DELIRIUM

"An Old Word with a New Importance"

GOALS:

Introduce and describe delirium

OBJECTIVES:

The Student will be able to:

-define delirium

-describe the clinical presentation

-list the major causes and contributing factors to delirium.

-initiate prevention

-initiate management

by Ed Vandenberg MD Assist. Prof., Sec. of Geriatrics, UNMC

*********************************DELIRIUM*******************************

Definition: I-ACUTE ONSET, FLUCTUATING COURSE

II-ALTERED LEVEL OF CONSCIOUSNESS

(INATTENTION)

III-CHANGE IN COGNITION

examples: -MEMORY

-DISORIENTATION

-LANGUAGE

IV-HAS A MEDICAL CAUSE

DSM-IV

I-ACUTE ONSET, FLUCTUATING COURSE

-Symptoms develop over hours to days

(See graph contrasting dementia and delirium)

-Symptoms vary throughout the day ----(e.g."the sun-downer")

II-ALTERED LEVEL OF CONSCIOUSNESS

Main symptom-------- inattention

that is: -the inability to maintain focus,

-wandering speech and thought

-inability to shift focus at will..

(Includes both hyperactive and hypoactive inattention)

 

1

III-CHANGE IN COGNITION

This may manifest in all or one of the following areas

Memory-------------------Short Term Memory Dysfunction

Language------------------Language production

Orientation----------------Disorientation

Perception-----------------Delusions

How can I tell if it is Delirium or Dementia?

Symptom contrast: DELIRIUM versus DEMENTIA

FEATURE DELIRIUM DEMENTIA

ATTENTION SHORT, SHIFTING INTACT UNTIL LATE IN DZ.

COGNITION SUDDEN ALTERATION CHRONIC SLOW DECLINE (ALZHEIMERS)

STEP-WISE DECLINE

(VASCULAR)

CLINICAL COURSE FLUCTUATING STEADY OR STEP-WISE

DECLINE IV MEDICALLY CAUSED

MEDICALLY CAUSED (pathophysiology not well worked out)

Anatomy involved: cortical and subcortical structures and pathways

Pathophysiology:

Neurotransmitters associated with delirium

Acetylcholine : -decreased production in cerebral hypoxia or hypoglycemia

-cholinergic inhibition produces behavioral and EEG findings consistent with delirium.

Dopamine: -increased levels associated with delirium

- dopamine inhibitors reduce symptoms (Haldol)

Serotonin -increased levels associated with delirium

Other neurotransmitters associated with delirium:

-noradrenergic, GABA, opiate agonists, histamine.

Cytokines,

 

NO CLEAR PATHOPHYSIOLOGY TO HELP YOU REMEMBER OR TREAT

Evaluation focused on factors that can affect CNS function.

(You need a Memory device---- a mnemonic perhaps?)

Medical---e.g. DELIRIUMS (mnemonic)

 

D rugs

E motional

L ow PO2 states (MI, PE, anemia, CVA)

I nfection

R etention of urine or feces

I ctal states

U ndernutrition/underhydration

M etabolic (lytes, glucose, thyroid)

S ubdural (acute CNS processes)

Always add P ain

 

WHY IS DELIRIUM IMPORTANT ?

I. INCIDENCE

10-30% of elderly admissions to medical or surgical care ,,,,,,,,,

Additional: 5-30% of elderly develop delirium during hospitalization.

Total risk delirium during illness-------------15-60%

 

II. MORBIDITY: -prolonged hospital stay 11

-increased incidence of nursing home placement 11,12

-long term physical and cognitive effect 13,14,15

 

III. MORTALITY Delirium=1 month-14%, 6 month-22%

Controls= 1 month--5%, 6 month-10% 11

IV. COST ENORMOUS-!!!--estimates that if we could reduce

hospital days by one day of stays lengthen by delirium we

would save $1-$2 billion per year. 2

WHAT CAN WE DO? I. PREVENT

II. DIAGNOSE

III MANAGE

 

I. PREVENTION

We must identify the patients at risk before we can plan management to prevent and reduce symptoms.

Eddie 1998

A. Risk factors----------DEMENTIA

-hearing loss

-vision impairment

-severe illness

-dehydration

-advance age: ( >80 y.o).

-impaired physical function (measure by ADLíS)

-depression16

-chronic alcohol use

-liver disease with dysfunction

-hypothermia

-fractures--major joints

-drugs (How to know what to look for)

"No NAPS-Here"(The house officer caring for delirium GETS NO NAPS !!!)

-N saidís

-o piates

-N ausea (antiemetics)

-a nticholinergics

-P arkinsonian drugs

-s edative-hypnotics

-H-2 blockers (cimetidine,)

-e toh

-r hythm (antiarrhythmics & B-blockers)

-e pileptics (anticonvulsants)

 

Post -operative factors-----"in addition to the above"

-low cardiac output

-perioperative hypotension

-postoperative hypoxia

 

3

I. PREVENTION-continued

Hospitalization factors 16------physical restraints

-malnutrition

- >three medications

-bladder catheter

-iatrogenic event

"How can we prevent delirium"?

