Case. 83בן • שנה חצי לפני נפטרה ואשתו אלמן מוגן בדיור• , ,. . לב: תעוקת סיבוכים עם סוכרת ד ל יתר ברקע• . . למועדון הגיע לא בתפקוד ירד שבועיים

• , . אי בדיבור קושי היה הטלוויזיה מול ישן למיון העברה לפני יוםבשתן שליטה

ברקע • נפש מחלת אין

פעולה • ושיתף שקט היה

לו • שיש ונמצא נמוך UTIנתרן

לדיכאון • מצבו להעריך הגיע פסיכאטר

Insulin, normiten, Vasodip, Aspirinלוקח: •

אליך. 9/30צבר MMSEבמבחן • מסתקל לא

He is presenting as a classic example of hypoactive delirium however:

• Urinary incontinence with altered mental status should prompt concerns about normal pressure hydrocephalus

• He could have had a stroke or fall given his diabetes, hypertension and peripheral neuropathy- he needs a head CT

• The UTI and hyponatremia could cause delirium and even with appropriate treatment mental status may take weeks and even months in the elderly- some may never return to baseline

Other possible contributing factors:

• Meds such as benzodiazapines• Glycemic abnormalities- how are his blood sugars?• Would need to rule out alcohol withdrawal or

overdose-always do a urine tox screen• Is he depressed?• Is he demented?• The low MMSE reveals severe impairment which is

common in delirium. His poor effort could signal inattention or depression.

Confusion

Dr Gary SinoffDepartment of Gerontology

University of Haifa

Outline of Lecture

1. Definition of Delirium2. Pathophysiology3. Epidemiology4. Clinical Presentation5. Causes6. Diagnosing7. Treatment8. Prognosis

8

Confusion

Confusion: a loss of one's capacity to think clearly and coherently, and it is a non-specific symptom of many different mental disorders or organic pathology.

Both delirium and dementia are characterized by a global impairment in cognitive functioning.

Why is Delirium Important?

Common, Morbidity/Mortality,

& Costly!

1. Definition

Characteristics of Delirium

• Disturbance of consciousness

• Abnormal cognition

• Acute in onset and fluctuating in course

• Precipitated by a cause

• Misdiagnosis is frequent

Definition DSM –IV TR (APA, 2000)1. Disturbance of consciousness : reduced ability to focus, sustain, or

shift attention, easily distracted.

2. Disturbance in memory: disorientation to time and place, disturbed recall.

3. Disturbance in language: dysarthria, dysgraphia, incoherent speech, switching of topics.

4. Over a short period of time: usually hours to days, fluctuating during the course of the day

5. Evidence that it is caused by a medical condition, substance intoxication, or medication side effect.

2. Pathophysiology

Many hypotheses exist including:

• Neurotransmitter abnormalities

• Inflammatory response with increased cytokines

• Changes in the blood-brain barrier permeability

• Widespread reduction of cerebral oxidative metabolism

• Increased activity of the hypothalamic-pituitary adrenal axis

Neurotransmitters and Cytokines

• ↓ Acetylcholine• ↑ Dopamine• ↑ Noradrenaline• ↑ Serotonin• ↓ Histamine• GABA• Cytokines : IL-1, IL-2,

IL-6, TNF; IF

3. EPIDEMIOLOGY

Prevalence RatesCommon in hospitalized older adults:Approximately 40% of hospitalized elderly >65

• Emergency Department 10%• Post-hip fracture 35 - 65%• Surgical Wards 15 - 30%• General Medicine 11 - 26%• Known dementia 30 - 90%

Residential care 9% -16%

Community dwelling elderly?

Expect higher rates with an ageing population and a shift away from hospital-based care.

EPIDEMIOLOGY

• Delirium is OFTEN UNRECOGNIZED!!

• Many cases undiagnosed– ~40% of elderly with delirium sent home from ED in

one study

• Misdiagnosed as depression – ~40% of cases in one study

Cole MG. Am J Geriatr Psychiatry. 2004;12(1):7-21

Epidemiology of delirium

Delirious patients experience greater morbidity:• Prolonged hospitalizations

• More hospital-acquired complications

• Greater cognitive decline

• Functional decline

• High risk for institutionalization.

