長照體系內譫妄症長照體系內譫妄症的評估與處置的評估與處置

台大醫院老年醫學部台大醫院老年醫學部陳人豪陳人豪

8/23/20148/23/2014

課程內容課程內容• 譫妄症譫妄症 (delirium)(delirium)

– – 流行病學流行病學 – – 致病機轉與病因致病機轉與病因

– – 診斷與評估診斷與評估 – – 預防與治療預防與治療

• 長照體系內譫妄症長照體系內譫妄症

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譫妄症譫妄症• 注意力和急性認知功能障礙的一種症候群注意力和急性認知功能障礙的一種症候群 – – 急性混亂狀態急性混亂狀態 (acute confusional state)(acute confusional state) – – 典型的多因性典型的多因性 (( 如同其他老年病症候群如同其他老年病症候群 ))

• 在臨床上常被忽略在臨床上常被忽略

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譫妄症的流行病學譫妄症的流行病學• 老年人譫妄症老年人譫妄症 – – 社區盛行率社區盛行率 : 1-2%: 1-2% – – 在急診的盛行率在急診的盛行率 : 1/3: 1/3 (( 但但 2/32/3 被忽略被忽略 )) – – 在入住院時的盛行率在入住院時的盛行率 : 14-24%: 14-24% – – 住院中的發生率住院中的發生率 : 6-56%: 6-56% – – 手術後的發生率手術後的發生率 : 15-53%: 15-53% – – 加護病房的發生率加護病房的發生率 : 70-87%: 70-87% – – 護理之家護理之家 // 急性後期照護急性後期照護 : : 可高達可高達 60%60%

Inouye SK. N Engl J Med. 2006;354(11):1157-1165.Inouye SK. N Engl J Med. 2006;354(11):1157-1165.4

譫妄症的預後譫妄症的預後• 急性後期機構急性後期機構 – – 入住時的盛行率入住時的盛行率 : 23%;: 23%; 其中其中 14%14% 會完全恢復會完全恢復 – – 入住後入住後 11 個月仍有譫妄症個月仍有譫妄症 : 51%: 51%

• 健康指標健康指標 (health outcome)(health outcome) – – 有譫妄症的住院病人有譫妄症的住院病人 : : 入住護理之家入住護理之家 – – 急性後期機構病人急性後期機構病人 : : 日常生活功能恢復較差日常生活功能恢復較差 – – 急性後期機構病人急性後期機構病人 : : 併發症或再住院併發症或再住院 – – 死亡率死亡率

Lyons WL. J Am Med Dir Assoc. 2006;7(4):254–261.Lyons WL. J Am Med Dir Assoc. 2006;7(4):254–261.5

「精神疾病診斷與統計手冊第五「精神疾病診斷與統計手冊第五版」診斷準則版」診斷準則

A.A. 注意力 注意力 (( 引導、集中、維持及轉移能力降低引導、集中、維持及轉移能力降低 )) 及清醒及清醒度度 (( 對環境的定向力變差對環境的定向力變差 )) 的障礙的障礙

B.B. 該障礙在短時間內發展該障礙在短時間內發展 (( 通常是幾個小時到幾天通常是幾個小時到幾天 ) ) ，，表現出與之前在注意力與清醒度上的改變，且傾向在表現出與之前在注意力與清醒度上的改變，且傾向在2424 小時內呈現起伏的病程表現小時內呈現起伏的病程表現

C.C. 認知功能障礙（例如：記憶力缺損、無定向感、及語認知功能障礙（例如：記憶力缺損、無定向感、及語言障礙、視覺空間能力或感官功能障礙言障礙、視覺空間能力或感官功能障礙 ))

D.D. AA 、、 CC 的障礙無法以已有的神經認知症的障礙無法以已有的神經認知症(neurocognitive disorder)(neurocognitive disorder) 來解釋，且並非發生在清醒來解釋，且並非發生在清醒程度嚴重變差程度嚴重變差 (( 例如：昏迷例如：昏迷 ))

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E.E. 從病史、理學檢查及實驗室檢查的結果顯示，該障礙從病史、理學檢查及實驗室檢查的結果顯示，該障礙是由內科疾病、物質中毒或戒斷，暴露到毒素、或多是由內科疾病、物質中毒或戒斷，暴露到毒素、或多重病因所造成重病因所造成

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「混亂評估法」「混亂評估法」 (Confusion (Confusion Assessment Method, CAM)Assessment Method, CAM)

• 由美國精神醫學會出版之「精神疾病診斷與統計手冊第由美國精神醫學會出版之「精神疾病診斷與統計手冊第三版的修正版」發展出來篩檢譫妄症的工具三版的修正版」發展出來篩檢譫妄症的工具

• 包括四個要件，病患一定要符合前兩個要件加上至少第包括四個要件，病患一定要符合前兩個要件加上至少第三或第四個要件其中之一，才能診斷譫妄症：三或第四個要件其中之一，才能診斷譫妄症：1.1. 急性發作的症狀且其病程時好時壞急性發作的症狀且其病程時好時壞2.2. 注意力不集中注意力不集中3.3. 無組織的思考無組織的思考4.4. 意識障礙意識障礙

