1. Week 1 Module B: Instructions  Please view video 2 and review charts prior to starting this module.  When you see this slide, put the mouse pointer over it and right click.  In the menu of options, click "full screen."  This opens the presentation. To advance the slides, either use the mouse or the arrow keys on the keyboard.

2. Week 1 Module A: Instructions  For each question, please choose one answer that best addresses the question and then hit “click here.”  For those slides where there are "click here" instructions, please do so or else you might skip over slides.

3. Week 1 Module B: Question 1  Mrs. Rivera has now been in the hospital for one full day; she was sent to BMC straight from clinic. What is the ICD-9 diagnosis of her cognitive status in video clip 2?  A. Δ MS click hereclick here  B. Dementia with sundowning click hereclick here  C. Delirium click hereclick here  D. Acute mental status change click hereclick here

4. Delirium Takes Various Forms  It’s obvious that Mrs. Rivera has hyperactive delirium now: – 25% of all delirium cases are hyperactive  However, there is also a hypoactive form: – Less recognized or appropriately treated  Mixed: with hypo- and hyperactive features  Additional features include emotional and psychotic symptoms

5. Week 1 Module B: Question 2  Your initial evaluation of the etiologies of Mrs. Rivera’s delirium should include all of the following EXCEPT:  A. Complete history, including what prn meds were given overnight click hereclick here  B. Vital signs and oxygen saturation click hereclick here  C. Complete physical exam, including neurological exam click hereclick here  D. CT scan of head click hereclick here

6. Always see the delirious hospital patient!  When the nurse pages you about an agitated, hyperactive delirious patient, resist the urge to order medications or restraints over the phone.  GO EXAMINE THE PATIENT BEFORE TAKING ACTION

7. Evaluation begins with history & physical  Focus on time course of cognitive changes esp. their association with other symptoms or events  Medication review, including OTC drugs, alcohol, prn meds  Vital signs, oxygen saturation  General medical evaluation  Neurologic and mental status examination

8. Week 1 Module B: Question 3  Mrs. Rivera has a temp of 101.2 despite one day of antibiotic treatment, no nuchal rigidity, rales in the left base, and a non-focal neuro exam. She has not received any prn medications recently.  Given her history and exam findings, the following tests are appropriate to order as part of the initial evaluation EXCEPT:  (go to next slide)

9. Week 1 Module B: Question 3 continued  A. CBC click hereclick here  B. BMP click hereclick here  C. UA and urine C&S click hereclick here  D. TSH click hereclick here  E. EKG click hereclick here

10. Evaluation: Laboratory Testing  Base on history and physical  Think of possible precipitating factors and let this guide your choice of testing  Include electrolytes, renal function tests, CBC, and UA for every patient (these are high yield)  Cerebral imaging rarely helpful, except for head trauma or new focal neuro findings  EEG and CSF rarely helpful, except for associated seizure activity or signs of meningitis

11. Management: General Principles  Requires interdisciplinary effort by MDs, nurses, family, others (such as PT)  Multifactorial approach is most successful because multiple factors contribute to delirium in most cases  Failure to diagnose and manage delirium: life-threatening complications, loss of function, costly

12. Keys to Effective Management  TREAT THE UNDERLYING DISEASE  Address contributing factors – Including medications: see if you can reduce or eliminate suspected contributors

13. Week 1 Module B: Question 4  Because Mrs. Rivera is agitated, initial management should include all of the following EXCEPT:  A. Wrist restraints and Posey vest click hereclick here  B. Asking family members to stay with her click hereclick here  C. Removal of the Foley catheter click hereclick here  D. Placing her in a cardiac chair at the nurses station click hereclick here

14. Always try nonpharmacologic measures first

15. Nonpharmacologic Management  Presence of family members  Interpersonal contact and reorientation  Provide visual and hearing aids if needed  Remove indwelling devices (such as Foley catheters) ASAP  Wrap IV lines in kerlix (so patient can’t see them)  Mobilize patient as soon as possible  Keep patient awake during the daytime  Provide uninterrupted sleep at night

16. Week 1 Module B: Question 5  Despite the presence of family members, removal of the Foley catheter, and giving Mrs. Rivera her glasses, she remains agitated and refuses to take her meds. The most appropriate next management step is:  A. lorazepam 2 mg IV click hereclick here  B. haloperidol 1 mg IV click hereclick here  C. haloperidol 5 mg IV click hereclick here

17. Pharmacologic Management  Reserved for patients at risk for harm of self or others – Including refusal to take potentially life-saving treatment  Use LOW DOSE antipsychotic agents  Remember: haloperidol and other antipsychotics have side effects – Anticholinergic – Orthostatic hypotension – Extrapyramidal side effects and acute dystonias – Can prolong the QT interval

18. Management: Hyperactive, Agitated Delirium  Avoid pharmacologic or physical restraints  If absolutely necessary, use haloperidol (IV, IM, or PO) – For mild delirium: 0.25-0.5 mg PO or 0.125- 0.25 mg IV/IM – For severe delirium: 0.5-1 mg IV/IM repeated every 30 min until patient is calm (total dose = loading dose)

19. Key Points about Antipsychotic Use  Patients who have never been exposed to haloperidol or antipsychotics in the past will usually only need less than 5 mg as a total loading dose  If patient is willing to take PO, try low doses of atypical antipsychotics such as olanzepine and risperidone – lower risk of extrapyramidal side effects than haloperidol

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. Can delirium be prevented?

