Delirium in the hospital

Report
Delirium
Susan Cox, DO
Chief Resident
July 2014
Goals
 Understand the different presentations of delirium
 Know the most common causes of delirium in the hospital
 Learn a diagnostic approach to the delirious patient
 Obtain skills to minimize and manage delirium in your
patients
Case 1
 Any elderly woman is admitted for sepsis secondary to UTI.
At baseline she has mild dementia, but is pleasant and
functional.Yesterday she was doing well. Today, hospital day
#4, she is talking to herself, and it is difficult to understand
what she is saying. She is anxious, yelling at you, and
repeatedly pulling at her clothes. She argues with the nursing
staff and refuses blood draws.
What is this patient displaying?
 Delirium
 Psychosis
 Dementia
 Depression with psychotic features
What is this patient displaying?
 Delirium
 Psychosis
 Dementia
 Depression with psychotic features
Delirium: DSM 5
 Disturbance in attention or cognition
 Acute onset
 Change from baseline
 Fluctuating severity
 Not fully explainable by chronic psychiatric disorder
 Level of impairment does not occur in the context of coma
Delirium: Confusion Assessment
Method (CAM)
1. Acute Onset and Fluctuating Course
2. Inattention
3. Disorganized thinking
4. Altered Level of consciousness
To diagnose delirium by CAM you need 1 and 2 with
either 3 or 4.
Epidemiology
 Delirium complicates at least 25% of all hospitalizations in
the elderly
Prevalence of delirium
100%
75%
50%
25%
0%
Community
Hospital
admission
Post-op
ICU
Fong et al 2009
Consequences
12 month mortality post-discharge
50%
Hospital length of stay (days)
20
40%
15
30%
10
20%
5
10%
0%
0
Control
Delirium
McCusker et al 2002
Control
Delirium
McCusker et al 2003
• In ONE THIRD of patients, it will take >8 weeks for delirium to completely
resolve
• Delirium can initiate a cascade of events that lead to functional decline, loss of
independence and death
Case 2
 An elderly man is on your team for a hip fracture. Previously
he was independent and active. He is POD #1 s/p ORIF and
you have not heard any calls from the RN overnight. On your
morning rounds, he is sleepy and falls asleep as you talk to
him.You return to his room at 2:00 PM and he is napping
again. He missed his breakfast and lunch because he was
asleep. He has not used any of his prn medications.
What is this patient displaying?
 Depression
 Status epilepticus
 Delirium
 He’s just tired
What is this patient displaying?
 Depression
 Status epilepticus
 Delirium
 He’s just tired
Types of delirium
Hyperactive
Restlessness, agitation, hallucinations, delusions
Hypoactive
Lethargy, sedation, responds slowly, little spontaneous movement
Mixed
Components of both
 More than half of elderly patients with delirium present with
hypoactive or mixed type
Fong et al
 Which ones do you get called about?
It’s up to you!
 You must have a high index of suspicion for delirium in your
elderly patients
 Remember, 25-80% of your patients will suffer from this
depending on your location in the hospital
 Most of the time they will just appear sleepy and the RN
won’t call you about it
 Do not normalize lethargy
 Delirium predicts your patient’s mortality
Delirium is a SYMPTOM
 That means you must recognize it and decide what is causing
it – NOT just treat it
 What are some of the causes of delirium in the hospital?
Causes of delirium
 Your patient brings along his/her own non-modifiable risk
factors
 Add an acute illness
 Add the stressful hospital environment
 Add medication side effects
Age >65
Kidney or
liver
disease
Physical
frailty
Patient
risk factors
Polypharmacy
Sensory
impairment
Dementia
Case 3 – What’s going on?
 An 86 year old man presents to the ER brought in by his son
because he is not responding appropriately for the last day.
He is inattentive and won’t follow commands. He keeps
asking for his wife; she died 15 years ago.
 On exam he appears frail and he has a hearing aid.
 His son doesn’t know his medications, but knows he takes 15
pills daily.
