CHAMP Delirium Part 2: Evaluation & Management

1. CHAMPDelirium Part 2:Evaluation & Management Andrea Bial, M.D. University of Chicago

2. Goals • Develop a plan for teaching a Systematic Approach to the Evaluation of hospitalized older patient with delirium. • Develop a plan for teaching an appropriate Treatment Plan for the hospitalized older patient with delirium

3. Overnight Events: Morning Rounds at the Bedside • 75yo W admit 2d ago w/ COPD, bronchitis • Intern reports: o/n she pulled out her IV, thought she was at home • X-cover ordered Prosom 1mg & po abx

4. Overnight, cont’d • Currently, pt w/o c/o. Doesn’t recall events of previous night. • PE: sleepy, arouseable 37.6 148/62 88 20 93%2L Lungs w/ faint wheeze bilat Rest w/o change Labs WBC 13.2, diff P; H/H stable Na 133, BUN 26, Cr 1.2

5. Overnight, cont’d • A/P #1) COPD—cont nebs, steroids, po abx #2) HTN—stable on meds #3) Confusion—add risperdal 1mg QHS prn #4) Disp—await PT/OT

6. Systematic Approach to the Evaluation of Delirium • No one “gold standard” approach • Multiple Mnemonics (e.g., Delirium) & algorithms • Need individualized, systematic approach to avoid missing potential causes • Few studies exist specifically looking at causes

7. Evaluation of Delirium: Causes • Francis (1990) • Large teaching hospital • General medicine patients (n=229) • Delirium developed in 22% (n=50) • Determined cause(s) as: definite, probable, or possible • 18 (36%) w/ one definite cause (Drug toxicity, then infection=fluid/lyte imbalance) • 10 (20%) w/ one probable cause • 22 (44%) w/ >1 cause; 62 possible etiologies (2.8/pt)

10. Evaluation: Dementia Teaching Points • Hx of dementia? • Hx of sundowning? • Agitated dementia ≠ delirium 4. Importance of considering dx: DEMENTIA DELIRIUM

11. Evaluation: Physical Exam • Head to toe: • Vitals (temp, HR, RR, BP, pulse ox, pain) • Head (CVA, bleed, meningitis, sz, blind, deaf) • Lung (pneumonia, PE, CHF) • Chest (ischemia, CHF, arrhythmia) • Abd (ischemia, impaction, bleed) • GU (UTI, retention) • Extrem (pain, volume status, CVA) • Skin (pressure ulcer, volume status)

12. Evaluation: Head CT? • No evidence to support routine ordering • Order if: • new focal finding(s) on exam • head trauma • suspicion of encephalitis • no other identifiable causes found

13. Evaluation: Medication Review • Too little (alcohol or other drug w/d) • Francis (1990) 1/50pts (2%) • Lawlor (2000) 4/71pts (6%) • Too much • narcotics, neuroleptics, anticholinergics, antiemetics Francis 1990, Schor 1992, Lawlor 2000

14. Evaluation: Medication List • Antibiotics (aminogly, PCN, ceph, sulfa) • Benadryl • Benzodiazepines (triazolam, alprazolam, diazepam) • Digoxin • GI (Reglan, Bentyl) • Lithium • Narcotics • Neuroleptics • Steroids • NSAIDs (Indocin) • H2 Blockers (Cimetidine,…) • Parkinsons drugs (Levodopa, Benztropine, Amantadine) • Tricyclics

15. Evaluation: Medication List • Antibiotics (aminogly, PCN, ceph, sulfa) • Benadryl • Benzodiazepines (triazolam, alprazolam, diazepam) • Digoxin • GI (Reglan, Bentyl) • Lithium • Narcotics • Neuroleptics • Steroids • NSAIDs (Indocin) • H2 Blockers (Cimetidine,…) • Parkinsons drugs (Levodopa, Benztropine, Amantadine) • Tricyclics

16. Evaluation: Medications, cont’d Anticholinergic properties frequently overlooked: Elavil (amitriptyline) Flexeril (cyclobenzaprine) Cogentin (benztropine) Atarax/Vistaril(hydroxyzine) Bentyl (dicyclomine) Welbutrin/Zyban (bupropion) Ditropan (oxybutynin) Antivert (meclizine) Detrol (tolterodine) Ipratropium (atrovent) Benadryl (diphenhydramine) Phenergan (promethazine) Zyprexa (olanzapine) Atropine Levsin (hyoscyamine) Quinidine

