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Delirium
Medical Emergencies SeriesInternal Medicine – July 2011
Royal Victoria Hospital – McGill U
J Verdon MD MSc FRCPC
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Scenario …NIGHT FLOAT
You are called at 5 am
82 y.o. women admitted for pneumonia
Nurse found her all a sudden agitated
Pulled her iv out
Not keeping her O2 on
What do you do???
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Confusion is not always Delirium!
ALL confused Older patients
Do NOT
NECESSARILY
have
DELIRIUM
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Confusion is not always Delirium!
It could be a
SHOCK Stroke Encephalitis / meningitis Seizure & Post ictal Dementia with behavior disturbance Speech or hearing impairment
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Delirium in NOT normal ….
URBAN LEGEND: It is normal to be confused
when you are older…
They won’t remember anyways
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The Problem with delirium…
it is often missed • BUT easy to screen
there is no ‘deliriumin’ level• BUT excellent criteria!
it is hard to treat • BUT treatable!
it is reversible anyways• BUT NOT ALWAYS!
It is mostly preventable• BUT prevention measures not taken!
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What you may learn about delirium..
Update on Management
Drugs & Delirium in ED
Delirium and Prognosis
Delirium is a lethal condition that needs attention
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Delirium Management
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Delirium is ……….?
A) problem with memory mainly
B) problem of agitation, tremor, hallucinations mainly
C) problem with attention mainly
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Delirium is ... ?
The A.D.D.
of older persons
Disturbance of consciousness with ATTENTION DEFICIT
Change in cognition or perceptual disturbance Develop over a short period Evidence that related to medical condition
• DSM IV -
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Delirium & neurochemical explanation:Cholinergic Buzz Theory
Cholinergic deficiency is most plausible
Dopaminergic and/or Noradrenergic imbalance may give different types of delirium
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Delirium: Who is at risk?
Patients with , severe illness, cognitive
impairment, Dehydration, impaired vision
are more likely to develop delirium
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Delirium: What triggers it!
Metabolic derangement
Change in environment, use of restraints & catheter
Rx, Rx, Rx
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Who is at risk x what we do = DELIRIUM or NO DELIRIUM
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Delirium: think about it! look for it!
THE MORE
YOU’LL LOOK,
THE MORE
YOU’LL FIND!!!
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How could I manage delirium
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What about getting the history for delirium….
History limited with patient ASK for PAIN ASK the nurse or room mates
History hard to get from family 90% undiagnosed MCI or mild dementia Look for change from baseline
Concentrate on the Rx history New, change, accidental overdose, compliance
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How do I assess someone with delirium ?
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The ABC of Delirium Assessment
A - Airway B - Breathing C - Circulation
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The ABC of Delirium assessment
A - Airway aspiration, obstruction, O2 non compliant
B - Breathing pneumonia, pulm oed, PE
C - Circulation MI, tachy, low BP, shock
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and DEF of Delirium!
A - Airway B - Breathing C - Circulation
in DELIRIUM D - Drugs new, d/c, error, anticholinergic E - Electrolytes dehydration,glycemia,Na,Ca F - For the rest INFECTION, acute ischemia,
neurological problem
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Assessment of patient with delirium: DIFFICULT!
Exam limited and
often impossible
THINK ABOUT YOUR SAFETY & Get some help
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Delirium - STOP and OBSERVE !!!
HANDS OFF !
Before
The patient get their
HANDS ON YOU!
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Delirium - STOP and OBSERVE
Observe for
- Agitation – anxiety - Apathy- lethargy- Hallucination –
delusions- Main physical findings
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Focus your physical exam
Focus on
Vitals Sensorium, attention ask about PAIN! …….
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Focus your physical exam
then ; Lungs (& heart) Abdo (urin retention,
gallbladder, rebound) Limbs (swelling, skin, dvt) then, neuro if possible and
SAFE for you!
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What work-up to be done?
