Delirium Lindsay Wilson, MD Jan Busby-Whitehead, MD Ellen Roberts, PhD, MPH The University of North Carolina at Chapel Hill With Support from The Donald W. Reynolds Foundation ©The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.

2 Self-Test: 1. Delirium is associated with a _________-fold increase in mortality in the hospital. 2. _________ is the most common complication of hospital admission for older people. 3. Patients with delirium have an average increase of _________ days in the length of hospital stay. 4. If an appropriately trained person uses a brief cognitive assessment, they can diagnose delirium ________% of the time. 5. Up to ______% of cases in the hospital are unrecognized.

3 How Did You Do? 1. Delirium is associated with a 10-fold increase in mortality in the hospital. 2. Delirium is the most common complication of hospital admission for older people. 3. Patients with delirium have an average increase of 8 days in the length of hospital stay. 4. If an appropriately trained person uses a brief cognitive assessment, they can diagnose delirium approx 90% of the time. 5. Up to 70% of hospital cases are unrecognized.

4 Goals 1. Define delirium and describe its cardinal features and underlying pathophysiology 2. Recognize that delirium is common, under- diagnosed, and associated with significant morbidity and mortality 3. Regarding delirium, know ways to: prevent diagnose evaluate manage 4. Feel comfortable with teaching key concepts in < 1 minute

5 Goals 1. Define delirium and describe its cardinal features and underlying pathophysiology.

6 Delirium Definition Medical condition characterized by acute onset of: Fluctuating course Altered level of awareness Inattention Disorganized thinking Increased or decreased psychomotor activity Disturbance of sleep-wake cycle

7 Pathophysiology Image of black box or another image showing the multiple inputs to the brain that cause delirium

8 Predisposing factors Dementia Age Male sex Frailty Malnutrition Depression Terminal illness Functional impairment Immobility Alcohol abuse Sensory impairment High medical comorbidity Polypharmacy

9 Precipitating factors Medications Neurologic disease Surgery Uncontrolled pain Hypoxia Metabolic derangements Severe illness Low Hct Bed rest Indwelling devices Restraints Sleep deprivation Dehydration

10 Tipping the scale... The greater the predisposing factors, the fewer precipitating factors required to initiate the delirium. Delirium is usually MULTIFACTORIAL. Picture of scales

11 Prediction models: Example by Inouye et al: Assign 1 point for each of four risk factors: 1) Vision impairment 2) Severe illness 3) Cognitive impairment 4) BUN:Cr > 18 (signifying dehydration) Those with 3-4 points have risk of delirium 32-83%. Other predictive models specific for certain subsets of geriatric patients (ex. surgical patients). Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission characteristics. Ann Intern Med 1993: 119 (6);

12 Goals 2. Recognize that delirium is common, under- diagnosed, and associated with significant morbidity and mortality

13 How many geriatric patients have delirium? At presentation to the ED: 7-33%. At hospital admission: 14-25%. Postoperatively: 15-53%. In the ICU: 70-87%. In the community, ages 65-85: 1-10%, those >85: 14%. At the end of life: Up to 83%.

14 Why under-diagnosed??? 70% of cases go unrecognized! #1 cause is neglecting to determine the acuity of change in mental status and dismissing presentation as dementia. We ALL miss more of the hypoactive cases. Diagnosis is delirium unless otherwise proven! Don’t be tempted to attribute the presentation to dementia or depression.

15 Prognosis May persist weeks, months- 44% at 1 month, 33% at 3 months. Has a waxing and waning course. Has been associated with a 10-fold increased risk of death in the hospital 3-5 increased risk of nosocomial complications prolonged length of stay impaired physical and cognitive recovery at 6 and 12 months need for post-acute nursing home placement Has an associated one-year mortality rate of 35-40%!

16 Goals 3. Regarding delirium, know ways to: prevent diagnose evaluate manage

17 Prevention Preventing delirium is the most effective strategy for reducing its frequency and complications. At least 30-40% of cases may be preventable. How do we prevent delirium???

18 Picture of hearing aids Picture of person sleeping Picture of a walker Picture of eye glasses Picture of a calendar Picture of a beside toilet Picture of earwax in ear Picture of a glass of water Picture of a clock

19 Prevention: Yale Delirium Prevention Trial Demonstrated the effectiveness of intervention protocol that included: 1.Orientation and therapeutic activities 2.Early mobilization 3.Nonpharmacologic approaches 4.Adaptive equipment 5.Early intervention for volume depletion 6.Sleep-enhancement protocol Development of delirium reduced from 15% to 9.9% Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM 1999; 340(9):

20 Diagnosis Picture of a patient or someone at the bedside

21 Diagnosis *****CAM: Confusion Assessment Method***** Based on the 4 cardinal elements of the DSM-3 criteria for delirium: 1.Acute onset and fluctuating cource 2.Inattention 3.Disorganized thinking 4.Altered level of consciousness Must have have 1 and 2 and either 3 or 4 Sensitivity 94%-100% Specificity 90-95% Positive LR 9.6 Negative LR 0.16 Inouye SK et al. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990: 113 (13):

22 Feature 1. Acute Onset or Fluctuating Course: Must have this one! This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: Is there evidence of an acute change in mental status from the patient’s baseline? Did the (abnormal) behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?

