Delirium: Is There a Cure for "Hospitalitis"? - Healthcare Professionals

DELIRIUMSabitha Rajan, MD, MSc, FHMScott &White HealthcareTexas A&M Health Science Center School of Medicine

Disclosure• Milliman Care Guidelines - Editor

Objectives• Define delirium• Epidemiology• Diagnose• Prevent• Treat• Counsel

Define Delirium• Acute state of confusion• Sudden onset• Progresses during several hours to days• Fluctuating course• Can alternate between agitation/restlessness and fatigue/indifference• Inattention• Hallmark of diagnosis – forgetful, confused• Abnormal level of consciousness at times• Hypoactive delirium (25%)• Fatigued• Hyperactive delirium (25%)• Hallucinations• Agitated• Mixed (50%)

AKA• Acute confusional state• Toxic encephalopathy• Organic brain syndrome• ICU psychosis

In patients aged 70 and olderGeneral Medical Inpatient Ward17%No Delirium17%66%Present on AdmissionDevelops duringAdmission

Epidemiology• Up to 75% of patients in an ICU• Up to 85% at the end of life

Important? In the Hospital:• Up to ten times the risk of mortality• Three to five times the risk of a nosocomial infection• Prolonged length of stay• Greater chance of nursing home discharge as opposed toa home discharge (73% vs 30% in one study)• Increased costs estimated at $38-152 Billion annually

After Discharge• Once thought to be an acute problem that resolved• Prolonged risk for mortality lasts for up to 2 years• At risk for poor functional and cognitive recovery

Post-operative deliriumSaczynski JS et al. N Engl J Med 2012;367:30-39

Challenging to Diagnose• Index of suspicion• Agitation present in less than 25% of cases• 50-80% of cases remain undiagnosed• Screening• SQiD (single question in delirium)• “Do you think [insert pt name] has been more confused lately?”• 80% sensitive and 71% specific in hospitalized oncology patients

Differential Diagnosis• Sundowning• If it is a new pattern, assume delirium• Established sundowning can be worse in the hospital• Neurologic (focal)• Wernicke’s aphasia• Bifrontal lesions• Nonconvulsive status epilepticus• Facial twitching• Nystagmus• Automatisms• Psychiatric diagnosis• Depression• Dementia

Delirium vs. Dementia• Why is it difficult to differentiate?• Often co-exist• Dementia with Lewy bodies can be associated with fluctuations inmental status and visual hallucinations

Delirium vs. DementiaOnset and courseDementiaslow onset over monthsor yearsDeliriumsudden onset over hoursor daysSpeech normal slurredinattentive, easilyAttentionnormaldistractedMemory gradual memory loss more forgetful than usualHallucinations possible commonMoodnormal or depressedanxious, fearful,suspicious, indifferentGeneral health usualsign of illness or drugside effect

Diagnosis• Entirely clinical! There is no objective test.• Determine the timeline of the mental status changes• Are they fluctuating?• What is the level of consciousness?• What is the ability to pay attention?

Multifactorial Risk AssessmentPredisposing FactorsAgeDementiaStrokeParkinson’s DiseaseMultiple Co-morbiditiesImpaired VisionImpaired HearingFunctional Impairment (ADL)MalesAlcohol abusePrecipitating FactorsNew acute medical problemExacerbation of chronic medicalSurgery and/or anesthesiaNew psychoactive medicationAcute strokePainChange in environmentUrinary retentionConstipation/ImpactionDehydrationSepsis/Infection

Mnemonic for Precipitating FactorsDrugsElectrolyte imbalanceLack of drugsInfectionReduced sensory inputIntracranialUrinary or fecal problemsMyocardial (heart) and lungsmedications, recently started or stopped,changes in dosages, over-the-countermedications, herbals, alcoholespecially from dehydrationstopping medications, alcohol withdrawalurinary or respiratory tract infections;blood or wound infection after an injuryor surgerypoor or uncorrected vision and hearingstrokeinability to empty bladder or bowelheart attack, pneumonia, or othercondition causing lack of oxygen in theblood and the brain

Scales• Delirium Observation Screening Scale (DOSS)• Delirium Rating Scale (DRS)• Delirium Rating Scale-Revised-98 (DRS-R-98)• Digit Span Test• Global Attentiveness Rating (GAR)• Memorial Delirium Assessment Scale (MDAS)• Mini-Mental State Examination (MMSE)• Nursing Delirium Screening Scale (Nu-DESC)• Vigilance “A” Test

Confusion Assessment Method (CAM)The copyright of the CAM is owned bySharon K. Inouye, Yale University Schoolof Medicine. A training manual andpermission to use the CAM are availableonline athttp://www.hospitalelderlifeprogram.org/pdf/TheConfusionAssessmentMethod.pdf

Tests for Attention• Squeeze or raise hand when they hear a letter in a list:• G D H A U A I W P A• Spell WORLD backwards• Recite serial 7’s or 3’s• Show pictures or objects and ask for recall in one minute• Days of the week (or months) backwards• Digit span - up to 5 forwards and 4 backwards

Labs and Imaging• Tailored to history and exam• Electrolytes• CBC if anemia is considered• LFT’s, ammonia if hepatic encephalopathy is considered• ABG for hypercarbia• Toxicology screen and drug levels• Cultures and UA• CXR• MRI Brain• EEG• Lumbar Puncture

Prevention and Management of Delirium in the Older Hospitalized Patient.Inouye SK. N Engl J Med 2006;354:1157-1165.