CBC SMA7 Glucose O2sat urine MINIMAL
CBC SMA7 Glucose LFT Trops Rx serum level Urine c&s ECG O2sat CXR
URGENT
CBC SMA7 Glucose LFT Trops Druglevel Urine c&s ECG O2sat CXR Ca Mg TSH B12 Folate
CT-head COMPLETE
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How do I treat Delirium?
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1- Tx acute conditions
REMEMBER:
There is USUALLY more than 1 acute condition causing delirium: If you only have 1 cause, you are missing 2 others! Look for and treat them ALL!
Try limiting the LINES: be inventive!
Don ’t forget retention, infection!
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2- Review and Simplify all Rx
Discontinue or taper all anticholinergic Rx
Substitute if necessary
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3- Institute the non pharmacological treatment
Sleep enhancement Reorientation Early mobilisation Compensation for
hearing, visual impairment
Hydration Safe environment
• Inouye, Cole
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DRUGS & DELIRIUM
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Rx are acommonly missed cause of delirium
A good internist MUST look for this!
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Famously unfamous delirium related prescriptions!
Drug withdrawal• Benzos, Rivotril,
Drug intoxication• Dilantin, Digoxin
Drug interaction
Over the counter• Benadryl• Gravol• Ranitidine
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Rx adjustmentare needed in delirium
A good internist knows this!
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Individualize the prescription!
STOP what needs to be stopped anticholinergic
RESTART what should not have been stopped Benzos,
ADJUST doses for WEIGHT and Renal Fx USE P.O. route, to avoid lines AVOID possible Rx interaction
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Delirium and Rx for symptoms
The internist survival kit!
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The urgent prescription!
Different options
Haldol 0.25-0.5mg po or im q6h prn + regular seroquel 12.5-25 mg po qHS
Or
Haldol 0.25-0.5mg po or im q6h prn + regular risperdal 0.25 mg bid po
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Treat Delirium symptoms
For Rx Tx as Tx for acute pain
REGULAR doses with some prn x 72 hours and r/a
Tx symptoms (psychosis, hallucin, or anxiety) with most appropriate PSYCH Rx
Tx small dose short acting benzos occasionnally
ALSO Tx PAIN with regular analgesics IMPORTANT
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Atypical Antipsychotics
Olanzapine(zyprexa) 2.5 mg qD ( also ZYDIS) up to 10 mg tot /day
Quietapine (seroquel) 12.5mg qHS to bid - up to 150 mg tot/day
Risperidone (risperdal) 0.25 mg daily up to 2 mg tot/day
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Delirium & Prognosis
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Delirium is lethal…
Delirium associated risk of mortality/ nursing home up to 3 months after discharge is…. increased by 2-3
O.R. for death/nursing home,adjusted for age, gender, apache score, functional status, dementia
at discharge; 2.1 (1.4-4)at 3 months; 2.6 (1.4-4.5)
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Delirium is a Medical Emergency!
Delirium can be easily diagnosed The more you’ll look, The more you’ll find
Look and Treat all causes and symptoms
Always think Rx!
Multidisciplinary approach makes a difference!
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References.
N Engl J Med Volume 340:669–676 1999. A multicomponent intervention to prevent delirium in hospitalized older patients. Inouye SK et al.
J Am Geriatr Soc Volume 48:1697–1706, 2000.The Hospital Elder Life Program: a model of care to prevent cognitive and functional decline in hospitalized older patients. Inouye SK et al
Cleveland Clinic Journal of medicine Volume 71(11): 890-896, 2004. A practical program for preventing delirium in hospitalized elderly patients. Inouye SK et al.
Journal of Psychosomatic Research Volume 65; 273–282, 2008. Drug treatment of delirium: Past, present and future.
Age and Ageing 2011; 40: 23–29. Which medications to avoid in people at risk of delirium: a systematic review.
JAMA. 2010;304(4):443-451. Dementia: A Meta-analysis Ann Intern Med. 2011;154:746-751. Guideline for Prevention of Delirium
THANK YOU