1. Delirium in the Elderly Serena Chao, MD, MSc Department of Medicine-Geriatrics Section May 2008 CRIT 5/10/08

2. Incidence Among Elderly Patients is HIGH 1/3 of patients presenting to ER 1/3 of inpatients aged 70+ on general med units Incidence ranges 5.1% to 52.2% after noncardiac surgery ( Dasgupta M et al. J Am Geriatr Soc 2006;54:1578-89) –Highest rates after hip fracture and aortic surgeries

3. Delirium: Increased Mortality One-year mortality: 35-40% Independent predictor of higher mortality up to 1 year after occurrence Hazard Ratio between 2 and 3 –Elderly medical inpatients: Adjusted for dementia, comorbidity, clinical severity, APACHE II score, admitting service (med vs. geri), demographic variables ( McCusker J et al. Arch Intern Med. 2002; 162:457-463) –Mechanically ventilated MICU & CCU patients: Adjusted for coma, age, Charlson Comorbidity Index, APACHEII score, SOFA, admitting diagnosis of sepsis or ARDS, sedative and narcotic use (Ely EW et al. JAMA. 2004; 291:1753-62)

4. Delirium: Increased Risk of… Functional decline New nursing home placement Persistent cognitive decline: –18-22% of hospitalized elders with complete resolution 6-12 months after discharge –CAVEAT: Many subjects with preexisting cognitive impairment (Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704)

5. Diagnosis: Call it what it is… DELIRIUM : ICD-9 code 780.09 “Δ MS” or “mental status change”: –No ICD-9 code

6. Diagnosis: Confusion Assessment Method (CAM) (1) Acute change in mental status with a fluctuating course (2) Inattention AND (3) Disorganized thinking OR (4) Altered level of consciousness Inouye SK et al. Ann Intern Med. 1990; 113: 941-948 Sensitivity: 94-100%, Specificity: 90-95%

7. How to Distinguish Delirium from Dementia Features seen in both: –Disorientation –Memory impairment –Paranoia –Hallucinations –Emotional lability –Sleep-wake cycle reversal Key features of delirium: –Acute onset –Impaired attention –Altered level of consciousness

8. Assume it is Delirium until Proven Otherwise Delirium may be the only manifestation of life-threatening illness in the elderly patient

9. A Model of Delirium A multifactorial syndrome that arises from an interrelationship between: Predisposing factors  a patient’s underlying vulnerability AND Precipitating factors  noxious insults

11. Predisposing Factors i.e. baseline underlying vulnerability Baseline cognitive impairment –2.5 fold increased risk of delirium in dementia patients –25-31% of delirious patients have underlying dementia Medical comorbidities: –Any medical illness Visual impairment Hearing impairment Functional impairment Depression Advanced age History of ETOH abuse Male gender

12. Precipitating Factors i.e. noxious insults Medications BedrestBedrest Indwelling bladder cathetersIndwelling bladder catheters Physical restraintsPhysical restraints Iatrogenic events Uncontrolled painUncontrolled pain Fluid/electrolyte abnormalities Infections Medical illnesses Urinary retention and fecal impactionUrinary retention and fecal impaction ETOH/drug withdrawal Environmental influences

13. Some drug classes that are associated with delirium Medications with psychoactive effects : –3.9-fold increased risk –2 or more meds: 4.5-fold Sedative-hypnotics : 3.0 to 11.7-fold Narcotics : 2.5 to 2.7-fold Anticholinergic drugs : 4.5 to 11.7-fold Risk of delirium increases as number of meds prescribed rises

14. Prevention of Delirium: It can be done! Find patients with 1 to 4 of the following predisposing characteristics: –Visual impairment (worse than 20/70 corrected) –Severe illness –Cognitive impairment (MMSE<24/30) –High BUN/Cr ratio (>18) (Inouye SK et al. Ann Intern Med. 1993; 119:474-481)

15. Prevention=Good Hospital Care for the Elderly Patient (Inouye SK et al. NEJM. 1999;340:669-76) RISK FACTORINTERVENTION Cognitive impairment Orientation protocol, cognitively stimulating activities 3x/day Sleep deprivation Nonpharmacologic protocol, noise reduction, schedule adjustments Immobility Ambulation or active ROM exercises; minimize equipment Visual impairment Glasses or magnifying lens, adaptive equipment Hearing impairment Portable amplifying devices, earwax disimpaction Dehydration Early recognition and volume repletion

16. A Multicomponent Intervention to Prevent Delirium (Inouye SK et al. NEJM. 1999;340:669-76)

17. Keys to Effective Management Find and treat the underlying disease(s) and contributing factors –Comprehensive history and physical –Including neurological and mental status exams –Choose lab tests and imaging studies based on the above –Review medication list

18. Always Try Nonpharmacologic Measures First Presence of family members Interpersonal contact and reorientation Provide visual and hearing aids Remove indwelling devices: i.e. Foley catheters Mobilize patient A quiet environment with low-level lighting Uninterrupted sleep

19. Management: Hyperactive, Agitated Delirium Use drugs only if absolutely necessary: harm, interruption of medical care First line agent: haloperidol (IV, IM, or PO) –For mild delirium: Oral dose: 0.25-0.5 mg IV/IM dose: 0.125-0.25 mg –For severe delirium: 0.5-1 mg IV/IM repeated q30 min until calm Patient will likely need 2-5 mg total as a loading dose –Maintenance dose: 50% of loading dose divided BID May use olanzepine and risperidone (Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD05594)

20. What about Ativan (lorazepam)? Second line agent Reserve for : –Sedative and ETOH withdrawal –Parkinson’s Disease –Neuroleptic Malignant Syndrome

21. AVOID RESTRAINTS AT ALL COSTS: Measure of LAST(!!!) resort

22. Take Home Points: Delirium in the Elderly A multifactorial syndrome: predisposing vulnerability and precipitating insults Delirium can be diagnosed with high sensitivity and specificity using the CAM Prevention should be our goal If delirium occurs, treat the underlying causes Always try nonpharmacologic approaches Use low dose antipsychotics in severe cases