Incidence Among Elderly Patients is HIGH

UMMS CRIT Module II: Delirium in the Elderly

Sarah McGee, MD, MPHDepartment of MedicineDivision of Geriatric MedicineUniversity of Massachusetts Medical School

UMMS CRIT 2010 Module II: Delirium

Advancing Geriatrics Education (AGE) A UMMS initiative funded by the Donald W. Reynolds Foundation

• 1/3 of patients presenting to ER• 1/3 of inpatients aged 70+ on general med units• Incidence ranges 5.1% to 52.2% after noncardiac surgery

– 15-53% of older patients post op– Highest rates after hip fracture and aortic surgeries– 70-87% of patients in the ICU

Dasgupta M et al. J Am Geriatr Soc 2006;54:1578-89

Incidence Among Elderly Patients is HIGH



• One-year mortality: 35-40%• Independent predictor of higher mortality up to 1 year after occurrence• Hazard Ratio between 2 and 3

– Elderly medical inpatients: Adjusted for dementia, comorbidity, clinical severity, APACHE II score, admitting service (med vs. geri), demographic variables (McCusker J et al. Arch Intern Med. 2002; 162:457-463)

– Mechanically ventilated MICU & CCU patients: Adjusted for coma, age, Charlson Comorbidity Index, APACHEII score, SOFA, admitting diagnosis of sepsis or ARDS, sedative and narcotic use

Ely EW et al. JAMA. 2004; 291:1753-62

Delirium: Increased Mortality



• Functional decline• New nursing home placement• Persistent cognitive decline:

– 18-22% of hospitalized elders with complete resolution 6-12 months after discharge

– CAVEAT: Many subjects with preexisting cognitive impairment

Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704

Delirium: Increased Risk of…



• Complicates the hospital stays for >7.3 older pts• Diagnosis increases the hospital costs by $2,500 per patient• 6.9 billion (2004) of Medicare hospital expenditures

Delirium: Costs



• DELIRIUM: ICD-9 code 780.09• “Δ MS” or “mental status change”:

– No ICD-9 code

Diagnosis: Call it what it is…



Why is diagnosis not made?

• Fluctuating course• Overlap with dementia• Lack of formal cognitive assessment• Under appreciation of consequences• Failure to consider it important



Diagnosis: Confusion Assessment Method (CAM)

1. Acute change in mental status with a fluctuating course

2. Inattention

AND

3. Disorganized thinking

or

4. Altered level of consciousness

Inouye SK et al. Ann Intern Med. 1990; 113: 941-948

Sensitivity: 94-100%; Specificity: 90-95%



How to Distinguish Delirium from Dementia

• Features seen in both:– Disorientation– Memory impairment– Paranoia– Hallucinations– Emotional lability– Sleep-wake cycle reversal

• Key features of delirium:– Acute onset– Impaired attention– Altered level of

consciousness



Delirium may be the only manifestation of life-threatening illness in the elderly patient.

Assume it is Delirium until Proven Otherwise



A Model of Delirium

A multifactorial syndrome that arises from an interrelationship between:

• Predisposing factors a patient’s underlying vulnerability

AND• Precipitating factors noxious insults



Predisposing Factors (vulnerability) versus Precipitating Factors (insults)



Predisposing Factorsi.e. baseline underlying vulnerability

• Baseline cognitive impairment– 2.5 fold increased risk of

delirium in dementia patients

– 25-31% of delirious patients have underlying dementia

• Medical comorbidities:– Any medical illness

• Visual impairment• Hearing impairment• Functional impairment• Depression• Advanced age• History of ETOH abuse• Male gender



Precipitating Factorsi.e. noxious insults

• Medications• Bed rest• Indwelling bladder catheters• Physical restraints• Iatrogenic events• Uncontrolled pain• Fluid/electrolyte abnormalities

• Infections• Medical illnesses• Urinary retention and fecal

impaction• ETOH/drug withdrawal• Environmental influences



Some Drug Classes Associated with Delirium

• Medications with psychoactive effects: – 3.9-fold increased risk – 2 or more meds: 4.5-fold

• Sedative-hypnotics: 3.0 to 11.7-fold• Narcotics: 2.5 to 2.7-fold• Anticholinergic drugs: 4.5 to 11.7-fold• Risk of delirium increases as number of meds prescribed rises



Prevention of Delirium: It can be done!

Find patients with 1 to 4 of the following predisposing characteristics:

•Visual impairment (worse than 20/70 corrected)•Severe illness•Cognitive impairment (MMSE<24/30)•High BUN/Cr ratio (>18)

Inouye SK et al. Ann Intern Med. 1993; 119:474-481



Prevention = Good Hospital Care for the Elderly Patient

RISK FACTOR INTERVENTION

Cognitive impairment Orientation protocol, cognitively stimulating activities 3x/day

Sleep deprivation Nonpharmacologic protocol, noise reduction, schedule adjustments

Immobility Ambulation or active ROM exercises; minimize equipment

Visual impairment Glasses or magnifying lens, adaptive equipment

Hearing impairment Portable amplifying devices, earwax disimpaction

Dehydration Early recognition and volume repletion

Inouye SK et al. NEJM. 1999;340:669-76



A Multicomponent Intervention to Prevent Delirium

Outcome(n=852)

Intervention group

Usual care group Statistical analysis

1st delirium episode 9.9% 15% OR=0.60 (95% CI 0.39 to 0.92)

Total days delirium 105 161 P=0.02

# delirium episodes 62 90 P=0.03

Inouye SK et al. NEJM. 1999;340:669-76



Find and treat the underlying disease(s) and contributing factors– Comprehensive history and physical– Including neurological and mental status exams– Choose lab tests and imaging studies based on the above– Review medication list

Keys to Effective Management



Always Try Nonpharmacologic Measures First

• Presence of family members• Interpersonal contact and reorientation• Provide visual and hearing aids• Remove indwelling devices: i.e. Foley catheters• Mobilize patient • A quiet environment with low-level lighting• Uninterrupted sleep



• Use drugs only if absolutely necessary: harm, interruption of medical care• First line agent: haloperidol (IV, IM, or PO)

– For mild delirium: • Oral dose: 0.25-0.5 mg• IV/IM dose: 0.125-0.25 mg

– For severe delirium: 0.5-1 mg IV/IM repeated q30 min until calm• Patient will likely need 2-5 mg total as a loading dose

– Maintenance dose: 50% of loading dose divided BID• May use olanzepine and risperidone

Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD05594

Management: Hyperactive, Agitated Delirium



• Second line agent• Reserve for:

– Sedative and ETOH withdrawal– Parkinson’s Disease– Neuroleptic Malignant Syndrome

What about Ativan (lorazepam)?



AVOID RESTRAINTS AT ALL COSTS:Measure of LAST(!!!) resort

Delirium in the Elderly: Take Home Points



• A multifactorial syndrome: predisposing vulnerability and precipitating insults

• Delirium can be diagnosed with high sensitivity and specificity using the CAM

• Prevention should be our goal• If delirium occurs, treat the underlying causes• Always try nonpharmacologic approaches • Use low dose antipsychotics in severe cases

Delirium in the Elderly: Take Home Points

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Incidence Among Elderly Patients is HIGH