Delirium Management• Make diagnosis• Support/educate patient and family• Non pharmacologic interventions• Establish goals (need prognosis)• Consider work up/treatment of potentially correctibleetiologies• Aggressively treat distressing symptoms

Non-pharmacologic Interventions• Cognitive• Orientation (calendar, caregiver names)• Activities (cognitively stimulating)• Sleep• Regular routine• Sleep aids (relaxing music, massage)• Environmental (eliminate noise, night time meds)• Mobility (range of motion, limit IV’s, etc)• Visual Aids (glasses, large dial phones, etc)• Hearing Aids (check ear wax)• Volume repletion for dehydration (beverage of choiceavailable and offered frequently)

Pharmacologic Treatments• No medication is FDA approved for the treatment ofdelirium• No published double blind, randomized, placebocontrolled trials• Few controlled trials• Small numbers• Various patient populations• post op, ICU, cancer, AIDS, hip fractures

Haldol vs. Benzodiazapenes• Double blind RCT• 244 AIDS patients• 30 (12%) patients developed delirium• Haloperidol (n =11)• Chlorpromazine (n = 13)• Lorazepam (n = 6)• Haloperidol equivalent to chlorpromazine > lorazepam

Inouye SK. N Engl J Med 2006;354:1157-1165

Antipsychotics• Typicals (haloperidol, chlorpromazine) have greatestevidence base, are cheaper, and have multiple routes ofadministration

Antipsychotics & Black Box• Mortality increased in dementia with antipsychotics• Black Box Warning Issued in 2004• Consistent across all antipsychotics• Relative risk = 1.6 1.7• Absolute risk = 3.5% vs. 2.3% with placebo• Number Needed to Harm = 83• Number need to treat = 5 14• For every 9 25 persons helped, 1 death associated with use• Delirium• No evidence that mortality is increased• Not examined closely

Prevention• Prospective matched trial of usual care vs ELP (Elder LifeProgram) in 852 enrolled patients• Inouye SK. A Multicomponent Intervention to Prevent Delirium inHospitalized Older Patients. N Engl J Med. N Engl J Med 1999;340:669-676• Geriatric Consult• Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducingdelirium after hip fracture: a randomized trial. J Am Geriatr Soc2001;49:516-522• Antipsychotics• Kalisvaart KJ, de Jonghe JF, Bogaards et al. Haloperidol prophylaxisfor elderly hip-surgery patients at risk for delirium: a randomizedplacebo-controlled study. J Am Geriatr Soc. 2005;53:1658-66.

Risk Factors for Delirium and Intervention Protocols.Inouye SK et al. N Engl J Med 1999;340:669-676.

Cumulative Incidence of Delirium According to Study Group.Inouye SK et al. N Engl J Med 1999;340:669-676.

Prevention – ELP intervention• The cost of intervention per case of delirium preventedwas $6,341• No difference in LOS or mortality• HELP (Hospital Elder Life Program)• http://www.hospitalelderlifeprogram.org/public/public-main.php

Prevention – Geriatric Consult• Geriatric Consultation• 126 patients aged 65 and older admitted emergently with hipfracture• Randomized trial of Usual care vs Geriatric consults• Average of 10 (!) recommendations with 77% compliance• Delirium in consult group reduced by over 1/3• Severe delirium in consult group reduced by over 1/2

Prevention - Medication• High risk patients with hip fractures received haloperidol0.5mg three times daily• Reduced severity and duration of delirium but notincidence• All three approaches were preventative

Delirium at end of life• Up to 85%• At end of life, etiology varies• 42% dehydration• 29% liver failure• 25% medication• Why treat?• QOL• Time for patient and family• Can help 50% of the time• Constipation, Retention• Adjust medications• Hydrate as per family and patient wishes

Guidelines and Resources• PIER from ACP• http://pier.acponline.org• American Psychiatric Association• http://psychiatryonline.org/guidelines• National Institute for Excellence (NICE)• http://www.nice.org.uk/cg103• Vanderbilt University ICU• www.ICUdelirium.com (Pocket cards can be downloaded here)

Patient and Family information

Selected References• Marcantonio ER. In the clinic. Delirium. Ann Intern Med.2011 Jun 7;154(11):ITC6-16.• Lonergan E, Britton AM, Luxenberg J, Wyller T.Antipsychotics for delirium. Cochrane Database Syst Rev.2007:CD005594.• Inouye SK. Delirium in older persons. N Engl J Med.2006;354:1157-65.