• 敏感度敏感度 : 0.94-1.0: 0.94-1.0 ，特異度，特異度 :: 0.90-0.950.90-0.95

Inouye SK, et al. Ann Intern Med. 1990:113(12):941-948Inouye SK, et al. Ann Intern Med. 1990:113(12):941-948..8

譫妄症的嚴重度譫妄症的嚴重度• 混亂評估法混亂評估法 -- 嚴重度嚴重度 (( 短 表短 表 ))(CAM-Severity (CAM-S) (CAM-Severity (CAM-S)

short form)short form)1.1. 急性發作的症狀且其病程時好時壞急性發作的症狀且其病程時好時壞 (( 無無 : 0; : 0; 有有 :: 1)1)2.2. 注意力不集中注意力不集中 (( 無無 : 0; : 0; 輕微輕微 :: 1; 1; 顯著顯著 : 2): 2)3.3. 無組織的思考無組織的思考 (( 無無 : 0; : 0; 輕微輕微 :: 1; 1; 顯著顯著 : 2): 2)4.4. 意識障礙意識障礙 (( 無無 : 0; : 0; 輕微輕微 :: 1; 1; 顯著顯著 : 2): 2) – – 總分總分 : 0-7: 0-7

• Four different risk groups: None: 0, Low (mild): 1, Four different risk groups: None: 0, Low (mild): 1, Moderate: 2, High (severe): 3-7 pointsModerate: 2, High (severe): 3-7 points

Inouye SK. Ann Intern Med. 2014;160(8):526-533.Inouye SK. Ann Intern Med. 2014;160(8):526-533.9

譫妄症的臨床表現譫妄症的臨床表現

可依可依精神活動型態分成四型精神活動型態分成四型• 高活動型高活動型 (hyperactive)(hyperactive)

–– 躁動躁動 (agitation)(agitation) 、增加警戒狀態、增加警戒狀態 (vigilance)(vigilance) –– 較易被察覺、較低的死亡率較易被察覺、較低的死亡率

• 低活動型低活動型 (hypoactive)(hypoactive) ：：最常見最常見 – – 嗜睡、精神活動功能減低嗜睡、精神活動功能減低 – – 不易被察覺，常被忽略或誤診，或被不適當治療不易被察覺，常被忽略或誤診，或被不適當治療 – – 預後較差預後較差

• 混合型混合型 (mixed)(mixed) – – 表現上具有上述兩種形式的譫妄症表現上具有上述兩種形式的譫妄症

• 正常型正常型Liptzin B, et al. Liptzin B, et al. Br J Psychiatry. 1992;161:843-Br J Psychiatry. 1992;161:843-848455..

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致病機轉致病機轉• 十分複雜，至今仍不是很清楚十分複雜，至今仍不是很清楚• 並無最後共通途徑，可能由數個病理機轉相互連結並無最後共通途徑，可能由數個病理機轉相互連結 –– 神經傳導物質調控異常神經傳導物質調控異常 (neurotransmitter disturbance)(neurotransmitter disturbance)

膽鹼缺乏膽鹼缺乏 (acetylcholine deficiency)(acetylcholine deficiency) 多巴胺多巴胺 (dopamine) (dopamine) 血清素血清素 (serotonin)(serotonin), γ-, γ-胺基酪酸胺基酪酸 (GABA)(GABA)

–– 壓力引起下視丘壓力引起下視丘 --腦垂腺腦垂腺 --腎上腺軸過度活動腎上腺軸過度活動 (stress (stress related hypothalamic-pituitary-adrenal axis related hypothalamic-pituitary-adrenal axis

overactivity)overactivity)• 細胞激素細胞激素 (cytokine) (cytokine) • 血漿酯酶血漿酯酶 (esterase)(esterase) 活性降低活性降低

Young J, et al. BMJ. 2007;334(7598):842-846.Young J, et al. BMJ. 2007;334(7598):842-846.11

前置因子前置因子 (Predisposing factor)(Predisposing factor)

• 認知功能障礙認知功能障礙 // 失智症失智症• 多重疾病 多重疾病 • 功能障礙 功能障礙 • 年紀大 年紀大 • 慢性腎臟病慢性腎臟病

• 營養不良營養不良• 血清白蛋白偏低血清白蛋白偏低• 憂鬱症憂鬱症• 知覺障礙知覺障礙• 物質濫用史物質濫用史

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誘發因子誘發因子 (Precipitating factor)(Precipitating factor)

• 藥物及藥物改變藥物及藥物改變 (( 包括停包括停藥藥 ))

• 並發的各種疾病並發的各種疾病• 電解質失調 或代謝異常電解質失調 或代謝異常• 手術手術• 疼痛控制不佳疼痛控制不佳

• 中風中風• 感染感染• 留置管留置管• 約束 約束 • 酗酒或娛樂性藥物的使酗酒或娛樂性藥物的使用用

• 重大精神社會壓力源重大精神社會壓力源

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譫妄症：多因性模式譫妄症：多因性模式

Hazzard’s geriatric medicine and gerontology, 6th Ed.Hazzard’s geriatric medicine and gerontology, 6th Ed.14

