most common causes of delirium in the hospital Learn a diagnostic approach to the delirious patient Obtain skills to minimize and manage delirium in your patients Slide 3 Case 1 Any elderly woman is admitted for sepsis secondary to UTI. At baseline she has mild dementia, but is pleasant and functional. Yesterday she was doing well. Today, hospital day #4, she is talking to herself, and it is difficult to understand what she is saying. She is anxious, yelling at you, and repeatedly pulling at her clothes. She argues with the nursing staff and refuses blood draws. Slide 4 What is this patient displaying? Delirium Psychosis Dementia Depression with psychotic features Slide 5 What is this patient displaying? Delirium Psychosis Dementia Depression with psychotic features Slide 6 Delirium: DSM 5 Disturbance in attention or cognition Acute onset Change from baseline Fluctuating severity Not fully explainable by chronic psychiatric disorder Level of impairment does not occur in the context of coma Slide 7 Delirium: Confusion Assessment Method (CAM) 1. Acute Onset and Fluctuating Course 2. Inattention 3. Disorganized thinking 4. Altered Level of consciousness To diagnose delirium by CAM you need 1 and 2 with either 3 or 4. Slide 8 Epidemiology Delirium complicates at least 25% of all hospitalizations in the elderly Fong et al 2009 Prevalence of delirium Slide 9 Consequences 12 month mortality post-discharge McCusker et al 2002 Hospital length of stay (days) McCusker et al 2003 In ONE THIRD of patients, it will take >8 weeks for delirium to completely resolve Delirium can initiate a cascade of events that lead to functional decline, loss of independence and death Slide 10 Case 2 An elderly man is on your team for a hip fracture. Previously he was independent and active. He is POD #1 s/p ORIF and you have not heard any calls from the RN overnight. On your morning rounds, he is sleepy and falls asleep as you talk to him. You return to his room at 2:00 PM and he is napping again. He missed his breakfast and lunch because he was asleep. He has not used any of his prn medications. Slide 11 What is this patient displaying? Depression Status epilepticus Delirium Hes just tired Slide 12 What is this patient displaying? Depression Status epilepticus Delirium Hes just tired Slide 13 Types of delirium HyperactiveRestlessness, agitation, hallucinations, delusions HypoactiveLethargy, sedation, responds slowly, little spontaneous movement MixedComponents of both More than half of elderly patients with delirium present with hypoactive or mixed type Which ones do you get called about? Fong et al Slide 14 Its up to you! You must have a high index of suspicion for delirium in your elderly patients Remember, 25-80% of your patients will suffer from this depending on your location in the hospital Most of the time they will just appear sleepy and the RN wont call you about it Do not normalize lethargy Delirium predicts your patients mortality Slide 15 Delirium is a SYMPTOM That means you must recognize it and decide what is causing it NOT just treat it What are some of the causes of delirium in the hospital? Slide 16 Causes of delirium Your patient brings along his/her own non-modifiable risk factors Add an acute illness Add the stressful hospital environment Add medication side effects Slide 17 Age >65 Kidney or liver disease Sensory impairment Dementia Poly- pharmacy Physical frailty Patient risk factors Slide 18 Case 3 Whats going on? An 86 year old man presents to the ER brought in by his son because he is not responding appropriately for the last day. He is inattentive and wont follow commands. He keeps asking for his wife; she died 15 years ago. On exam he appears frail and he has a hearing aid. His son doesnt know his medications, but knows he takes 15 pills daily. You dont have any labs back yet. Slide 19 What is the cause of his delirium? WBC 15, Hgb 19, Plt 300k. 80% N, 10% Bands Sodium 153, K 4.3, Cl 105, CO2 15, BUN 30, Crt 1.9 LFTs and coags normal Lactate 6 UA 1.022 pH 5, 30WBC +nitrite +LE Slide 20 Delirium in this patient Elderly Frail Polypharmacy Hypernatremia Severe sepsis secondary to UTI Slide 21 Case 4 Whats going on? You are the medicine inpatient consultant for the surgical teams You receive a consult from orthopedics for MS a 70 year old female admitted for ankle fracture, POD #2 s/p ORIF is now disoriented, climbing out of bed and pulling off her splint. Slide 22 What is the cause of her delirium? Her medications are: Metoprolol 25mg PO BID Lisinopril 10mg PO Qday Lasix 10mg PO daily Oxybutynin 5mg PO daily Ativan 0.5mg IVP Q2 prn agitation Benadryl 25mg PO QHS prn insomina You see this