Management of Delirious States In The Elderly

George T. Grossberg, MDSamuel W. Fordyce Distinguished Professor

Director, Geriatric Psychiatry Department of Neurology & Psychiatry

Saint Louis University School of Medicine

Disclosure

No relevant disclosures for this presentation.

Presentation Architecture

• Defining delirium including screening, tools• Prevalence• Risk factors• Pathophysioloy• Treatment

• Non-pharmacologic• Pharmacologic

• Conclusions

Defining Delirium in the Elderly

• Often called: acute confusion or acute cognitive/mental status change

• Central features include:– Acute/dateable onset with fluctuating course– Disturbance of consciousness (drowsy for hyper-alert)– Inattention (problem focusing or maintaining/shifting focus)– Disturbance of sleep/wake cycle; perception; and thinking

(disorganized, incoherent)– Reduced awareness of environment

Ref: DSM – IV- TR- Am Psychiatry Association; 2000

Defining Delirium in the Elderly (cont.)

• Acute onset (hours/ 1-2 days) vs. Subacute onset (days to weeks)

• Delirium may be accompanied by psychosis (usually visual hallucinations)

• Should always be assumed to be reversible until proven otherwise.

Prevalence of Delirium in Elderly

• Varies according to population examined– In ICU – 70-87%1

– In hospital – 6-56%– Post-Op – 15-62%– Long-Term care – Up to 60% at some point

during their stay2

Ref: 1. Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nat Rev Neurol 2009. 2. Fann JR. The epidemiology of delirium. Seminars in Clinical Neuropsychiatry, 2000

Risk Factors for Delirium

• Advanced Age• Pre-existing Cognitive Impairment• Increased number of medical co-

morbidities• Increased medications

Ref: Saxena S, Lawley D: Delirium in the elderly: a clinical review. Postgrad Med J 2009

Delirium Subtypes

1. Agitated / increased psychomotor activity – hyperalert – hallucinations – inappropriate behavior – 25-30%

2. Quiet/decreased psychomotor activity – apathetic, lethargic, withdrawn, often missed – 50-55%

3. Mixed delirium – fluctuates between agitation and quiet confusion

4. Normal psychomotor activity

Ref: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

The CAM

Features 1. Acute Onset and Fluctuating Course2. Inattention3. Disorganized thinking4. Altered level of Consciousness

Diagnosis requires presence of 1 and 2 and either 3 or 4

Ref: Inouye S, van Dyck C, Alessi C, et al. Clarifying confusion: the confusion assessment method. Annals of Internal Medicine, 1990

Delirium in LTC – Assessment Pearls

• CNA or housekeeping staff report that resident is not acting like her or himself (last 1-5 days)

• Resident who was at least partly oriented is now acutely disoriented; distractible; disorganized in thinking/speech

• Acute onset (1-5 days) of depression; or not eating; or of agitation

• Sudden exacerbation of BPSD• Frequent napping, but arrousable• Inability to repeat 5 digit number – new onset

Ref: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

Pathophysiology of Delirium

• Not well understood• Reversible dysregulation of neuronal

membrane function neurotransmitter alterations: – Acetylcholine deficiency– Dopamine increase– GABA/NE – less studied

Ref: Maldonado JR. Delirium in the acute care setting: characteristics, diagnosis and treatment. Crit Care Clin, 2008.

Pathophysiology of Delirium (cont.)

• Direct neuronal injury e.g. hypoxia, hypoglycemia

• Inflammation – systemic• Stress response• Neuroanatomic changes – cortical atrophy,

ventricular enlargement, white-matter lesions

Ref: Mittal V, Muralee S, Williamson D, McEnerney N, Thomas J, Cash M, Tampi RR. Am J Alzheimers Dis Other Demen. 2011 .