造成譫妄症的原因造成譫妄症的原因• 藥物藥物 ((DDrugs)rugs)• 電解質失調電解質失調 ((EElectrolytes)lectrolytes)• 藥物戒斷藥物戒斷 ((LLack of drugs)ack of drugs)• 感染感染 ((IInfections)nfections)• 感覺輸入減少感覺輸入減少 ((RReduced sensory input): educed sensory input): 失明、失聰、失明、失聰、

環境昏暗環境昏暗• 顱內疾病顱內疾病 ((IIntracranial disorder): ntracranial disorder): 中風、腦膜炎、癲中風、腦膜炎、癲癇癇

• 尿滯留及糞石箝塞尿滯留及糞石箝塞 ((UUrinary retention, fecal impaction)rinary retention, fecal impaction)• 心臟疾病心臟疾病 ((MMyocardial): yocardial): 心肌梗塞、心律不整、心衰竭心肌梗塞、心律不整、心衰竭

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譫妄症的評估譫妄症的評估• 確立診斷確立診斷 –– 鑑別診斷鑑別診斷 : : 譫妄症、失智症、憂鬱症譫妄症、失智症、憂鬱症 –– 失智症是譫妄症的危險因子，反之亦然失智症是譫妄症的危險因子，反之亦然

• 確立可能造成譫妄症的原因，及會造成立即生命危險確立可能造成譫妄症的原因，及會造成立即生命危險的病因的病因

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Evaluation: Medical HistoryEvaluation: Medical History

• Baseline level of functionBaseline level of function• Changes in mental statusChanges in mental status• History for identifying acute organic illnessesHistory for identifying acute organic illnesses• Drug reviews, including alcohol, benzodiazepineDrug reviews, including alcohol, benzodiazepine• Social habitsSocial habits• Review of systemsReview of systems

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Evaluation: Physical ExaminationEvaluation: Physical Examination

• Vital signs and oxygen saturationVital signs and oxygen saturation• General medical evaluationGeneral medical evaluation

– – Signs of infectionsSigns of infections – – Signs of organ failureSigns of organ failure – – Suprapubic and rectal examinationSuprapubic and rectal examination

• Neurological examinationNeurological examination – – Mental status examinationMental status examination – – Speech, thought, perception, activitySpeech, thought, perception, activity

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Evaluation: Laboratory TestsEvaluation: Laboratory Tests

For most patients:For most patients: – – CBC, blood sugar, renal and liver function tests, CBC, blood sugar, renal and liver function tests,

electrolytes (Na, Ca), urinalysis, chest x-rayelectrolytes (Na, Ca), urinalysis, chest x-ray – – Consider ECG, cardiac enzymes, TSH, ABG, drug levels, Consider ECG, cardiac enzymes, TSH, ABG, drug levels,

vitamin Bvitamin B1212

For selected patients:For selected patients: – – Neuroimaging: head trauma or new focal neurologic Neuroimaging: head trauma or new focal neurologic

findingsfindings – – EEG and CSF study: seizure or signs of meningitisEEG and CSF study: seizure or signs of meningitis

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Principles of ManagementPrinciples of Management

• Management of delirium requiresManagement of delirium requires – – Interdisciplinary effort by doctors, nurses, familyInterdisciplinary effort by doctors, nurses, family – – Multifactorial approach because delirium usually Multifactorial approach because delirium usually

results from concurrent multiple factorsresults from concurrent multiple factors – – Correction of all reversible contribution factorsCorrection of all reversible contribution factors – – Avoidance of new precipitantsAvoidance of new precipitants

• Identify and treat predisposing and precipitating Identify and treat predisposing and precipitating factors promptlyfactors promptly

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• Avoid complications of deliriumAvoid complications of delirium – – Remove unnecessary indwelling devicesRemove unnecessary indwelling devices – – Monitor bowel and urinary outputMonitor bowel and urinary output – – Achieve proper sleep hygiene and avoid sedativesAchieve proper sleep hygiene and avoid sedatives – – Monitor for nosocomial complications, including Monitor for nosocomial complications, including

aspiration, pressure sores, UTIaspiration, pressure sores, UTI• Optimize medication regimenOptimize medication regimen

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Nonpharmacologic StrategiesNonpharmacologic Strategies

• EnvironmentEnvironment – – Provide quiet, well-fit surroundingsProvide quiet, well-fit surroundings – – Provide orienting stimuli (e.g., clocks, calendar, Provide orienting stimuli (e.g., clocks, calendar,

familiar objects)familiar objects) – – Encourage family involvementEncourage family involvement – – Provide regular reorienting communicationProvide regular reorienting communication – – Limit room and staff changesLimit room and staff changes

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• Activities during daytimeActivities during daytime – – Cognitive activitiesCognitive activities – – Encourage early mobilization and rehabilitationEncourage early mobilization and rehabilitation

• Correct sensory deficits: eyeglasses, lighting, hearing Correct sensory deficits: eyeglasses, lighting, hearing aids or cerumen removalaids or cerumen removal