on physical exam Slide 23 Delirium in this patient >65 years old Post-op Polypharmacy Anticholinergic drugs Benadryl Scopolamine patch Oxybutynin Sedative hypnotics Ativan Slide 24 Causes of delirium - organizing Categories Acronym Slide 25 Causes of delirium Infections Sepsis UTI, PNA, etc. Meningitis Encephalitis Metabolic derangements Sodium Hypercalcemia Hypoglycemia Uremia Ammonia Hypovolemia Hypercarbia DKA Lactic acidosis Poor perfusion Shock Heart failure MI Hypoxia DrugsStressNeurologic Slide 26 Causes of delirium Infections Sepsis UTI, PNA, etc. Meningitis Encephalitis Metabolic derangements Sodium Hypercalcemia Hypoglycemia Uremia Hepatic encephalopathy Hypercarbia DKA Lactic acidosis Poor perfusion Hypoxia Hypovolemia Shock Heart failure MI Ventricular arrhythmias Slide 27 Causes of delirium Drugs Street drugs Anticholinergics Hypnotics Psychotropics Steroids Analgesics Stress Post-op Pain Urinary retention Constipation Sleep deprivation Neurologic Wernickes encephalopathy ( thiamine) Post-ictal state Intracranial hemorrhage Hypertensive emergency Status epilepticus Ischemic stroke Slide 28 Causes of delirium D Drugs E Eyes, ears L Low oxygen states (hypoxia, MI, stroke) I Infection R Retention of urine or stool I Ictal U Underhydration, undernutrition (hypoglycemia, thiamine deficiency) M Metabolic Slide 29 Uncovering the responsible illness There are dozens of causes of delirium! How do you approach a patient with delirium? 1. Recognize/identify it 2. Find the etiology 3. Treat the central cause 4. Manage patient symptoms Slide 30 Case 5 You are the medicine night float. It is 3:00 AM. You are covering 60 patients tonight. You get a page from the med/surg RN. She says, Doctor, Mr. Johnson is getting agitated again. Hes trying to pull out his foley. Can we get a prn ativan? What do you do? Slide 31 Uncovering the responsible illness History: Evaluate for: recent febrile illness, organ failure, detailed medication list, alcohol or drug abuse Slide 32 Case 5 You review your signout 80 year old male, diabetic, nursing home resident here for decompensated heart failure and AKI, diuresing. HD day #4. He has been NPO because of an ileus, not on any fluids because of volume overload. His last labs were drawn 48 hours ago. Meds: Lasix 40mg IV BID, Coreg 6.25mg PO BID, Lisinopril 20mg PO daily, Lantus 10 units QHS, Heparin 5000units SQ BID What are you thinking? Now what? Slide 33 Uncovering the responsible illness History: Evaluate for: recent febrile illness, organ failure, detailed medication list, alcohol or drug abuse Physical Exam: Vitals, volume status, infection, hyperventilation Jaundice, breath (smell of alcohol, ketones), tongue biting, retinal hemorrhages, asterixis, myoclonus, nystagmus Slide 34 Case 5 38C, HR 99, BP 105/70, RR 22, O2 90% RA He is tachypneic, agitated, pulling at his foley JVD to jaw Crackles at bases 2+ edema He has only diuresed 2 L since admission despite aggressive lasix What are you thinking? Now what? Slide 35 Case 5 What is on your differential diagnosis? Hypoxia Hypoglycemia Infection / sepsis Uremia Hyponatremia Arrhythmias Heart failure Slide 36 Uncovering the responsible illness Accucheck ABG CXR CBC CMP UA, urine culture Blood cultures EKG / cardiac enzymes Utox Ammonia Drug levels (lithium, digoxin) Lumbar puncture Head CT Slide 37 Case 5 pH7.37 pCO2 33 pO2 55 on 4L NC Blood glucose 122 Slide 38 Uncovering the responsible illness THE KEY POINTS: You must find out WHY the change occurred You then can address the primary issue and manage symptoms NUMBER ONE Is the change in mental status acutely life threatening? Slide 39 Life threatening causes UpToDate Slide 40 Life threatening causes Hypoxia & Hypoglycemia Bedside testing Reverse with treatment Sepsis May present with fever or hypothermia Look for SIRS criteria Hypertensive Encephalopathy Diagnosis of exclusion Reduce blood pressure appropriately Slide 41 Life threatening causes Wernickes Encephalopathy Uncommon Alcoholic or malnutritioned patients Tx: empirically with Thiamine (high dose, more than what is inside a banana bag) Drug overdose (opiates, benzos, etc.) Remember ABC Poison control or medical toxicology for help Slide 42 Life threatening causes Acute neurologic disorders Meningitis and subarachnoid hemorrhage Confusion, headache, or fever Acute or delayed CNS trauma Subdural hematoma Seizures Postictal state Some seizures may present without convulsions and persistent confusion (status epilepticus) Slide 43 Diagnostic approach DELIRIUM Adequate Oxygen and Blood Glucose Fever or other signs of infections? Correct as needed Determine cause YES NO Slide 44 Diagnostic approach