Treatment of Delirium Is Identifying the Cause: Treating It

• Dehydration• Electrolyte imbalance; Endocrine; End-organ failure; ETOH; Electrical

(Brain + Heart)• Lack of oxygen to brain – TIA/CVA, MI, PE, AF, COPD• Injury (hip fx; subdural); Impaction; Intestinal obstruction• Rule our other psychiatric disorders: mania, depression, psychosis,

PTSD• Infection (urinary, pulmonary, cellulitis)• Urinary retention; unfamiliar environment• Medication – anticholinergics; benzos (intoxications withdrawal;

Opiates; Malignancy)

Adapted from Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

Treatment/Identifying Cause(s) of Delirium

• Review of systems/ Head to Toe Approach• Ask: What has gone wrong acutely in this 85 y/o to

upset the delicate cognitive equilibrium she/he was having

• Always start with medication review including OTC, herbs, supplements. Focus on what has been recently started or dose increased

• Always consider a UTI-early

Untreated Delirium In The Elderly

• Increased mortality – 10-65% in hospital and 30% over 6 months in ER1

• In LTC- associated with increased mortality, hospitalization, risk of falls, increases caregiver burden, accelerated cognitive decline2

Ref: 1. Kakuma R, du Fort GG, Arsenault L et al. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc 2003;

2. Gleason OC. Delirium. American Family Physician. 2003

Treatment of Delirium –Non-pharmacologic

• Psycho-social environmental interventions are primary and include:– Bright light; massage/aromatherapy; soothing music

(Snoezelen room); one-on-one monitoring, presence of family members; orientation via clocks/calendars; minimize physical restraints; address hearing/vision/sensory impairments; a quiet environment.

Ref: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

Pharmacologic Treatment of Delirium

• No FDA-Approved treatments• Mandatory if safety of patients or staff/family is an

issue• Antipsychotics (PO or IM) are first line

– Haloperidol (oral tablet/liquid, IM, IV)• 0.25 – 0.5 mg and 30 minutes to achieve sedation• Beware of EPS and akathisia

• Risperidone (liquid/tablet)– 0.125 – o.25 mg and 30 minutes to achieve sedation

Ref: 1) Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment of delirium: a sys- tematic review. J Clin Psychiatry. 2007. 2)Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

Pharmacologic Treatment of Delirium (cont.)

• Quetiapine (po) 12.5-25 mg qid –up to 200 mg/ day⁻ Beware of sedation and orthostatis

• Ziprasidone (IM) – 10-20 mg up to 80 mg /day⁻ Beware QT prologation

• Aripiprazole (IM) – 5-10 mg up to qid- Beware akathisia

• Olanzapine (IM) 5-10 mg up to qid- Beware sedationWith all antipsychotics “Black-Box Warning” in patients with

dementia

Ref: 1. Seitz DP, Gill SS, van Zyl LT. Antipsychotics in the treatment of delirium: a sys- thematic review. J Clin Psychiatry. 2007. 2. Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

Outcomes of Delirium

1. Complete resolution (days to weeks) – usually in patients who are cognitively intact at baseline

2. Persistent delirium (weeks to months) – in those with cerebrovascular disease or end-organ failure; pre-existing cognitive impairment.

3. Delirium followed by progressive dementia – patient had subtle, undiagnosed, pre-existing dementia

4. Delirium causing dementia – controversial5. Accelerated cognitive decline with pre-existing dementia

Ref: 1. Inouye SK. Delirium in older persons. NEJM 2006. 2. Inouye SK, Ferrucci L. Elucidating the pathophysiology of delirium and the inter-relationship of delirium and dementia. J Gerontol Med Sci. 2006.

Strategies To Reduce Risk of Delirium In LTC

• Obtain pro-active geriatric consultation (Gero Psych, Geromed) for residents admitted for rehab from hospital or high-risk (cognitively impaired) patients

• Decrease anti-cholinergic drugs• Decrease unnecessary meds• Monitor for UTI• Reduce indwelling catheters and restraints• Use interventions to prevent infections e.g. vaccines• Diagnose/treat dementias in their early stages• Reduce inactivity/immobility (walk 1-3x/day)• Treat depression and pain optimally

Adapted from: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

Strategies To Reduce Risk of Delirium In LTC (cont.)

• Institute sleep enhancing strategies/avoid sleep deprivation• Treat hearing/vision impairment• Improve hydration/nutritional status• Daily cognitive stimulation• Provide written daily schedule/orientation strategies• Continuous activity programming – prevent boredom• Encourage residents to stay out of bed and encourage self-care

Adapted from: Desai, AK, Grossberg, GT. Psychiatric Consultation in Long-Term Care . Johns Hopkins University Press, 2010.

Conclusions

• Delirium is common in the elderly and is associated with increased morbidity and mortality

• Prompt diagnosis, through evaluation and appropriate treatment of delirium is crucial

• Prevention strategies may be useful