• SleepSleep – – Provide uninterrupted sleep time at nightProvide uninterrupted sleep time at night – – Normalize sleep-wake cycleNormalize sleep-wake cycle

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• Prevent dehydrationPrevent dehydration – – Adequate intake of nutrition and fluidsAdequate intake of nutrition and fluids – – Feeding by hand if necessaryFeeding by hand if necessary

• Use sittersUse sitters• Avoid use of restraints and urinary cathetersAvoid use of restraints and urinary catheters• Avoid psychoactive drugsAvoid psychoactive drugs

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Pharmacologic StrategiesPharmacologic Strategies

• Remove offending and unnecessary drugsRemove offending and unnecessary drugs• Reserve for patients at risk for interruption of essential Reserve for patients at risk for interruption of essential

medical care or patients who pose safety hazard to medical care or patients who pose safety hazard to themselves or staffthemselves or staff

• Start low doses and adjust until effect achievedStart low doses and adjust until effect achieved• Maintain effective dose for 2–3 daysMaintain effective dose for 2–3 days

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Typical AntipsychoticsTypical Antipsychotics

For acute agitation or aggressionFor acute agitation or aggression• HaloperidolHaloperidol

– – 0.25-0.5 mg po (peak effect: 4-6 hours) twice 0.25-0.5 mg po (peak effect: 4-6 hours) twice daily with additional doses every 4 hours as daily with additional doses every 4 hours as neededneeded – – 0.25-0.5 mg im (peak effect: 20-40 minutes), 0.25-0.5 mg im (peak effect: 20-40 minutes), observe after 30 minutes and repeat the same observe after 30 minutes and repeat the same or or twice the origin dosestwice the origin doses – – Titrate upward as needed (up to 3-5 mg/day)Titrate upward as needed (up to 3-5 mg/day)

• Goal: A manageable patientGoal: A manageable patient• Observe for akathisia, extrapyramidal effects and Observe for akathisia, extrapyramidal effects and

prolonged QTcprolonged QTc

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Atypical AntipsychoticsAtypical Antipsychotics

• Studied only in small uncontrolled studiesStudied only in small uncontrolled studies• Associated with increased risk ofAssociated with increased risk of

– – StrokeStroke – – Mortality among older patients with dementiaMortality among older patients with dementia

• Observe for extrapyramidal effects and prolonged QTcObserve for extrapyramidal effects and prolonged QTc – – Risperidone 0.5-1 mg/day po (qd-bid)Risperidone 0.5-1 mg/day po (qd-bid) – – Quetiapine 25-800 mg/day po (qd-bid)Quetiapine 25-800 mg/day po (qd-bid) – – Olanzapine 2.5-10.0 mg po (qd)Olanzapine 2.5-10.0 mg po (qd)

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BenzodiazepinesBenzodiazepines

• Reserve for alcohol/benzodiazepine withdrawalReserve for alcohol/benzodiazepine withdrawal• Adjuncts to antipsychotics (agitation/insomnia)Adjuncts to antipsychotics (agitation/insomnia)

– – Lorazepam 0.5-1.0 mg po, with additional doses Lorazepam 0.5-1.0 mg po, with additional doses every 4 hours as neededevery 4 hours as needed

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Physical RestraintPhysical Restraint

• The highest relative risk of the precipitating factors for The highest relative risk of the precipitating factors for deliriumdelirium**

• Significant association with the severity of deliriumSignificant association with the severity of delirium††

• Misconceived reason for physical restraint use among Misconceived reason for physical restraint use among delirious patients to prevent injurydelirious patients to prevent injury

• Restraint reduction: not associated withRestraint reduction: not associated with falls falls• Restraint free care: the standard of careRestraint free care: the standard of care

**Inouye SK, et al. JAMA. 1996;275(11):852–857.Inouye SK, et al. JAMA. 1996;275(11):852–857.

††McCusker J, et al. J Am Geriatr Soc. 2001;49(10):1327–1334.McCusker J, et al. J Am Geriatr Soc. 2001;49(10):1327–1334.29

Prevention of DeliriumPrevention of Delirium

• Primary prevention of delirium: the most effective Primary prevention of delirium: the most effective strategy to reduce deliriumstrategy to reduce delirium

• Avoid medications known to precipitate deliriumAvoid medications known to precipitate delirium• Multicomponent approachesMulticomponent approaches• 40% risk reduction for delirium in hospitalized older 40% risk reduction for delirium in hospitalized older

patientspatients

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Yale Delirium Prevention TrialYale Delirium Prevention Trial

• To evaluate effectiveness of intervention protocols To evaluate effectiveness of intervention protocols targeted toward six risk factorstargeted toward six risk factors – – Cognitive impairmentCognitive impairment – – Sleep deprivationSleep deprivation – – ImmobilityImmobility – – Visual impairmentVisual impairment – – Hearing impairmentHearing impairment – – DehydrationDehydration

Inouye SK, et al. N Engl J Med. 1999;340(9):669-676.Inouye SK, et al. N Engl J Med. 1999;340(9):669-676.31

