Delirium in the Elderly Evaluation and Management

1、Delirium in the Elderly: Evaluation and ManagementM. Andrew Greganti, MDSeptember 9, 2008Outline of DiscussionCase PresentationCharacteristics of Delirium Etiology/Pathogenesis Risk FactorsPrevalenceClinical PresentationDiagnosisEvaluationPrevention and TreatmentCase Presentation86 yo woman presents

2、 with confusion post hip fracture surgery. Medical Problems:CHF - compensated Pacemaker for sick sinus syndrome Chronic atrial fibrillationChronic anxiety about health Case PresentationLong-term resident of life care community living in an intermediate care facilitySevere anxiety with tendency to ob

3、scess over health issuesLess intellectually “sharp” over previous 6 monthsIncreasing anxiety levelHospital CourseIn the ED could not process that she had broken her hipNo immediate perioperative complications Postop day 2: Confused, agitated, waxing and waning of sensoriumDifficulty recognizing fami

4、lyMisinterpreted environmental stimuli“Sundowning” requiring a sitterHospital CourseHypoxia secondary to aspirationImproved post antibioticsConfusion and difficulty understanding directions - effective PT impossiblePoor hearing exacerbated confusion.Hospital CourseAfter 10 days, cognition improved b

5、ut not back to baselineDischarged to skilled nursing floor of her life care community with persisting:Confusion DisorientationSevere anxietyPoor recent memoryPost Hospital CourseFell 2 months post discharge, fracturing R ankleSevere delirium postop marked by episodic yelling outNever returned to bas

6、eline: Intermittent confusion Somnolence followed by agitation Repetitive vocalizationsPartial response to clonazepam 0.25mg tidPartial response to olanzepine 2.5mg am, 5mg pmCharacteristics of DeliriumDisturbance of consciousnessAbnormal cognitionOrientationAttention MemoryThought processingPercept

7、ionAcute in onset and fluctuating in coursePrecipitated by acute medical illness, medication, or substance intoxicationHyperactive, hypoactive, and mixed formsOther CharacteristicsMisdiagnosis is frequent confused with depression and mania May develop over hours to days. Abrupt onset more common.The

8、 line between dementia and delirium is often unclear.Etiology Etiology - Multifactorial in a patient predisposed by underlying dementia and/or other conditions:InfectionsToxins, including drugsSubstance withdrawalOrgan failure: heart, liver, kidney, etc.Metabolic derangementsPrimary brain disordersP

9、athogenesisPathogenesis:No specific structural brain lesion identified:Subcortical: thalamus, pontine reticular activating system, basal ganglia involvedCortical: frontal, parietal, and temporal lobe dysfunctionEEG showing slow waves but nonspecificDepleted acetylcholine Dopamine, GABA, serotonin, a

10、cetylcholine imbalanceCytokine activation (sepsis)How common is delirium?On admission to medical wards, 15 to 20% of older patients meet criteria for delirium.Incidence during medical hospitalization: 5 to 10% - in some studies 30%.Prevalence higher in postop patients:10 to 15% post general surgery

11、30% post cardiac surgery50% post hip fractureRisk FactorsDementia is the strongest risk factor 25 to 75% of patients have dementia.Other predisposing brain diseases: stroke, ParkinsonsAdvanced ageSevere medical illnessHyponatremia, dehydration, other metabolic problemsAnticholinergic drugs, sedative

12、 hypnotics, narcoticsOther Risk FactorsLow activity levelHearing or vision impairmentNumber of hospital room changesEnvironmental high noise levelMale genderProdromePatients may describe and/or manifest:Decreased concentrationIrritability, restlessness, anxiety, depressionHypersensitivity to light a

13、nd soundPerceptual disturbancesSleep disturbance - daytime somnolence and nocturnal agitationClinical PresentationDisorientation to place, time, situationImpaired consciousnessReduced awarenessReduced or clouded consciousness with or without overt hallucinationsClinical PresentationDecreased ability

14、 to focus, sustain, or shift attention Decreased selective attentionDistractibilityCognition is made worse by inattention.Speech: Tangential Poorly organizedSlowed, slurred Word finding difficultiesClinical PresentationImpaired registration, recent/remote memory with associated confabulationPerceptu

15、al abnormalities: MicropsiaMacropsia Frank auditory or visual hallucinations, distortion of body imageMay take action in response to hallucinationsDiagnosisHistory from family and/or caregiversBedside observationsDSM-IV diagnostic criteriaReliable diagnostic instruments: Confusion Assessment MethodT

16、he Delirium Rating Scale- Revised-98 Delirium Symptom ReviewDiagnostic errors are common in: Hypoactive form The setting of rapid fluctuations of cognition. Those with the patient the entire day (nurses) or less likely to be deceived.Differential DiagnosisDementiaAlzheimer dementiaLewy body dementia

17、Functional psychiatric disorders delusional psychosis or depressive statesMisdiagnosed as depression in as many as 40% of cases Schizophrenia has a more chronic hx with highly systematized delusions.PrognosisDelirium is independently associated with:Increased functional disability Increased LOS Admi

18、ssion to long-term careIncreased hospital mortality of 2 to 20 fold May persist for months or indefinitely Two factors related to better outcomes:Admission from homeBetter premorbid functioning EvaluationSearch for causative medication is especially important up to 40% of cases.Psychotropics, narcot

19、ics, anticholinergicsDigoxin, prednisone, furosemide, cimetidine have anticholinergic properties.EvaluationCBC, electrolytes, BUN, Cr, glucose, LFTs, albuminO2 SaturationUrinalysisTSH, B12? Toxin screenCXRCNS imaging remains debatable. LP in febrile patient with meningeal signsPhysostigmine challeng

20、e test in some patientsCause not identified in 15 to 25%Preventive Measures PerioperativelySupportive overall approach with constant reorientationEffective management of anxietyEffective management of painCareful preop medical evaluation:Check meds Metabolic parametersBaseline function, etc.Focus on

21、 assuring optimal vision and hearing.Such interventions preop in one study documented a median absolute risk reduction of 13%.TreatmentBased mainly on observational dataReduce or discontinue psychotropic, anticholinergic, narcotic meds.Careful focus on po intake, nutrition, physical therapy/mobility

22、, aspiration risk.Antipsychotics: haloperidol vs atypical antipsychotics like quetiapine, olanzepineBenzodiazepinesTreatment of “Yelling Out”Morphine for pain controlSSRIs for suspected underlying depression/anxietyBenzodiazepines for anxietyAmantadine for frontal lobe disinhibitionEnvironmental con

23、trol measuresTreatmentNonpharmacologic measures:Increase interpersonal contact and environmental support. ? use of around the clock sittersProvide clocks, calendars, soft lighting.Reduce noise levels.Maximize visual and auditory acuity.Minimize room changes in the hospital.TreatmentRecognize and treat the prodromal stage subsyndromal delirium Future therapies:Cholinergic drugs: donepezil, physostigmineBenzodiazepine receptor (GABA) antagonist especially if