23. YES! Prevention is possible.  Find patients who do not have delirium with 1-4 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)  Give them the following targeted interventions:

24. 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

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

26. Take Home Points: Delirium in the Elderly  A multifactorial syndrome arising from a patient’s 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  Try nonpharmacologic approaches first  Use low dose antipsychotics in severe cases  Avoid physical restraints

27. References and Resources  Inouye SK. Delirium in hospitalized older patients. Clinics in Geriatric Medicine.14(4):745-64, 1998.  American Psychiatric Association: Practice Guideline for the Treatment of Patients with Delirium, May 1999.  Inouye SK et al. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Based on Admission Characteristics. Ann Intern Med. 119:474-481, 1993.  Inouye SK et al. A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients. NEJM. 340(9): 669-76, 1999.  Delirium. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Teaching Slides. Volume 1, Fifth Edition. Blackwell Publishing, copyright American Geriatrics Society, 2003.  click here to end click here to end

28. Delirium is the diagnosis with an ICD-9 code  Because Mrs. Rivera’s MMSE is 22/30, it is possible that she may have dementia and that her agitation could be due to the “sundowning” phenomenon.  However, “sundowning” does not have an ICD-9 code.  Again, assume delirium until proven otherwise, as it may be the only manifestation of acute life- threatening illness in elders.  click here for the correct answer click here for the correct answer

29. Delirium is the diagnosis with an ICD-9 code.  Oftentimes, you will see Δ MS or acute mental status change written in chart notes.  However, these entities do not have ICD-9 codes.  Delirium has its own ICD-9 codes: – Delirium = 780.09 – Acute delirium = 293.0  click here for the next slide click here for the next slide

30. Correct answer.  Yes, this is delirium.  ICD-9 code = 780.09  click here for the next slide click here for the next slide

31. Initial evaluation should always include…  A complete history: including what medications were given prn during the last 24 hours.  A comprehensive physical exam: including vital signs, skin examination to look for pressure sores, and neurological and mental status examinations (i.e. CAM)  click here for the correct answer click here for the correct answer

32. Correct answer.  A head CT scan should be ordered only after you have obtained a history and done a physical exam of the delirious patient.  If the history is suggestive of a fall with possible head trauma, then a CT scan is warranted.  If the physical exam reveals focal neuro deficits, then a CT scan is appropriate.  click here for the next slide click here for the next slide

33. This test is appropriate to order.  For all delirious elderly patients, order a basic metabolic profile (sodium disorders, hypo- or hyperglycemia, hypercalcemia, and prerenal azotemia).  Given the likely presence of infection, checking a CBC is warranted.  Given Mrs. Rivera’s persistent fever and Foley catheter, check a UA and urine culture.  An EKG is appropriate given her risk factors for cardiac ischemia (HTN, age > 65).  click here for the correct answer click here for the correct answer

34. Correct answer.  Of the choices for testing, checking a TSH level is the least likely to yield an etiology given the time course of her symptoms.  Usually, cognitive changes of hypo- and hyperthyroidism worsen gradually over time.  click here for the next slide click here for the next slide

35. Nonpharmacologic measures should always be initiated first.  Since Mrs. Rivera is yelling out for her daughter, asking family members to stay with her might calm her down.  Does Mrs. Rivera really need the Foley catheter? Probably not, and it’s likely to be one source of her agitated delirium.  Sometimes placing agitated patients in cardiac chairs by the nursing station (without any physical restraints) can calm them down.  click here for the correct answer click here for the correct answer

36. Correct answer.  Pharmacologic and physical restraints are last-resort measures.  They should never be used before nonpharmacologic interventions are attempted.  click here for the next slide click here for the next slide

37. Avoid benzodiazepines  Mrs. Rivera is agitated now, not anxious.  Therefore, lorazepam is not the ideal medication choice.  Furthermore, 2 mg of lorazepam is too high an initial starting dose.  Remember: benzodiazepines increase falls risk in elderly patients (another reason to avoid this class of meds).  click here for the correct answer click here for the correct answer

38. Start low, go slow.  Haloperidol 5 mg is too large a dose to use in an elderly patient who is not accustomed to taking antipsychotic medications.  You are likely to make Mrs. Rivera quite lethargic with this dose.  click here for the correct answer click here for the correct answer

39. Correct answer.  Haloperidol 1 mg IV is a reasonable medication and dose to give at this time.  Because Mrs. Rivera has never taken antipsychotic medications in the past, a small dose of haloperidol will likely be sufficient to calm her down.  click here for the next slide click here for the next slide

40. End of Week 1 Module B