Delirium in Long-term CareDelirium in Long-term Care

• American Medical Directors Association (AMDA) American Medical Directors Association (AMDA) clinical practice guideline in 2008 for “delirium and clinical practice guideline in 2008 for “delirium and acute problematic behavior in the long-term care acute problematic behavior in the long-term care setting”setting” – – RecognitionRecognition – – AssessmentAssessment – – TreatmentTreatment – – MonitoringMonitoring

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RecognitionRecognition

Step 1Step 1: Identify the patient’s current behavior, mood, : Identify the patient’s current behavior, mood, cognition and functioncognition and function

• Review the history, observe the patient in various Review the history, observe the patient in various situations, and identify and document pertinent details situations, and identify and document pertinent details about how the patient looks, thinks, and actsabout how the patient looks, thinks, and acts

• Assessment process should be coordinated among staff Assessment process should be coordinated among staff from various disciplines involvedfrom various disciplines involved

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Key Elements in Evaluating Key Elements in Evaluating Mental StatusMental Status

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Step 2Step 2: Identify and clarify problematic behavior and : Identify and clarify problematic behavior and altered mental functionaltered mental function

– – Symptoms, current diagnoses, history and medicationsSymptoms, current diagnoses, history and medications• Review the patient’s medical, surgical, family and Review the patient’s medical, surgical, family and

social history; pertinent behavioral history; baseline social history; pertinent behavioral history; baseline functional status; and any prior diagnostic work-up functional status; and any prior diagnostic work-up and managementand management

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• Check available transfer information and any pertinent Check available transfer information and any pertinent consultation reports for related diagnoses (delirium, consultation reports for related diagnoses (delirium, dementia, bipolar disorder, or psychosis)dementia, bipolar disorder, or psychosis)

• Review current orders for treatments and medications Review current orders for treatments and medications that address cognition, mood, problematic behavior, or that address cognition, mood, problematic behavior, or psychiatric disorders, and for medications with psychiatric disorders, and for medications with anticholinergic properties or side effects, which are anticholinergic properties or side effects, which are known to adversely affect behavior and mental known to adversely affect behavior and mental functionfunction

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Define behavioral issuesDefine behavioral issues – – Nature and relevant factorsNature and relevant factors – – SeveritySeverity – – CourseCourse

Identify deliriumIdentify delirium – – Require a high index of suspicionRequire a high index of suspicion – – Should be considered in any patient who has a Should be considered in any patient who has a

change in behavior or mental function, change in behavior or mental function, regardless of whether they also have dementiaregardless of whether they also have dementia – – Use screening instrumentsUse screening instruments (e.g., CAM)(e.g., CAM)

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Step 3Step 3: Assess the patient for individual risk factors for : Assess the patient for individual risk factors for problematic behavior and deliriumproblematic behavior and delirium

– – Having dementia is the most common risk factor for Having dementia is the most common risk factor for the development of deliriumthe development of delirium

• Avoid using indwelling urinary catheters and minimize Avoid using indwelling urinary catheters and minimize use of other medical devices (e.g., intravenous use of other medical devices (e.g., intravenous catheters) that may restrict mobility or functioncatheters) that may restrict mobility or function

• Avoid using restraintsAvoid using restraints

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• Minimize the number and reduce the dose of Minimize the number and reduce the dose of medications with central nervous system effects or medications with central nervous system effects or potential side effectspotential side effects

• Pay careful attention to fluid and electrolyte balance in Pay careful attention to fluid and electrolyte balance in older patients who are taking diuretics; who have older patients who are taking diuretics; who have diarrhea, pneumonia, or diarrhea, pneumonia, or urinary tract infection; or urinary tract infection; or who are otherwise at risk for dehydrationwho are otherwise at risk for dehydration

• Identify and manage treatable causes of anemiaIdentify and manage treatable causes of anemia

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• Optimize sensory function (e.g., provide corrective Optimize sensory function (e.g., provide corrective lenses for impaired vision, hearing aides)lenses for impaired vision, hearing aides)

• Optimize sleep (e.g., address reversible causes of sleep Optimize sleep (e.g., address reversible causes of sleep impairment, minimize nighttime noises)impairment, minimize nighttime noises)

• Avoid unnecessary isolation or restriction (e.g., for Avoid unnecessary isolation or restriction (e.g., for infection control purposes)infection control purposes)

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AssessmentAssessment

Step 4Step 4: Determine the urgency of the situation and the : Determine the urgency of the situation and the need for additional evaluation and testingneed for additional evaluation and testing

• Simply giving medications to try to control behavior, or Simply giving medications to try to control behavior, or routinely requesting the immediate transfer of patients routinely requesting the immediate transfer of patients to the emergency room or hospital, are often not helpfulto the emergency room or hospital, are often not helpful

• Some situations may require more urgent evaluation Some situations may require more urgent evaluation and managementand management

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AssessmentAssessment

Step 4Step 4: Determine the urgency of the situation and the : Determine the urgency of the situation and the need for additional evaluation and testingneed for additional evaluation and testing

• Simply giving medications to try to control behavior, or Simply giving medications to try to control behavior, or routinely requesting the immediate transfer of patients routinely requesting the immediate transfer of patients to the emergency room or hospital, are often not helpfulto the emergency room or hospital, are often not helpful