 You don’t have any labs back yet.
What is the cause of his delirium?
 WBC 15, Hgb 19, Plt 300k. 80% N, 10% Bands
 Sodium 153, K 4.3, Cl 105, CO2 15, BUN 30, Crt 1.9
 LFTs and coags normal
 Lactate 6
 UA 1.022 pH 5, 30WBC +nitrite +LE
Delirium in this patient
 Elderly
 Frail
 Polypharmacy
 Hypernatremia
 Severe sepsis secondary to UTI
Case 4 – What’s going on?
 You are the medicine inpatient consultant for the surgical
teams
 You receive a consult from orthopedics for “∆MS” – a 70 year
old female admitted for ankle fracture, POD #2 s/p ORIF is
now disoriented, climbing out of bed and pulling off her
splint.
What is the cause of her delirium?
 Her medications are:
 Metoprolol 25mg PO BID
 Lisinopril 10mg PO Qday
 Lasix 10mg PO daily
 Oxybutynin 5mg PO daily
 Ativan 0.5mg IVP Q2 prn agitation
 Benadryl 25mg PO QHS prn insomina
You see this on physical exam
Delirium in this patient
 >65 years old
 Post-op
 Polypharmacy
 Anticholinergic drugs
 Benadryl
 Scopolamine patch
 Oxybutynin
 Sedative hypnotics
 Ativan
Causes of delirium - organizing
 Categories
 Acronym
Causes of delirium
Metabolic
derangements
Infections
•
•
•
•
Sepsis
UTI, PNA, etc.
Meningitis
Encephalitis
Drugs
•
•
•
•
•
•
•
•
•
↑ ↓ Sodium
Hypercalcemia
Hypoglycemia
Uremia
Stress
↑ Ammonia
Hypovolemia
Hypercarbia
DKA
Lactic acidosis
Poor perfusion
•
•
•
•
Shock
Heart failure
MI
Hypoxia
Neurologic
Causes of delirium
Metabolic
derangements
Infections
•
•
•
•
Sepsis
UTI, PNA, etc.
Meningitis
Encephalitis
•
•
•
•
•
•
•
•
↑ ↓ Sodium
Hypercalcemia
Hypoglycemia
Uremia
Hepatic encephalopathy
Hypercarbia
DKA
Lactic acidosis
Poor perfusion
•
•
•
•
•
•
Hypoxia
Hypovolemia
Shock
Heart failure
MI
Ventricular arrhythmias
Causes of delirium
Drugs
•
•
•
•
•
•
Street drugs
Anticholinergics
Hypnotics
Psychotropics
Steroids
Analgesics
Stress
•
•
•
•
•
Post-op
Pain
Urinary retention
Constipation
Sleep deprivation
Neurologic
• Wernicke’s
encephalopathy
(↓ thiamine)
• Post-ictal state
• Intracranial hemorrhage
• Hypertensive
emergency
• Status epilepticus
• Ischemic stroke
Causes of delirium
 D Drugs
 E Eyes, ears
 L Low oxygen states (hypoxia, MI, stroke)
 I Infection
 R Retention of urine or stool
 I Ictal
 U Underhydration, undernutrition (hypoglycemia, thiamine
deficiency)
 M Metabolic
Uncovering the responsible illness
 There are dozens of causes of delirium!
 How do you approach a patient with delirium?
Recognize/identify it
2. Find the etiology
3. Treat the central cause
4. Manage patient symptoms
1.
Case 5
 You are the medicine night float. It is 3:00 AM.You are
covering 60 patients tonight.You get a page from the
med/surg RN. She says, “Doctor, Mr. Johnson is getting
agitated again. He’s trying to pull out his foley. Can we get a
prn ativan?”
 What do you do?
Uncovering the responsible illness
 History: Evaluate for: recent febrile illness, organ failure,
detailed medication list, alcohol or drug abuse
Case 5
 You review your signout
 80 year old male, diabetic, nursing home resident here for
decompensated heart failure and AKI, diuresing. HD day #4. He
has been NPO because of an ileus, not on any fluids because of
volume overload. His last labs were drawn 48 hours ago.
