Delirium Ashley Duckett, MD Pamela Pride, MD Medical University of South Carolina 2012

CAM Definition of Delirium Acute onset or fluctuating course AND Inattention (decreased ability to focus, shift or sustain attention) PLUS EITHER Disorganized thinking (incoherent or illogical speech ( questions – does a stone float on water, etc) OR Altered Level of Consiousness (anything other than alert and calm) – RASS other than 0 Confusion Assessment Method- Inouye, Ann Intern Med 1990

-INATTTENTION is the cardinal feature for diagnosis -Can use serial 7’s, WORLD, reciting days or months in reverse, etc; ICU uses letter test (SAVEAHAART) -SUBTYPES -Hyperactive – agitated, hyperalert -Hypoactive – calm and confused, lethargic -Mixed – features of both *no difference in etiology or outcomes among the subtypes *hypoactive pts commonly missed without formal screen

Why do we care? VERY common (esp if older, had ICU stay) although underdetected VERY common (esp if older, had ICU stay) although underdetected Increased morbidity and mortality Increased morbidity and mortality –Higher risk for falls, decubs, pna –Higher risk of functional decline and institutional care –Longer LOS –Predictor of 12 mo mortality

Risk factors (far from an exhaustive list) Age >70 Age >70 Dementia or underlying brain dysfunction Dementia or underlying brain dysfunction Alcohol abuse Alcohol abuse Hearing or visual impairment Hearing or visual impairment History of delirium History of delirium Inouye et al, Multicomponent Intervention of Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76)

Modifiable risk factors Medications Medications Polypharmacy (>3 new inpt meds) Polypharmacy (>3 new inpt meds) Physical restraints and catheters Physical restraints and catheters Sleep deprivation Sleep deprivation Immobility Immobility Uncontrolled pain Uncontrolled pain Medical illness (organ failure, electrolytes, etc) Medical illness (organ failure, electrolytes, etc)

A ntiparkinson drugs C orticosteroids U I drugs T heophylline E mptying drugs (motility drugs) C ardiovascular Drugs H 2 blockers A ntimicrobials N SAIDs G eropsychiatric drugs E NT drugs I nsomnia drugs N arcotics Muscle relaxants S eizures Drugs Look to these medications if there is an ACUTE CHANGE IN MS Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1):

Mini-Cog Recall 0Recall 1-2Recall 3 Abnormal Clock Normal Clock Impaired Not ImpairedImpaired Not Impaired Borson S et al. (2000), Int J Geriatr Psychiatry 15(11):

Serial administration of a modified RASS for delirium screening Chester, JG et al. J Hosp Med 2012 May-June 7 (5)

Evaluation Vital signs, pulse ox, volume status Vital signs, pulse ox, volume status Focused exam including determining baseline cognition, urine output, last BM Focused exam including determining baseline cognition, urine output, last BM Blood glucose Blood glucose Review medications Review medications Consider withdrawal as a cause Consider withdrawal as a cause Testing – CBC, BMP, UA, CXR, EKG Testing – CBC, BMP, UA, CXR, EKG Additional testing if clinically indicated Additional testing if clinically indicated

Management Try to identify underlying cause Try to identify underlying cause Prevent complications and provide supportive care Prevent complications and provide supportive care – Avoid bed rest, catheters, mobilize patient –Sleep at night, awake during day –Monitor nutrition status and output –Consider aspiration precautions –Enlist the help of family

Management Antipsychotics are drug of choice for treating agitation Antipsychotics are drug of choice for treating agitation –Can consider treating hypoactive delirium to treat subjective stress (paranoia, hallucinations) Haldol – cheap, can be given PO, IV, IM Haldol – cheap, can be given PO, IV, IM –CAN’T be used in Parkinson’s, Lewy body dementia, prolonged QT DON’T USE BENZOs UNLESS YOU’RE TREATING WITHDRAWAL or NMS!!! DON’T USE BENZOs UNLESS YOU’RE TREATING WITHDRAWAL or NMS!!!

What’s the evidence? Best drug? Haldol v Atypicals ( Risperidone, Olanzipine, Quetipine) Best drug? Haldol v Atypicals ( Risperidone, Olanzipine, Quetipine) –Systematic reviews show similar efficacy, question of fewer side effects –NEED larger and better studies 2005 FDA warning re risk of death 2005 FDA warning re risk of death –Use for shortest duration, with caution –NEED larger and better studies

Haldol and EKGs? Concern for prolonged QTc and torsades or polymorphic VT Concern for prolonged QTc and torsades or polymorphic VT Review showed that most conduction disturbances involve heart disease and high doses (50mg/24 hrs) Review showed that most conduction disturbances involve heart disease and high doses (50mg/24 hrs) More recent review – heart dz, >65, female, hypokalemia More recent review – heart dz, >65, female, hypokalemia Stop if QTc>500 Stop if QTc>500 Don’t wait to give Haldol until after EKG Don’t wait to give Haldol until after EKG Lawrence, Pharmacotherapy 1997; 17(3);

Screening Inpatients Delirium task force Delirium task force Goal should be prevention; cutting back on physical restraints Goal should be prevention; cutting back on physical restraints Nurses will screen each shift with RASS Nurses will screen each shift with RASS Delirium protocol - order set with suggested workup and drug dosing based on patient factors Delirium protocol - order set with suggested workup and drug dosing based on patient factors

References DSM-IV TR, 2000 DSM-IV TR, 2000 Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76) Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76) Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76) Inouye et al, Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients, NEJM; 1999 (340) 9:669-76) Borson S et al. (2000), The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 15(11): Borson S et al. (2000), The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 15(11): Borson S et al. (2000), The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 15(11): Borson S et al. (2000), The mini-cog: a cognitive 'vital signs' measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 15(11): Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): Flaherty, J.H. (1998). Psychotherapeutic agents in older adults. Commonly prescribed and over-the-counter remedies: causes of confusion. Clinics in Geriatric Medicine, 14(1): Lawrence, Conduction Disturbances Associated with Administration of Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Pharmacotherapy 1997; 17(3); Lawrence, Conduction Disturbances Associated with Administration of Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Pharmacotherapy 1997; 17(3); Lawrence, Conduction Disturbances Associated with Administration of Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Pharmacotherapy 1997; 17(3); Lawrence, Conduction Disturbances Associated with Administration of Butyrophenone Antipsychotics in the Critically Ill: A Review of the Literature. Pharmacotherapy 1997; 17(3); Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): Wenzel-Seifert, QTc Prolongation by Psychotropic Drugs and the Risk of Torsade de Pointes. Dtsch Arztebl Int 2011; 108 (41): Delirium. Updates in Hospital Medicine Harvard Medical School Delirium. Updates in Hospital Medicine Harvard Medical School Antipsychotics for delirium. Cochrane review Antipsychotics for delirium. Cochrane review