Delirium Is Deadly !!!

Mortality rates:10% - 65%

BUT

With appropriate management, may be reversible in up to 50%.

Recognizing Delirium

– Nurses recognize and document <50% of cases – Physicians recognize and document only 20%

Recognized by doctors

Recognized by nurses

Not recognized Not recognized

4. Clinical Presentation

Prodrome Stage

• Patients may describe and/or manifest:– Decreased concentration– Irritability, restlessness, anxiety, depression– Hypersensitivity to light and sound– Perceptual disturbances– Sleep disturbance

Precipitating factors

• Polypharmacy • Infections• Dehydration• Immobility including restraint use• Malnutrition• The use of bladder catheters• Sensory Deprivation• Change of room• High noise level• Male gender• Dementia

Identified risk factors for prevention

RR 9.0“Severe pain”

RR 5.4< 10 mg morphine/day

RR 2.9CHF

RR 2.3Abnormal BP

RR 3.6Cognitive impairment

Clinical characteristics

• Develops acutely (hours to days)• Characterized by fluctuating level of

consciousness.• Reduced ability to maintain attention• Agitation or hypersomnolence• Extreme emotional lability• Cognitive deficits occur• Disturbed concentration

Types of delirium

• Hyperactive or hyperalert

• Hypoactive or hypoalert

• Mixed

Hyperactive or hyperalert

– Patient is hyperactive, combative and uncooperative.

– May appear to be responding to internal stimuli– Frequently these patients come to our attention

because they are difficult to care for.

Hypoactive or hypoalert

– Patient appears to be sleeping on and off throughout the day

– Unable to sustain attention when awakened, quickly falls back to sleep

– Misses meals, medications, appointments– Does not ask for care or attention– This type is easy to miss because caring for these

patients is not problematic to staff

Mixed

– a combination of both types just described

– The most common types are hypoactive and mixed accounting for approximately 80% of delirium cases

5. Causes

Causes

• D• E• L• I• R• I• U• M• S

Causes

• Drugs - particularly narcotics and anticholinergics, withdrawal of alcohol and benzodiazepines• Endocrine - hypo /hyperglycemia, hypercalcemia, hypo /hyperthyroidism• Low oxygen – hypoxia• Infections - particularly UTI and

pneumonia

Causes

• Retention- urinary• Inflammatory arthritis - gout, meningitis Intoxication • Underperfused – CHF, CVA, Acute MI• Metabolic – sodium, potasium, liver

failure• Stool – fecal impaction

Drugs commonly causing delirium:

• AnalgesicsNSAIDs, opioids

• AntibioticsAcyclovir, cephalosporins, penicillin, quinolones, sulfonamides, tobramycin

• Anticholinergics• Anticonvulsants

Carbamazepine, phenytoin, valproate• Antidepressants

TCAs, SSRIs

• Cardiovascular Amiodarone, B blockers, digoxin, diuretics

• Corticosteroids• Dopamine agonists• H2 antagonists

Cimetidine, famotidine, ranitidine

• Sedative/Hypnotics• Miscellaneous

Baclofen, donepezil, interferons, oral hypoglycemics

6. Diagnosis

Diagnosis• History from family and/or caregivers

• Bedside observations

• DSM-IV diagnostic criteria

• Reliable diagnostic instruments: – Confusion Assessment Method– The Delirium Rating Scale- Revised-98 – Delirium Symptom Review

• Diagnostic errors are common in: – Hypoactive form – The setting of rapid fluctuations of cognition.

Confusion Assessment Method (CAM)

1. History of acute onset of change in patient’s normal mental status & fluctuating course

AND2. Lack of attention

AND EITHER

3. Disorganized thinking4. Altered Level of Consciousness

Inouye SK: Ann Intern Med 1990;113(12):941-8

Sensitivity: 94-100%Specificity: 90-95%Kappa: 0.81

Recognizing Delirium

Lewis et al. Unrecognized delirium in ED geriatric patients. Am J Emerg Med 1995; 13(2): 142-5.