 Meds: Lasix 40mg IV BID, Coreg 6.25mg PO BID, Lisinopril
20mg PO daily, Lantus 10 units QHS, Heparin 5000units SQ BID
 What are you thinking?
 Now what?
Uncovering the responsible illness
 History: Evaluate for: recent febrile illness, organ failure,
detailed medication list, alcohol or drug abuse
 Physical Exam: Vitals, volume status, infection,
hyperventilation
 Jaundice, breath (smell of alcohol, ketones), tongue biting,
retinal hemorrhages, asterixis, myoclonus, nystagmus
Case 5
 38C, HR 99, BP 105/70, RR 22, O2 90% RA
 He is tachypneic, agitated, pulling at his foley
 JVD to jaw
 Crackles at bases
 2+ edema
 He has only diuresed 2 L since admission despite aggressive
lasix
 What are you thinking?
 Now what?
Case 5
 What is on your differential diagnosis?
 Hypoxia
 Hypoglycemia
 Infection / sepsis
 Uremia
 Hyponatremia
 Arrhythmias
 Heart failure
Uncovering the responsible illness













Accucheck
ABG
CXR
CBC
CMP
UA, urine culture
Blood cultures
EKG / cardiac enzymes
Utox
Ammonia
Drug levels (lithium, digoxin)
Lumbar puncture
Head CT
Case 5
pH
pCO2
pO2
7.37
33
55 on 4L NC
Blood glucose 122
Uncovering the responsible illness
 THE KEY POINTS:
 You must find out WHY the change occurred
 You then can address the primary issue and manage symptoms
 NUMBER ONE
 Is the change in mental status acutely life threatening?
Life threatening causes
UpToDate
Life threatening causes
 Hypoxia & Hypoglycemia
 Bedside testing
 Reverse with treatment
 Sepsis
 May present with fever or hypothermia
 Look for SIRS criteria
 Hypertensive Encephalopathy
 Diagnosis of exclusion
 Reduce blood pressure appropriately
Life threatening causes
 Wernicke’s Encephalopathy
 Uncommon
 Alcoholic or malnutritioned patients
 Tx: empirically with Thiamine (high dose, more than what is
inside a banana bag)
 Drug overdose (opiates, benzos, etc.)
 Remember ABC
 Poison control or medical toxicology for help
Life threatening causes
 Acute neurologic disorders
 Meningitis and subarachnoid hemorrhage
 Confusion, headache, or fever
 Acute or delayed CNS trauma
 Subdural hematoma
 Seizures
 Postictal state
 Some seizures may present without convulsions and persistent
confusion (status epilepticus)
Diagnostic approach
DELIRIUM
Adequate Oxygen and
Blood Glucose
YES
Fever or other
signs of
infections?
NO
Correct as needed
Determine cause
Diagnostic approach
Fever or other
signs of infection?
YES
NO
Do history and
physical exam
suggest likely cause
of altered behavior?
Search for source
YES
Pursue likely cause
NO
Diagnosis
Uncertain
Diagnostic approach
Diagnosis
Uncertain
Basic Testing:
CBC, Electrolytes, UA, ECG, CXR
Advanced testing or consulting as need:
ABG, EEG, head CT, tox screen, drug levels,
consults
Case 5
 Doctor, Mr. Johnson is awaiting his ICU bed. He is still
pulling at his foley. What do you want to order?
Preventing Complications
 Protect Airway – prevent aspiration
 If applicable, maintain volume with IVF if unable to take PO
 Maintain nutrition
 Prevent pressure sores with frequent mobilization
 Minimize unnecessary IV’s, NG tubes, foley catheters, etc.