17. Evaluation: Additional tests • Labs • CBC, lytes, liver, renal • Consider TSH, B12, cortisol, ammonia, abg • Drug levels (digoxin, etc) • Urine tox, UA • CXR • EKG • EEG

18. Evaluation: EEG • Since 1950’s, recommendations for EEGs • Usually: generalized slowing • Sensitivity 75%

19. Management: Non-Pharmacologic • Cognition: orientation board (carry pen!) & open drapes during day • Sleep: minimize deprivation (no 2am labs, no o/n BS/vitals if able, give meds when awake) • Mobility: OOBchair asap, PT/OT, no foley/restraints • Vision: glasses • HOH: get aids; adapt environment; stethoscope trick • Dehydration: po fluids; observe at mealtime; avoid “Boost at nightstand” • Observation: Involve family (rotate members) or get sitter; move pt to room close to RN station

20. Management: Non-Pharmacologic Restraint Use • Avoid whenever possible • Increase risk of falls, injury, & delirium • Use only in emergency, for as short a duration as possible with frequent re-evaluations, and d/c asap • Absolutely no “sheeting”

21. Management: Pharmacologic • No RCT of treating delirium in hosp pt • Extrapolation from other populations studied (AIDS, NHs, outpatient AD, …) • See Table in handout

22. Management: Pharmacologic Antipsychotics Typical: Haldol, (Chlorpromazine) Advantages:min sedating less ↓BP Disadvantages: ↑ sz risk more EPS side effects ↑ QT ↑ risk of Torsades Dose: 0.25-0.5mg po, IM, IV can repeat 30 mins x1, then q4h t1/2=21h (10-38); peak 4-6h (IV not FDA-approved; short duration of action)APA 1999

23. Management: Pharmacologic Antipsychotics, cont’d Atypical Antipsychotics Advantages: less EPS +/- sedation Disadvantages: ↓ BP weight gain ↑ BS no evidence: short-term ↑mx (infection, CVS)

24. Management: Pharmacologic Antipsychotics, cont’d Atypical Antipsychotic Doses: Risperidone: 0.25-0.5mg po bid t1/2=20-30h Olanzapine/Zyprexa: 2.5-5mg po qd t1/2=30 (21-54h) Quetiapine/Seroquel: 25mg po bid t1/2=6h (better in PD pts)

25. Management: Pharmacologic Benzodiazepines Used best in w/d of EtOH or benzo’s (also consider use in PD, NMS) Lorazepam 0.5-1mg po, IM, IV q4-6 t1/2=12h (no adjustment needed for liver or renal dz)

26. Management: Pharmacologic Bottom Line • Try to avoid meds, but if needed: • Use Haldol in acute settings • Use risperidone for regular use (unless PD: quetiapine) • Use lorazepam for w/d

27. Back to case! • 75yo W admit 2d ago w/ COPD, bronchitis • Intern reports: o/n she pulled out her IV, thought she was a home • X-cover ordered Prosom 1mg & po abx • Currently, pt w/o c/o. Doesn’t recall events of previous night. • PE: sleepy, arouseable 37.6 148/62 88 20 93%2L Lungs w/ faint wheeze bilat Rest w/o change Labs WBC 13.2, diff P; H/H stable Na 133, BUN 26, Cr 1.2 • A/P #1) COPD—cont nebs, steroids, po abx #2) HTN—stable on meds #3) Confusion—add risperdal 1mg QHS prn #3) Disp—await PT/OT

28. Teaching Points • Ask: What do you think caused last night’s events? • Was a h/o dementia missed? (dementia/delirium relationship; role of MMSE; further family hx) • Was her PE different at the time x-cover was called? (systematic evaluation/head-to-toe) • Did we start or alter dose of any medications? (nebs, steroids, abx)

29. Teaching Points, cont’d • Ask: Is she delirious now? • Discuss use of CAM (comfort of tool; dx of delirium in chart) • Discuss outcomes of delirium (increases: LOS, healthcare costs, mx, d/c to LTCF) • Discuss use of Prosom (and other benzo’s) in delirium

30. Teaching Points, cont’d • Ask: Is there anything we should do today to follow-up on her confusion? • Discuss further studies that may or may not be needed (CXR? UA? Repeat Na?) • Discuss the non-pharmacologic measures that should be put into place (orient board, fluids, mobility, drapes, HS nebs & labs) • Discuss use of risperidone (and other antipsychotics) in delirium

31. Recommended Reading • Inouye SK. Delirium in older persons. NEJM 2006;354:1157-65 • Schneider LS et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. NEJM 2006;355:1525-38. • Sink KM et al. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA 2005;293:596-608.