23 Feature 2. Inattention: Must have this one! This feature is shown by a positive response to the following question: Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?

24 Feature 3. Disorganized thinking— May have this OR Feature 4 This feature is shown by a positive response to the folllowing question: Was the patient's thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

25 Feature 4. Altered Level of Consciousness—May have this OR Feature 3 This feature is shown by any answer other than “alert” to the following question: Overall, how would you rate this patient’s level of consciousness? -alert -vigilant -lethargic -stupor -coma

26 Practice Ms. G is a 73 year-old with mild Alzheimer's dementia. She is a new admit to rehab after surgery for a hip fracture. On morning rounds, she continuously sits up, then lies back in bed, picking at the bed sheets. Her family states that she did not sleep at all last night. This morning, she complained about "all the small children on her bed." Her family says she is not herself. You try to talk to the patient--she startles easily, then seems distracted and unable to pay attention to the conversation. What risk factors does this patient have for delirium? Is she CAM positive?

27 Diagnosis *****GAR: Global Attentiveness Rating***** Rate how easily patient can be engaged in a 2-minute conversation "How well did the patient keep his mind on interacting with you during the interview?" Supported by 1 study with geriatricians Sensitivity 94% Specificity 99% Positive LR 65 Negative LR 0.06 O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997; 45(4):

28 Diagnosis: Differentiating delirium from dementia and psychiatric conditions Talk with family/caregivers to establish baseline Observe the patient: An acute change in mental status is NOT dementia Rapidly fluctuating course is NOT typical for dementia Abnormal level of consciousness is NOT typical for dementia But, the lines are blurry and the diagnosis becomes more difficult in patients with dementia.

29 Evaluation: D.E.L.I.R.I.U.M Drugs!! Electrolyte/endocrine disturbances (dehydration, sodium imbalance, uremia, hypercalcemia, hypoglycemia, thyrotoxicosis) Lack of drugs (withdrawal from ETOH, benzos or poor pain control, B12 deficiency) Infection (sepsis, meningitis, encephalitis) Reduced sensory input (can't see or can't hear) Intracranial (infection, hemorrhage, stroke, tumor) Urinary, fecal (urinary retention, fecal impaction--can be a cause!) Major organ system issues-- infarction, arrhythmia, shock, COPD, hypoxia, hypercapnia, renal failure, liver failure, hypertensive encephalopathy

30 Evaluation Basics: History Physical exam Targeted labs Careful medication history Alcohol, illicit drug use Vital signs Multiple factors likely involved rather than a single "cause" but delirium can be the sole manifestation of serious underlying disease. Picture of pills

31 If still looking... LP Blood cultures UA/Urine culture Urine toxicology Cardiac enzymes and EKG Arterial blood gas Blood alcohol Head CT EEG

32 Practice: Our 73-year old You are concerned that Ms. G has delirium. What do you do to evaluate her delirium?

33 Additional history Ms. G does not drink any alcohol. She does have hearing loss and vision loss and usually wears hearing aids and glasses. She has not had either since being in the hospital. She has had trouble making it to the bathroom to urinate. A couple of times she has been incontinent. Also per hospital records, she has not had a bowel movement since being admitted (5 days ago). She has not reported any pain over the last 24 hours.

34 Physical exam Vitals T 98.9 Heart rate 83 BP 110/70 RR 14 Physical exam CTA bil, nl wob RRR, no MRGs No LE swelling Abd full, decreased bowel sounds, no tenderness to palpation Surgical wound appears CDI, no erythema/drainage Neuro exam unremarkable CAM +

35 Ms. G's medication list Lisinopril 5 mg q day Percocet 5/325 mg q 6 hours as needed for pain Benadryl 25 mg qhs as needed for insomnia Aricept 10 mg q day Aspirin 81 mg q day Calcium + D two tablets twice daily HCTZ 25 mg q day

36 Ms. G's tests Na 129 (baseline 135) K 4.9 Cr 1.3 (baseline 1.2) WBC 10 (baseline 5) Hgb 10 (baseline 11) UA 2+ LE, + nitrites, WBC clumps CXR clear Postvoid bladder scan <10

37 Management of delirium First, try to remove/treat precipitants of delirium. Provide frequent orientation and therapeutic activities. Provide glasses and hearing aids. Avoid constipation/urinary retention/dehydration/electrolyte imbalances. Avoid complete bed rest. Educate family and nursing support staff of ways to comfort patient. Try scheduled tylenol, ice/heat packs, warm milk in place of meds.