Management of delirium
 Remember, you have to identify the cause
 Non-pharmacologic therapies are the best
 Bedside sitter
 Family involvement
 Normalize patient’s sleep/wake cycle – uninterrupted sleep at
night
 Music relaxation
 Hearing/visual aids
 Light during the day, dark at night (pull the blinds open!)
Management of delirium
 Avoid the following as much as possible:
 Physical restraints
 Pharmacological agents given increased risk for:
 Falls
 Death
If nonpharmacologic methods fail…
 Haldol: 0.5 – 1 mg PO
 Prolongs QT
 Extrapyramidal symptoms (>3mg/day)
 IV has short duration – AVOID IV USE
 Seroquel: 12.5mg – 25mg PO
 Prolongs QT
 Extrapyramidal symptoms
 Don’t use benzos unless it is for alcohol or benzo withdrawal
 Atypical and typical antipsychotics are not approved for dementia
related psychosis due to increased risk of death (black box warning)
Clues in Association
 Altered mental status + Diabetes
 Think of oral hypoglycemics, get an accucheck
 Altered mental status + Fever
 Think meningitis/encephalitis/UTI/PNA
 Altered mental status + Hypotension
 Think sepsis or inferior MI
 Altered mental status + Dyspnea
 Think hypoxia, pneumonia or MI/CHF
 Altered mental status + Hemiparesis or Dysarthria
 Think stroke
 Altered mental status + Failure to thrive
 Think metabolic derangements
 A 75-year-old woman with a history of COPD is evaluated in the
intensive care unit for delirium. She had a median sternotomy and
repair of an aortic dissection and was extubated uneventfully on
POD #4. Two days later she developed fluctuations in her mental
status and inattention. While still in the intensive care unit, she
became agitated, pulling at her lines, attempting to climb out of
bed, and asking to leave the hospital. Her arterial blood gas values
are normal. The patient has no history of alcohol abuse. The use of
frequent orientation cues, calm reassurance, and presence of
family members has done little to reduce the patient's agitated
behavior.
Q: Which of the following is the most appropriate therapy
for this patient's delirium?
A. Diphenhydramine
B. Haloperidol
C. Lorazepam
D. Propofol
 A 75-year-old woman with a history of chronic obstructive
pulmonary disease is evaluated in the intensive care unit for
delirium. She had a median sternotomy and repair of an aortic
dissection and was extubated uneventfully on postoperative day 4.
Two days later she developed fluctuations in her mental status and
inattention. While still in the intensive care unit, she became
agitated, pulling at her lines, attempting to climb out of bed, and
asking to leave the hospital. Her arterial blood gas values are
normal. The patient has no history of alcohol abuse. The use of
frequent orientation cues, calm reassurance, and presence of
family members has done little to reduce the patient's agitated
behavior.
Q: Which of the following is the most appropriate therapy
for this patient's delirium?
A. Diphenhydramine
B. Haloperidol
C. Lorazepam
D. Propofol
References
 Alagiakrishnan, K. C.A. Wiens. An approach to drug induced delirium in the elderly.
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Postgrad Med J 80: 388-393. 2004.
Fong, T.G. Delirium in elderly adults: diagnosis, prevention and treatment. Nat. Rev.
Neurol. 5, 210-220. 2009.
Huff, J.S. UpToDate: Evaluation of abnormal behavior in the emergency department.
2013.
McCusker, J., M. Cole, N. Dendukuri, L. Han, E. Belzile. The course of delirium in
older medial inpatients. J Gen Intern Med 18: 696-704. 2003.
McCusker, J. M. Cole, M. Abrahamowicz, F. Primeau, E. Belzile. Delirium predicts 12month mortality. Arch Intern Med 162:457-463. 2002.
Medical Knowledge Self-Assessment Program (MKSAP 15).
Schnieder, L.S., K.S. Dagerman, P. Insel. Risk of death with atypical antipsychotic drug
treatment for dementia; meta-analysis of randomized placebo-controlled trials. JAMA
19: 1934-1943. 2005.
Young, J and S.K. Inouye. Delirium in older people. BMJ. 334: 842-846. 2007.

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