"Prevention uses the same management as treatment"

Does Prevention work?

Interventions in factors of: -cognitive impairment, -visual impairment,

- hearing impairment, -sleep deprivation,

- immobility, -dehydration.

Ėgave a significant reduction of primary delirium17

 

 

II. DIAGNOSIS

We donít do so good!!----missed the diagnosis. more that 50% of the time16,18,19,20

 

CRITERIA HISTORY EXAM

#1 ACUTE ONSET- interview----Collaborative sources

FLUCTUATING COURSE -nursing

-care givers

-family members

#2 ALTERED LEVEL OF establish baseline

CONSCIOUSNESS --- mental status serial mental work

main feature--INATTENTION WORLD-(MMSE)

or

Days of week

or

Months of the year

or

Serial 7's

#3 CHANGE IN COGNITION

Memory establish baseline

--memory 3 item recall (MMSE)

4

Disorientation

Usually: date, day, place

(From MMSE) Time- -year,

-season,

-date

- day

- month.

Place

-state

-county

-town/city

-hospital

-floor

Language -speech just listen!!!

(word searching or agnosia)

(rambling, incoherent)

Delusions "this is why nursing or family Still listen!!

will call in the first place"

 

#4 MEDICAL CAUSES: Most common etiologies/contributors (order does not imply incidence)

DELIRIUMS (mnemonic) + PAIN

 

FIRST STEP---History--looking for: -

A) Risk factors for causes

CLUES

D rugs (toxic & withdrawal)-------history and drug review

E motional------------------------------history

L ow PO2 states (MI, PE, anemia, CVA)

I nfection----------------------------catheter use, aspiration tendencies

R etention of urine or feces-------history, medications.

I ctal states---------------------------history

U ndernutrition/underhydrationĖrecent illness?

M etabolic (lytes, glucose, thyroid)--meds and medical problems

S ubdural (acute CNS processes)---mechanism of injury

P ain ----------------------------------source ? 5

B) Contributing factors

Hearing problems

Vision problems

SECOND STEP-----Physical exam-----full exam looking for "clues"

Looking for sources or evidence of:

-infection

-cardiac or pulmonary disturbance

-bowel or bladder dysfunction

-neurologic abnormalities

THIRD STEP----------Lab/imaging----choosing lab-----first------->basics

---remainder-->-problem/risk driven

Basic lab:---almost "knee-jerk"

-U.A. -SaO2

-Electrolytes -CBC

-Glucose -Creatinine/BUN

-CXR -EKG

Add the remainder of tests based on case

Problem/Risk Driven---------------------------------"release the hounds"

Diuretics, renal failure, laxatives-------Magnesium Cancers, renal failure--------------------Calcium

Liver disease-------------------------------AST, Ammonia

Copd, resp. Illness------------------------ABGís

Acidosis risk-------------------------------ABGís

Sepsis---------------------------------------- CBC, Cultures

Thyroid dz history-------------------------TSH

Drug use-------------------------------------Drug screens

Aids risk-------------------------------------HIV

Neuro. sx.ís,(localizing),or head trauma---CT/MRI

FOURTH STEP: "WHAT IF I CANíT FIND A CAUSE"

-Psychiatric ("the default diagnosis")

-Preexisting undiagnosed dementia (Lewey Body)

-Drug withdrawal

-If post-op blame the anesthesiologist.(joke!)

 

 

 

6

MANAGEMENT:

A) NON-PHARMACOLOGIC--------applies to both prevention and treatment

B) MEDICAL MANAGEMENT------applies to both prevention and treatment

C) PHARMACOLOGIC

D) FAMILY & LONG TERM MANAGEMENT

 

A) NON-PHARMACOLOGIC:

1) Interpersonal contact

2) Environment

3) Sensory enhancement

1) Interpersonal contact:

Nursing--Repetitive orientation

--Assist patient to establish sense of control

--Avoid "loose talk", medical jargon ---->confuses patient

--Consistent care givers

Family/friends

-enlist as "sitters"-------also gives opportunity to "forewarn" family

2) Environment:

-avoid restraints with "sitters"----"teach the family what to do"

-avoid two deliriums in same room

-orientation devices-- clocks and calenders

-auditory control---soft music, white noise, music pt. likes.

-visual control---soft lights, avoid delusional stimulation

-non-pharmacologic sleep assistance

Bedtime: (massage, warm milk, relaxing music)

3) Sensory enhancement

-vision---maximize==>eyeglasses, lighting, big print etc.

-hearing-maximize==>hearing aides, pocket talker, clean wax etc.

