1. Delirium in the Older Adult Patient: Not Just Altered Mental Status Lisa R. Mack, MD, FACEP Assistant Professor Emergency Medicine Emory University, Atlanta, GA June 14, 2003 Georgia College of Emergency Physicians St. Simons Island, Georgia

2. Goal  For you to recognize delirium as a specific disease entity and to begin ruling it in or out in your patients with AMS

3. Objectives 1. Identify the 4 risk factors for delirium 2. Identify the 4 features of the CAM diagnostic algorithm and the criteria for diagnosing delirium 3. Identify the top 3 causes of delirium 4. State the pharmacological treatment for delirium

4. Delirium?  Case 1: Patient dozes off when you’re trying to talk to him…  Case 2: Mr. P. keeps picking at his bed clothes as you try to talk to him…  Case 3: The nurse asks you to prescribe something to stop Mrs. B from being agitated, but when you go in to see her she “looks fine”…

5. Definition  Older adult= age > 65  Delirium= A disturbance of consciousness and an acute change in cognition or perception  3 types:  Hyperactive (22-30%)  Hypoactive (24-26%)  Mixed (42-46%)

6. Why Important?  In 2000, a consensus panel identified delirium as 1of 3 target conditions for quality improvement in older patients*  Missed diagnosis in up to 67% of pts.  Up to 55% of ED patients*  Prevalence in ED is 9.6 % *  Bundled as “AMS” by ED physicians *Sloss, EM, et al. J Am Geriatric Soc. 2000 *Hustey, FM et al. Academic EM 2000 *Elie, M. Et al. CMAJ 2000

7. Why Important? cont.  Under-recognized as a disease entity  Case 1, 2, 3  Increased morbidity/mortality*  Increased costs  Majority of causes are reversible  Potentially preventable *Kakuma, R et al. J Am Ger Soc. April 2003

8. Prevention  1993 Inouye identified 4 independent and cumulative risk factors:  Vision impairment  Severe illness (APACHE II score <16)  Cognitive impairment  Dehydration

9. Prevention cont.  1999, Inouye et al NEJM: “ A multicomponent intervention to prevent delirium in hospitalized older patients.” -Delirium developed in 9.9% of interventional group vs 15% control -Improvement in cognition and reduction in use of sleep medication were significant -Delirium prevented, but no impact on severity or recurrence once it developed

10. What we know: *Intervention before onset reduces delirium* *A validated assessment tool exists (CAM); 95-100% sens.; 89-100% spec. + So why are we frequently missing the diagnosis? *Inouye, SK et al. NEJM 1999; AGS Mtg May 2003 few studies ongoing + Ely, EW et al.Crit Care Med 2001; Monette, J et al General Hosp Psych 2001

11. Barriers to diagnosis  Individual patient presentation  The presentation of severe illness in older people  Differential diagnosis  Vascular dementia may present w/acute cognitive decline  Hypoactive delirium may be mistaken for depression

12. The Diagnosis  Delirium is a clinical diagnosis  The criteria: Confusion Assessment Method (CAM) 1. Inattention 2. Acute onset and fluctuating symptoms 3. Altered level of consciousness 4. Disorganized thinking Must have 1 and 2 and either 3 or 4

13. Inattention  Inability to shift attention (Perseverance)  Inability to focus  Simple test:  Recite the days of the week backward  Digit span test (repeat 5 numbers forward without errors)

14. Acute onset/fluctuating  Sxs usually present for <2 weeks  May fluctuate over the course of minutes to hours (Ask caregiver)

15. Altered Level of Consciousness Hyperactive vs hypoactive  Alert (normal)  Vigilant  Lethargic (drowsy, but easily aroused)  Stupor  Coma

16. Disorganized Thinking  Rambling  Illogical conversation

17. Management 1. Recognize and treat the underlying cause 2. Modify the environment 3. Control the symptoms

18. Etiologies Top 3 causes: 1. Infection 2. Metabolic disturbances 3. Medications -anticholinergics -opiates

19. Etiologies cont.  AMI  CVA  Drug withdrawal The work-up therefore reflects the above: CBC, Chem, U/A, CXR, ECG, +CT scan, +Drug screen

20. Environment  Keeping patient oriented to time/place  Adequate lighting, routine sleep times  Involving friends/family

21. Symptom control  First-line treatment= Haloperidol  Least anticholinergic activity  Rapid onset  Dose: 0.25- 0.5 mg, max 5mg/24hr  BDZs= first-line tx in ETOH w/drawal  Lorazepam 0.25-1 mg, titrate

22. Symptom control cont.  Haloperidol plus lorazepam  Synergistic effect  Allows for lower doses of haloperidol and therefore reduced extrapyramidal effects Note: BDZs can actually cause a paradoxical reaction of agitation

23. Summary  Delirium is misdiagnosed in up to 55% of ED patients  The 4 risk factors of delirium are:  The 4 features of the CAM are:  The top 3 causes of delirium are:  The drugs used to control symptoms are:

24. Take Home Points  Delirium is not a just “AMS”  ED physicians need to recognize delirium as a distinct disease entity  ED physicians need to recognize risk factors for delirium to assist in prevention

25. Questions???