• Some situations may require more urgent evaluation Some situations may require more urgent evaluation and managementand management

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Situations Requiring Urgent Situations Requiring Urgent EvaluationEvaluation

Medical issuesMedical issues – – Markedly abnormal vital signs (systolic BP <90, PR Markedly abnormal vital signs (systolic BP <90, PR

<50 or >120, RR>30, temp <35.5 or >38.3 )℃ ℃<50 or >120, RR>30, temp <35.5 or >38.3 )℃ ℃ – – New-onset respiratory distress, with increasing New-onset respiratory distress, with increasing hypoxia hypoxia and dyspneaand dyspnea – – Signs of serious underlying condition possibly Signs of serious underlying condition possibly causing causing delirium (e.g., symptoms of stroke)delirium (e.g., symptoms of stroke)

Psychiatric symptomsPsychiatric symptoms – – Escalating physically aggressive behavior or threats Escalating physically aggressive behavior or threats of of violenceviolence – – Intermittent or persistent change to self or othersIntermittent or persistent change to self or others

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Step 5Step 5: Identify the cause(s) of problematic behavior and : Identify the cause(s) of problematic behavior and altered mental functionaltered mental function

• A systematic approachA systematic approach – – A detailed description of current behavior, function A detailed description of current behavior, function

and mental status in proper contextand mental status in proper context – – Careful physical assessment by nursing staff, Careful physical assessment by nursing staff, supplemented by a practitioner assessment and supplemented by a practitioner assessment and pertinent laboratory testing as neededpertinent laboratory testing as needed

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• Consider unmet comfort needs, environmental issues Consider unmet comfort needs, environmental issues and nonspecific behavioral and psychological symptoms and nonspecific behavioral and psychological symptoms of dementia (BPSD)of dementia (BPSD)

• Certain physical impairments (e.g., aphasia, Certain physical impairments (e.g., aphasia, impairment of vision and hearing) may contribute to impairment of vision and hearing) may contribute to behavioral symptomsbehavioral symptoms

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Step 6Step 6: Assess the patient for medical illnesses with or : Assess the patient for medical illnesses with or without deliriumwithout delirium

• Additional medical, neurological, psychological or Additional medical, neurological, psychological or psychiatric assessment if above evaluations and tests do psychiatric assessment if above evaluations and tests do not reveal a specific causenot reveal a specific cause

• Stepwise approach may be more useful and cost-Stepwise approach may be more useful and cost-effective than the simultaneous ordering of many testseffective than the simultaneous ordering of many tests

• Infections, particularly pneumonia and urinary tract Infections, particularly pneumonia and urinary tract infection, are common in institutionalized elderlyinfection, are common in institutionalized elderly

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Conditions That May Affect Conditions That May Affect Behavior and Mental FunctionBehavior and Mental Function

Acute or abrupt onset or condition changeAcute or abrupt onset or condition change• Medication-related adverse consequencesMedication-related adverse consequences• Fluid and electrolyte imbalanceFluid and electrolyte imbalance• InfectionsInfections• Hypoglycemia or marked hyperglycemiaHypoglycemia or marked hyperglycemia• Acute renal failure, hypoxia, COAcute renal failure, hypoxia, CO22 retention retention• Cardiac arrhythmia, myocardial infarction or heart Cardiac arrhythmia, myocardial infarction or heart

failurefailure• Head traumaHead trauma• Stroke or seizureStroke or seizure• Pain, acute or chronicPain, acute or chronic

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• Urinary outlet obstructionUrinary outlet obstruction• Alcohol or drug abuse or withdrawalAlcohol or drug abuse or withdrawal• Postoperative statePostoperative stateAcute or abrupt onset or condition changeAcute or abrupt onset or condition change• Hypo or hyperthyroidismHypo or hyperthyroidism• NeoplasmNeoplasm• Nutritional deficiency (e.g., folate, thiamine, vitamin Nutritional deficiency (e.g., folate, thiamine, vitamin

BB1212))• AnemiaAnemia• Chronic constipation/fecal impactionChronic constipation/fecal impaction• Sensory deficitsSensory deficits

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Diagnostic Tests to Help Assess Diagnostic Tests to Help Assess CausesCauses

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Almost any medication if time course is appropriateAlmost any medication if time course is appropriate

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Step 7Step 7: Consider possible psychiatric illnesses: Consider possible psychiatric illnesses• Consider psychiatric illness if the assessment does not Consider psychiatric illness if the assessment does not

reveal a causereveal a cause – – Psychosis from schizophrenia, schizoaffective Psychosis from schizophrenia, schizoaffective

disorders, major depression, dementia, bipolar disorders, major depression, dementia, bipolar affective disorders and maniaaffective disorders and mania

– – Mood disordersMood disorders – – Personality disordersPersonality disorders

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Step 8Step 8: Consider dementia-related causes: Consider dementia-related causes• Environmental triggersEnvironmental triggers• BPSD: restlessness, aggression, delusion, hallucinations, BPSD: restlessness, aggression, delusion, hallucinations,

repetitive vocalization, wanderingrepetitive vocalization, wandering

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TreatmentTreatment

Step 9Step 9: Establish a working diagnosis and validate : Establish a working diagnosis and validate conclusionsconclusions