Fever or other signs of infection? Do history and physical exam suggest likely cause of altered behavior? Search for source Pursue likely causeDiagnosis Uncertain YES NO Slide 45 Diagnostic approach Diagnosis Uncertain Basic Testing: CBC, Electrolytes, UA, ECG, CXR Advanced testing or consulting as need: ABG, EEG, head CT, tox screen, drug levels, consults Slide 46 Case 5 Doctor, Mr. Johnson is awaiting his ICU bed. He is still pulling at his foley. What do you want to order? Slide 47 Preventing Complications Protect Airway prevent aspiration If applicable, maintain volume with IVF if unable to take PO Maintain nutrition Prevent pressure sores with frequent mobilization Minimize unnecessary IVs, NG tubes, foley catheters, etc. Slide 48 Management of delirium Remember, you have to identify the cause Non-pharmacologic therapies are the best Bedside sitter Family involvement Normalize patients sleep/wake cycle uninterrupted sleep at night Music relaxation Hearing/visual aids Light during the day, dark at night (pull the blinds open!) Slide 49 Management of delirium Avoid the following as much as possible: Physical restraints Pharmacological agents given increased risk for: Falls Death Slide 50 If nonpharmacologic methods fail Haldol: 0.5 1 mg PO Prolongs QT Extrapyramidal symptoms (>3mg/day) IV has short duration AVOID IV USE Seroquel: 12.5mg 25mg PO Prolongs QT Extrapyramidal symptoms Dont use benzos unless it is for alcohol or benzo withdrawal Atypical and typical antipsychotics are not approved for dementia related psychosis due to increased risk of death (black box warning) Slide 51 Clues in Association Altered mental status + Diabetes Think of oral hypoglycemics, get an accucheck Altered mental status + Fever Think meningitis/encephalitis/UTI/PNA Altered mental status + Hypotension Think sepsis or inferior MI Altered mental status + Dyspnea Think hypoxia, pneumonia or MI/CHF Altered mental status + Hemiparesis or Dysarthria Think stroke Altered mental status + Failure to thrive Think metabolic derangements Slide 52 A 75-year-old woman with a history of COPD is evaluated in the intensive care unit for delirium. She had a median sternotomy and repair of an aortic dissection and was extubated uneventfully on POD #4. Two days later she developed fluctuations in her mental status and inattention. While still in the intensive care unit, she became agitated, pulling at her lines, attempting to climb out of bed, and asking to leave the hospital. Her arterial blood gas values are normal. The patient has no history of alcohol abuse. The use of frequent orientation cues, calm reassurance, and presence of family members has done little to reduce the patient's agitated behavior. Q: Which of the following is the most appropriate therapy for this patient's delirium? A. Diphenhydramine B. Haloperidol C. Lorazepam D. Propofol Slide 53 A 75-year-old woman with a history of chronic obstructive pulmonary disease is evaluated in the intensive care unit for delirium. She had a median sternotomy and repair of an aortic dissection and was extubated uneventfully on postoperative day 4. Two days later she developed fluctuations in her mental status and inattention. While still in the intensive care unit, she became agitated, pulling at her lines, attempting to climb out of bed, and asking to leave the hospital. Her arterial blood gas values are normal. The patient has no history of alcohol abuse. The use of frequent orientation cues, calm reassurance, and presence of family members has done little to reduce the patient's agitated behavior. Q: Which of the following is the most appropriate therapy for this patient's delirium? A. Diphenhydramine B. Haloperidol C. Lorazepam D. Propofol Slide 54 References Alagiakrishnan, K. C.A. Wiens. An approach to drug induced delirium in the elderly. Postgrad Med J 80: 388-393. 2004. Fong, T.G. Delirium in elderly adults: diagnosis, prevention and treatment. Nat. Rev. Neurol. 5, 210-220. 2009. Huff, J.S. UpToDate: Evaluation of abnormal behavior in the emergency department. 2013. McCusker, J., M. Cole, N. Dendukuri, L. Han, E. Belzile. The course of delirium in older medial inpatients. J Gen Intern Med 18: 696-704. 2003. McCusker, J. M. Cole, M. Abrahamowicz, F. Primeau, E. Belzile. Delirium predicts 12- month mortality. Arch Intern Med 162:457-463. 2002. Medical Knowledge Self-Assessment Program (MKSAP 15). Schnieder, L.S., K.S. Dagerman, P. Insel. Risk of death with atypical antipsychotic drug treatment for dementia; meta-analysis of randomized placebo-controlled trials. JAMA 19: 1934-1943. 2005. Young, J and S.K. Inouye. Delirium in older people. BMJ. 334: 842-846. 2007.