• Compared the ED physician’s conventional assessment to the CAM

• 385 Patients over age 64• CAM: 38 of 385 (10% prevalence)• Physician: 34 of above 38 charts completed• 21 of 34 (62%) admitted• Only 6 of 34 (17%) identified with delirium• 13 of 34 (38%) discharged• 6 of 13 (46%) discharged as “status post fall”

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Differentiation Between Delirium and Dementia

Clinical feature Delirium Dementia

Nature of onset  Abrupt onset Gradual, ill-defined onset

Rapidity of progression Rapid - hours Slow - months

Duration of condition Temporary - days Long lasting - years 

Variability of symptoms Fluctuating from hour-to-hour Lucid intervals common

Stable from day-to-day No lucid intervals

Attention span  Very short, variable from moment-to-moment

Unaffected in early disease, stable in chronic disease

7. Treatment

Treatment

• Based mainly on observational data

• Reduce or discontinue psychotropic, anticholinergic, narcotic medications.

• Careful focus on intake, nutrition, physical therapy/mobility, aspiration risk.

NON-PHARMACOLOGICAL MANAGEMENT

Assess safety– Prevent harm to self or others– Try to avoid physical restraints

Establish physiological stability– Adequate oxygenation– Restore electrolyte balance– Restore hydration

Address modifiable risk factors– Correct sensory deficits– Manage pain– Support normal sleep pattern– Minimize room changes

Delirium Reduction

• You can get improvement of delirium with such simple measures as:

– Glasses– Using hearing aids– Fluids/nutrition– Reducing noise– Early mobility– Familiar faces– Soft lighting

Inouye S. N Engl J Med. 1999;340(9):669-76.

Treatment

• Morphine for pain control

• SSRIs for suspected depression/anxiety

• Benzodiazepines for anxiety

• Neuroleptics for agitation

8. Prognosis

Prognosis

• Delirium is independently associated with:– Increased functional disability – Increased LOS – Admission to long-term care

• Increased hospital mortality of 2 to 20 fold • May persist for months or indefinitely Delirium

becomes chronic in substantial numbers of patients • Two factors related to better outcomes:

– Admission from home– Better premorbid functioning

Prognosis

CMAJ 1993; 149 (1):41-6. Prognosis of delirium in elderly hospital patients. Cole MG; Primeau FJ

• Medline, 1980-1992. Meta-analysis of 8 studies• N = 563• LOS 21 days*

43%*6 months

14%*47%*55%1 month

DiedInstitutionalizedCognitively improved

* p < 0.05

Prognosis

J Gen intern Med 1998; 13(4):234-42. Does delirium contribute to poor hospital outcomes? A three-site epidemiololgic study. Inouye et al

• N = 727• New nursing home placement: OR 3.0 at d/c and at 3 months• Death or new nursing home placement: OR 2.1 (2.6 at 3 mo)• Functional decline: OR 3.0 (2.7 at 3 months)

25%13%3 months

14%9%discharge

Institutionalized or diedInstitutionalized

Prognosis

J Gen Intern Med 2003; 18(9):696-704. The course of delirium in older medical inpatients: a prospective study. McCusker et al.

• N = 193

3.52.212 months4.53.4Discharge

# delirium Sx (dementia)

# delirium Sx (cog intact)

Prognosis

JAGS 2003; 51(7): 1002-6. Dementia after delirium in patients with femoral neck fractures. Lundstrom et al

• 5 year prospective follow-up study• N = 78

38.5%Total group

72%69%Delirious

35%20%No delirium

DiedDementia

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Acute Confusional StatePearls

• Often not recognized• Common among hospitalized patients• Is frequently preventable• Accounts for significant morbidity and

mortality• Impaired attention is the hallmark

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Acute Confusional StatePearls

• In elderly think meds/polypharmacy first• Consider underlying dementia in elderly who

develop ACS• Known dementia patients may develop ACS due

to a treatable cause – it is not always deterioration due to dementia!

• Common irritants such as constipation or urinary retention may cause ACS in the elderly

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Acute Confusional StatePearls

• Consider capacity, competency, and surrogate issues in informed consent of ACS patients – write it in the record!

• There is often a time lag of days to weeks between effective Rx and clinical response (most significant lag in the elderly)

Next Week ?????

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