• Identify the rationale for and goals of treatmentIdentify the rationale for and goals of treatment – – Why is the patient’s behavior problematic?Why is the patient’s behavior problematic? – – Why does the patient’s behavior require an Why does the patient’s behavior require an intervention?intervention? – – How was the likely cause determined?How was the likely cause determined? – – How will the proposed interventions address the How will the proposed interventions address the causes or factors contributing to the problematic causes or factors contributing to the problematic behavior in order to moderate it?behavior in order to moderate it? – – How will the proposed interventions improve the How will the proposed interventions improve the patient’s well-being and quality of life?patient’s well-being and quality of life?

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• Determine the need for transferDetermine the need for transfer – – Many cases can be managed effectively in a Many cases can be managed effectively in a facility, facility, to the patient’s benefitto the patient’s benefit – – Hospitalization is only sometimes helpful and may Hospitalization is only sometimes helpful and may

be traumatic for the patientbe traumatic for the patient

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Step 10Step 10: Initiate a care plan for treatment: Initiate a care plan for treatment – – A: What are the A: What are the antecedentsantecedents to the behavior? to the behavior?

B: What is the B: What is the behaviorbehavior??C: What are the C: What are the consequencesconsequences of the behavior? of the behavior?

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• Address key aspects of the patient’s careAddress key aspects of the patient’s care – – Risk assessmentRisk assessment – – Cause identification and managementCause identification and management – – Need for staff support and for informing the Need for staff support and for informing the patient patient and familyand family – – Prevention and management of coexisting Prevention and management of coexisting conditions conditions and complicationsand complications – – Changes to the current treatment regimenChanges to the current treatment regimen – – Monitoring parametersMonitoring parameters

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Step 11Step 11: Provide symptomatic and cause-specific : Provide symptomatic and cause-specific managementmanagement

• Symptomatic interventions are often helpful in Symptomatic interventions are often helpful in combination with cause-specific approachescombination with cause-specific approaches – – Prevent and manage complications and functional Prevent and manage complications and functional

problemsproblems – – Address relevant ethical issuesAddress relevant ethical issues – – Treat underlying causesTreat underlying causes – – Treat delirium and psychosis aggressivelyTreat delirium and psychosis aggressively – – Address wandering and sleep disturbancesAddress wandering and sleep disturbances – – Address apathy and mood disordersAddress apathy and mood disorders – – Address sexually inappropriate behaviorAddress sexually inappropriate behavior

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– – Symptomatic (mostly nonpharmacologic) approaches to Symptomatic (mostly nonpharmacologic) approaches to addressing problematic behavioraddressing problematic behavior Address pain and discomfortAddress pain and discomfort Minimize sleep disruptionMinimize sleep disruption Encourage independence to the extent of the Encourage independence to the extent of the patient’s patient’s tolerancetolerance Provide activities for those with disruptive Provide activities for those with disruptive behaviorbehavior Involve the patient daily routine in a calm, quiet Involve the patient daily routine in a calm, quiet environmentenvironment Use different approach to bathing, feeding and other Use different approach to bathing, feeding and other

activities of daily livingactivities of daily living

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Step 12Step 12: Use medications appropriately to address : Use medications appropriately to address problematic behaviorproblematic behavior

– – Rational approach based on understanding mechanisms Rational approach based on understanding mechanisms of action and targeting medications to the identified or of action and targeting medications to the identified or likely underlying causeslikely underlying causes

– – No magic bulletsNo magic bullets – – Risk and complicationsRisk and complications

Short-half-life benzodiazepines (e.g., lorazepam): Short-half-life benzodiazepines (e.g., lorazepam): oversedation, “rebound” effects after each doseoversedation, “rebound” effects after each dose

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– – Systematic approachSystematic approach Obtain and review the details of the situation Obtain and review the details of the situation (Steps (Steps 1-3)1-3) Determine the most likely causesDetermine the most likely causes Identify what the staff has already done, or could Identify what the staff has already done, or could do, do, to try to understand and address the situationto try to understand and address the situation Consider whether the patient’s behavior orConsider whether the patient’s behavior orcondition condition is presenting an imminent or high level of is presenting an imminent or high level of danger to danger to himself or herself or to othershimself or herself or to others

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– – AntipsychoticsAntipsychotics Initiate treatment aggressively and taper the doses Initiate treatment aggressively and taper the doses as as underlying causes are addressed and symptoms underlying causes are addressed and symptoms

stabilize or subsidestabilize or subside Make individualized decisions about the potential Make individualized decisions about the potential

benefits and risksbenefits and risks

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MonitoringMonitoring

Step 13Step 13: Monitor and adjust interventions as indicated: Monitor and adjust interventions as indicated – – Monitor the patient’s progress periodically (Steps 1-8)Monitor the patient’s progress periodically (Steps 1-8) – – Initiate or modify interventions (Steps 9-12)Initiate or modify interventions (Steps 9-12) – – Document the patient’s course in enough detail Document the patient’s course in enough detail

