Delirium in the ward

1. Delirium in the ward Rohan Gunathilake AT General Medicine

2. Case scenario • You are the evening RMO. • You have been asked to see a 84-year-old man on D2 post-elective R/TKR. • Nurses state that he is confused since 1800, spitting out his medications, yelling at the staff, and wandering in the ward.

3. Background • 84-year-old man • Lives with wife in a retirement village • Independent in ADLs • Admitted for elective R/ TKR

4. Background • Previous R/ PACI (2010) • Mild cognitive impairment • Hearing impairment • Stable CAD • Hypertension • T2DM (metformin) • OA • Alcohol 1-2 Units/day

5. Medications • Aspirin • Metoprolol • Perindopril + indapamide • Atorvastatin • Meformin • Vitamin D • Temazepam • Prophylactic SC heparin • Regular paracetamol, PRN Oxycodone

6. Physical Examination • Agitated but cooperative • Confused • Disoriented • Vitals P 104, BP 110/72, RR18, spO2 98 RA • Chest clear • Abdomen SNT • No focal neurology, pupils normal • Clean surgical wound • No DVT

7. Questions • What is the likely diagnosis? • What might be the cause? • What are his risk factors? • What investigations will you request? • How will you manage him? • What is his prognosis?

8. Delirium • Derived from Latin term meaning “off track” • Not a disease, but a syndrome with multiple causes that result in a similar constellation of symptoms • An acute syndrome characterized by altered attention, cognition and consciousness • May be the only sign of a serious medical illness in an older person

9. Clinical hall marks • Acute onset + Waxing and waning symptoms • ↓ Attention span • Disorganized thinking • Altered LOC

10. Incidence/ prevalence • Very common but is often not detected or misdiagnosed • Prevalence and incidence varies across patient populations and health care settings • Prevalent delirium 10 - 24% • Incident delirium up to 56% among older hospitalized patients

11. Risk factors for delirium • advanced age • dementia • Hx of delirium • neurological damage • functional disability • visual and hearing impairment • polypharmacy • psychoactive drugs • alcoholism • multiple / severe chronic medical conditions • dehydration • depression

12. Precipitating factors • Metabolic – hypoxaemia, hypoglycaemia, electrolyte & acid-base derangements • Infective – urinary tract infection, pneumonia, CNS infection • Structural – Cerebrovascular event, urinary retention • Toxic – drugs (incl. withdrawal) or poisons • Environmental – being in hospital or ICU, physical restraints, bladder catheter, multiple procedures, surgery, pain

13. Medications known to cause delirium • Anticholinergics • Antihistamines • Narcotics • Benzodiazepines • Antiparkinson agents • Digoxin • Lithium • Steriods

14. Risk factors & precipitating factors High Vulnerability High Low Level of insult Inouye SK, Charpentier PA, Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275(11): 852-7

15. Clinical features • Fluctuation of symptoms • Clouding of consciousness • Cognitive deficits (disorientation, inattention) • Psychomotor abnormalities: • floridly agitated, hyperactive • drowsy, hypoalert, quiet (Hypoactive delirium) • Sleep–wake cycle disturbance • Perceptual & thought disturbances (e.g. misinterpretations, illusions, hallucinations)

16. Diagnosis • Clinical features • Collateral history • Medication review • Focused physical exam • CAMI

17. Several instruments for evaluating delirium are available. • The Confusion Assessment Method (CAM) is used widely • It has reported sensitivity > 94% and specificity > 90%

19. Further Investigation • FBC • EUC, Ca++, LFTs • Random BSL • ECG, cardiac enzymes • CXR • Urinalysis • Brain imaging, CSF • Drug levels

20. Differential diagnosis • Dementia • Depression • Psychotic illness • Sun downing

22. Management of delirium • Delirium is best managed by clinicians with expertise in delirium management, and in most cases should involve a multidisciplinary team.

23. Components of delirium Mx • Identify the cause where possible • Correct the cause / precipitating factors • Manage the symptoms of delirium • Provide a supportive care environment • Prevent complications • Educate the patient and their carers

24. Non-pharmacological management: Environmental • Calm, comfortable environment • Lighting appropriate to time of day • Orientation cues – clock, calendar • Familiar objects or photographs from home • Encourage family and carer involvement • Remove hazards : low bed, secure facility • Avoid restraints (aggravate delirium, increase injuries ) • Avoid room changes

25. Non-pharmacological management: Nursing care-based • Use of staff with training in delirium care • One-on-one nursing where relevant • Same staff members to care for the patient during and across shifts • Minimize sensory deprivation • Validation and reality orientation strategies • Providing relaxation strategies to assist with sleep.

26. Multicomponent Mx of delirium symptoms

27. Pharmacological interventions • Cease/ ↓ drugs that cause delirium • Manage discomfort or pain • Regulation of bowel function • Drug therapy is reserved for patients who are at risk of harming self /others

28. Pharmacological interventions • Understudied area, with only a limited number of small trials; Very few data comparing different drugs • Even drugs that are used to treat delirium, particularly if given in excess, can prolong or worsen delirium.

29. Pharmacological interventions: antipsychotics • Antipsychotics are generally the 1st line (except in delirium tremens) • Start low and go slow (e.g. haloperidol 0.5 mg, risperidone 0.5 mg or olanzapine 2.5 mg) • Titrate dose, review periodically, monitor for oversedation • No clear evidence that atypical antipsychotics are more effective > typical • But have fewer extrapyramidal side effects

30. Pharmacological interventions: benzodiazepines • Benzodiazepines are the treatment of choice for delirium tremens & delirium associated with benzo- withdrawal • Geriatric patient populations are at greater risk of developing complications from benzo- use • Long acting benzo-s, in particular, have been shown to increase the risk of delirium.

31. Prognosis Delirium is associated with ↑adverse outcomes: • Mortality • Hospital mortality 25 - 33% • independent marker for mortality < 12 months after discharge (HR 2.11) • length of stay (x2) • Complications : falls, bed sores, incontinence • Cognitive and functional decline • Nursing home admission

32. Course • Delirium may be very persistent. • Unresolved delirium: • 60% after 1 week • 20% after 2 weeks • 15% after 4 weeks • 5% persists >4 weeks • Inattention, memory impairment and disorientation may be still present at up to 12 months.

33. Prevention strategies • Reorient and mobilise the patient • Reduce sensory deprivation • Ensure the patient is hydrated • Implement a non-pharmacologic sleep regimen • Limit catheters and restraints

34. Summary • Delirium is a common medical emergency, with ↑morbidity and mortality rates, affecting elderly. • Risk for delirium should be assessed in all older persons admitted to a health care setting. • Timely diagnosis, multicomponent intervention and judicious use of medications can improve outcomes. • Antipsychotics are reserved for patients with severe behavioral and psychological symptoms.

35. References • Caplan G. Managing delirium in older patients. AustPrescr 2011;34:16–18) • Inouye AK. Delirium in older persons. NEJM 2006;354: 1157-65 • Australian Society for Geriatric Medicine; Position Statement No.13 : Delirium in Older People (2005) • Delirium Clinical Guidelines Expert Working Group. Clinical Practice Guidelines for the Management of Delirium in Older People. (AHMAC 2006) • Inouye SK, Charpentier PA, Precipitating factors for delirium in hospitalized elderly persons. Predictive model and interrelationship with baseline vulnerability. JAMA 1996; 275(11): 852-7