38 Medications to reduce or eliminate... Anticholinergics Diuretics Antidepressants Benzos Opioids Anticonvulsants Antiparkinsonian agents Nonbenzodiazepine hypnotics (zolpidem) Fluroquinolones (levaquin) Muscle relaxants Antiemetics Steroids

39 What is your plan for Ms. G?

40 Your management plan for Ms. G... 1) Stop benadryl!! 2) Have family bring in glasses and hearing aids... and have patient wear them!! 3) Start patient on an aggressive bowel regimen. 4) Stop her HCTZ and monitor her sodium closely. 5) Obtain urine culture. 6) Start antibiotic to cover UTI. 7) Stop percocet. Start patient on tylenol 1000 mg TID and oxycodone 2.5 mg-5 mg q 6 prn pain depending on how concerned you are that she may have pain. 8) Get patient out of bed to the chair by the window. Have the family provide frequent orientation. 9) Try other measures for insomnia.

41 About restraints... We DO NOT recommend restraints as they can cause bad outcomes (even death!). Always, evaluate the patient first. Always, try other interventions first: --Have family stay with patient --Use a sitter --Demonstrate calming the patient to those involved in the patient care. If medically necessary to the patient, use restraints for the least amount of time possible and always inform the family about why they are needed. Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4):

42 Pharmacologic Therapy, ie chemical restraints Consider only if safety is in issue or if patient's symptoms are very distressing to the patient High-potency antipsychotics (haldol) usually first-line Use low dose and go slow ex mg IV haldol or 0.5 mg po haldol Use for shortest duration possible Can see akathisia, which can be mistaken for worsening delirium

43 Goals 4. Feel comfortable with teaching key concepts in < 1 minute

44 If you have 30 seconds...Delegate! Ask the family, RNs, or your trusty medical students to 1) Turn on the lights or open the blinds during the daytime 2) Keep the calendar and clock right 3) Re-orient the patient frequently 4) Get the patient out of bed to chair as much as possible 5) Use eyeglasses, hearing aids 7) Distract, reassure the patient as needed to avoid restraints 8) Get rid of foley asap 9) Monitor closely for pain (nonverbal clues) 10) Evaluate the patient before ordering restraints (chemical or physical) and use only as a last resort 11) Monitor closely for constipation

45 If you have one minute... Be a good role model! *Assess all hospitalized elderly patient's for delirium on a daily basis *Use the language (the word "delirium") *Keep it on everyone's radar because medical students, nurses, etc won't think it is a big deal unless you do *Minimize use of restraints (including catheters and chemical restraints)

46 If you have 2 to 5 minutes... 1) Have a conversation with the patient to assess for delirium (GAR) 2) Use CAM to assess for delirium 3) Canned talks, examples: Ways to prevent delirium Ways to manage delirium Definition of delirium 4) Use/review DELIRIUM mneumonic

47 Hopefully we met these goals Define delirium and describe its cardinal features and underlying pathophysiology 2. Recognize that delirium is common, under-diagnosed, and associated with significant morbidity and mortality 3. Regarding delirium, know ways to: prevent diagnose evaluate manage 4. Feel comfortable with teaching key concepts in < 5 minutes

48 Take-home points Delirium is common, under-recognized and serious!! Cardinal features are acute onset, fluctuating awareness, impairment of memory and attention, increased or decreased psychomotor activity, disturbance of sleep- wake cycle and disorganized thinking. Preventing and managing delirium is key to minimizing poor outcomes for our geriatric patients. Use CAM to diagnose delirium. Remember D.E.L.I.R.I.U.M. for differential diagnosis. Drug treatment should be reserved for patients who pose a risk to themselves or others or who seem to be very distressed by their symptoms (ie hallucinations, delusions).

49 Works cited Botts, Angela. Delirium in Hospitalized Older Patients. Clinical Geriatrics 2010: Volume 18 (10): Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R.(1990). Clarifying confusion: the confusion assessment method. Annals of Internal Medicine, 113(12), Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM 1999; 340(9): Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission characteristics. Ann Intern Med 1993: 119 (6); Inouye SK. Delirium in Older Persons. NEJM 2006: 354 (11); O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997; 45(4): Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4): Wong et al. Does this patient have delirium? Value of bedside instruments. JAMA Aug 18, Vol 304.

50 Questions? THANK YOU! Contact information: Lindsay Wilson ext 256

51 Acknowledgments and Disclaimers 51 This project was supported by funds from The Donald W. Reynolds Foundation. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by The Donald W. Reynolds Foundation. The UNC Center for Aging and Health and The Division of Geriatric Medicine also provided support for this activity. This work was compiled and edited through the efforts of Carol Julian.

52 ©The University of North Carolina at Chapel Hill, Center for Aging and Health. All Rights Reserved.