-immobility

- exercise of some kind during the day and when agitated

at night.

- minimize restrictive devices (catheters, restraints)

 

B) MEDICAL MANAGEMENT-

1) Correct all factors discovered in evaluation (see above)

2) Anticipation of problems (derived from risk factors)

3) Tight management of all factors.

D rugs (toxic & withdrawal)--------review drugs, drug use hx

E motional------------------------------diagnose, treat and support

L ow PO2 states (MI, PE, anemia, CVA)

I nfection-------------------------------prevention & screening

R etention of urine or feces-----------bowel & bladder hygiene

I ctal states

U ndernutrition/underhydration-------careful management

M etabolic (lytes, glucose, thyroid)--monitor and correct

S ubdural (acute CNS processes)

(Don/t forget "S kin Protection"

Pain-----suspect, diagnose and treat

"Grandma handles like a Mazerati"

Eddie--1997

C) PHARMACOLOGIC-

1) "Medical debridement"

"Ask not what drug you can add to your patient, but rather

what you can take away"

Eddie--1998

 

Look for --"No NAPS Here"--mnemonic to guide debridement

*N saidís   N ausea (antiemetics) H-2 blockers (cimetidine, ranitidine)

O piates    A nticholinergics          E toh

P arkinsonian drugs R hythm (antiarrhythmics, B-blockers)

S edative-hypnotics E pilepsy (anti-convulsants)

 

2) Behavior control

Guide==>: only medicate to control behaviors that:

-interfere with cares

-that indicate patient is distressed:---- by the behavior itself

-behavior is sign of distress from other etiology (pain, fear)

a)Medication choices

1st- decide stimulus

Pain?--------pain management with least CNS affective agent first and work to more toxic

Tylenol(scheduled dose p.o./p.r.)ŤNarcotics (oxycodone/M.S.)

(Avoid Demerol, Darvon and codiene)

Withdrawal-- use benzodiazapines

Lorazepam(iv,im,po), or oxazepam

Lorazepam:

0.5 mg q. 2-4 hrs. prn behavior that impairs care.

Fear and everything else---------Haldol (iv,im,po)

Haldol

Initial dosing-

Average-0.5 mg q 30 min. to control

"Industrial dosing"-

Start with 0.5 mg and double dose

q 30 mins until behavior controlled

behaviors that impair care..

 

Maintenance dosing:

-use Ĺ the total loading dose divided over the next 24 hours then begin tapering 12

-if needed long term switch to atypical

anti-psychotics (Resperidal, Zyprexa, etc)

D) FAMILY & LONG TERM MANAGEMENT

FAMILY AND FRIENDS

1) Prepare them for the worst from the beginning

-request support services for family early

2) "Overestimate" time course to allow planning 13

- engage social services early

3) "Plan for the worst and hope for the best"

10

DELIRIUM

(PEARL CARD)

DIAGNOSIC FEATURE SCREEN WITH

CRITERIA HISTORY EXAM

#1 Acute ,fluctuating -caregivers, family

course

#2 Altered L.O.C. -baseline m.s e.g. world

(Inattention) (forwrd & backword)

#3 Change in cognition -baseline s.t. -3 item recall

-memory memory

-language

-orientation -date, day, place

# 4 Medical cause

DELIRIUMS (mnemonic)

D rugs Labs:

E motional

L ow PO2 states (MI, PE, anemia, CVA) SaO2, EKG,enzymes?

I nfection -CXR, UA,CBC

R etention of urine or feces

I ctal states -EEG?

U ndernutrition/underhydration

M etabolic -lytes, BG, cr/Bun, Ca, PCo2

S ubdural (acute CNS processes) -CT, CSF?

 

add: P ain

 

 

 

 

 

 

 

 

 

 

*****PREVENTION & MANAGEMENT*****

Risk factorsl -DEMENTIA -severe illness

-hyothermia -fx major joints

- hypoxia -liver dz.

- age > 80 y.o. -alcohol

-hypotension

- decreased cardiac output

-impaired ADLís

-drugs (No Naps Here *)

Non-pharmacologic:

- nursing: -reorient

-consistent care givers

-sense of control)

- environment:

-lighting

- "sitters"

- auditory control

- augment vision & hearing

 

Pharmacologic

-withdrawal?--------lorazepam:

-0.5 -1.0 mg po or iv q 2-4 hrs, & PRN

-pain?---------------tylenol,--> narcotics (m.s.)

-all else-------------haldol--0.5 mg q. 30 min to control behav.

(If long term--->-atypical antipsychotics)

Long term plan

-prepare family /social work for prolonged recovery

*N saidís N ausea (antiemetics) H-2 blockers (cimetidine)

O piates A nticholinergics E toh

P arkinsonian drugs R hythm (antiarrhythmics, B-blockers) S edative-hypnotics E pilepsy (anti-convulsants)

2/27/00evv