(treatment effect, diagnosis validity)(treatment effect, diagnosis validity) – – Adjust medication doses on the basis of symptoms and Adjust medication doses on the basis of symptoms and

adverse consequencesadverse consequences

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– – Review the situation, revisit the steps, reconsider the Review the situation, revisit the steps, reconsider the diagnoses and interventions if problematic behavior or diagnoses and interventions if problematic behavior or altered mental function does not at least begin to stabilize altered mental function does not at least begin to stabilize or improve within 72 hours of initiating interventionsor improve within 72 hours of initiating interventions

– – May add another medication as an adjunct if a maximum May add another medication as an adjunct if a maximum recommended dose or tolerated dose of one medication is recommended dose or tolerated dose of one medication is reached with partial improvement of symptoms or reached with partial improvement of symptoms or improvement of one symptom but not othersimprovement of one symptom but not others

– – Consider psychiatric consultation, but attending physician Consider psychiatric consultation, but attending physician must remain involvedmust remain involved

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Step 14Step 14: Review the effectiveness and continued : Review the effectiveness and continued appropriateness of all medicationsappropriateness of all medications

– – After delirium have subsided, review the situation and After delirium have subsided, review the situation and consider whether the underlying causes have improved or consider whether the underlying causes have improved or resolved and intervention remain appropriateresolved and intervention remain appropriate

– – Once the cause of delirium has been identified and Once the cause of delirium has been identified and managed effectively, it may be possible to taper or stop managed effectively, it may be possible to taper or stop any medications that were used to treat related any medications that were used to treat related behavioral symptomsbehavioral symptoms

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– – May be appropriate to reduce or stop the May be appropriate to reduce or stop the intervention(s), at least for a trial periodintervention(s), at least for a trial period

– – If symptoms endure or recur more than occasionally If symptoms endure or recur more than occasionally while the patient is on a stable dose of while the patient is on a stable dose of psychopharmacologic medications, reconsider the psychopharmacologic medications, reconsider the diagnosis and appropriateness of current medication diagnosis and appropriateness of current medication regimenregimen

– – If symptoms are little or no different as the dose is If symptoms are little or no different as the dose is reduced, additional attempted dose reduction may be reduced, additional attempted dose reduction may be indicatedindicated

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Step 15Step 15: Prevent, identify and address any complications of : Prevent, identify and address any complications of the conditions and treatmentsthe conditions and treatments

– – Fluid and electrolyte imbalance and pressure ulcers in a Fluid and electrolyte imbalance and pressure ulcers in a patient with deliriumpatient with delirium

– – Falling as a result of benzodiazepine, and other Falling as a result of benzodiazepine, and other psychopharmacologic medication usepsychopharmacologic medication use

– – Hyperglycemia or cardiac events related to the use of Hyperglycemia or cardiac events related to the use of some atypical antipsychoticssome atypical antipsychotics

– – Oversedation as a side effect of benzodiazepineOversedation as a side effect of benzodiazepine

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Take Home MessageTake Home Message

• Delirium, a geriatric syndromeDelirium, a geriatric syndrome – – Common among older personsCommon among older persons – – Resulting in functional declineResulting in functional decline – – Associated with substantial morbidity/mortalityAssociated with substantial morbidity/mortality – – Detected by using CAMDetected by using CAM – – Multi-factorial, with underlying causes usually Multi-factorial, with underlying causes usually

found by a comprehensive history, physical found by a comprehensive history, physical examination, and focused laboratory studiesexamination, and focused laboratory studies

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– – Successful prevention and management Successful prevention and management interventions include a multi-component interventions include a multi-component interventionintervention – – The best management is preventionThe best management is prevention – – Physical restraints should not be used in patients Physical restraints should not be used in patients

with delirium, and rarely should pharmacological with delirium, and rarely should pharmacological restraints be usedrestraints be used

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ReferenceReference

• 陳人豪：譫妄症。於臺灣老年學暨老年醫學會等主編陳人豪：譫妄症。於臺灣老年學暨老年醫學會等主編：老年醫學叢書系列：老年病症候群。臺北，臺灣老：老年醫學叢書系列：老年病症候群。臺北，臺灣老年醫學會；年醫學會； 20122012 ：： 15-2615-26。。

• J Am Med Dir Assoc. J Am Med Dir Assoc. Clinical Practice Guideline: Clinical Practice Guideline: Delirium and Acute Problematic Behavior in the Long-Delirium and Acute Problematic Behavior in the Long-Term Care Setting. 2008. 36p.Term Care Setting. 2008. 36p.

• Inouye SK. Delirium in older persons. Inouye SK. Delirium in older persons. N Engl J Med. N Engl J Med. 2006;354(11):1157-1165.2006;354(11):1157-1165.

• Lyons WL. Delirium in postacute and long-term care. J Lyons WL. Delirium in postacute and long-term care. J Am Med Dir Assoc. 2006;7(4):254-261.Am Med Dir Assoc. 2006;7(4):254-261.