CHAMPCHAMPDelirium Part 2:Delirium Part 2:Evaluation & ManagementEvaluation & Management

Andrea Bial, M.D.Andrea Bial, M.D.

University of ChicagoUniversity of Chicago

GoalsGoals

1.1. Develop a plan for teaching a Develop a plan for teaching a Systematic Approach to the Systematic Approach to the EvaluationEvaluation of hospitalized of hospitalized older patient with delirium.older patient with delirium.

2.2. Develop a plan for teaching Develop a plan for teaching an appropriate an appropriate Treatment Treatment PlanPlan for the hospitalized older for the hospitalized older patient with delirium patient with delirium

Overnight Events: Overnight Events: Morning Rounds at the Morning Rounds at the

BedsideBedside

• 75yo W admit 2d ago w/ COPD, 75yo W admit 2d ago w/ COPD, bronchitisbronchitis

• Intern reports: o/n she pulled out her Intern reports: o/n she pulled out her IV, thought she was at homeIV, thought she was at home

• X-cover ordered Prosom 1mg & po X-cover ordered Prosom 1mg & po abxabx

• Currently, pt w/o c/o. Doesn’t recall Currently, pt w/o c/o. Doesn’t recall events of previous night.events of previous night.

• PE: sleepy, arouseablePE: sleepy, arouseable

37.6 148/62 88 20 93%2L37.6 148/62 88 20 93%2L

Lungs w/ faint wheeze bilatLungs w/ faint wheeze bilat

Rest w/o changeRest w/o change

Labs WBC 13.2, diff P; H/H stableLabs WBC 13.2, diff P; H/H stable

Na 133, BUN 26, Cr 1.2Na 133, BUN 26, Cr 1.2

Overnight, cont’dOvernight, cont’d

Overnight, cont’dOvernight, cont’d

• A/P #1) COPD—cont nebs, steroids, A/P #1) COPD—cont nebs, steroids, po po abxabx

#2) HTN—stable on meds#2) HTN—stable on meds

#3) Confusion—add risperdal #3) Confusion—add risperdal 1mg 1mg QHS prnQHS prn

#4) Disp—await PT/OT#4) Disp—await PT/OT

• No one “gold standard” approachNo one “gold standard” approach• Multiple Mnemonics Multiple Mnemonics (e.g., Delirium)(e.g., Delirium) & &

algorithmsalgorithms• Need individualized, Need individualized, systematicsystematic

approach to avoid missing potential approach to avoid missing potential causescauses

• Few studies exist specifically looking Few studies exist specifically looking at causes at causes

Systematic Approach to the Systematic Approach to the Evaluation of DeliriumEvaluation of Delirium

• Francis (1990)Francis (1990)– Large teaching hospitalLarge teaching hospital– General medicine patients (n=229)General medicine patients (n=229)– Delirium developed in 22% (n=50)Delirium developed in 22% (n=50)– Determined cause(s) as: definite, Determined cause(s) as: definite,

probable, or possibleprobable, or possible• 18 (36%) w/ one 18 (36%) w/ one definitedefinite cause cause (Drug toxicity, then infection=fluid/lyte (Drug toxicity, then infection=fluid/lyte

imbalance)imbalance)• 10 (20%) w/ one 10 (20%) w/ one probableprobable cause cause• 22 (44%) w/ >1 cause; 62 22 (44%) w/ >1 cause; 62 possiblepossible etiologies etiologies

(2.8/pt)(2.8/pt)

Evaluation of Delirium: Evaluation of Delirium: CausesCauses

DELIRIUM

Evaluation Management

History (dementia?) andPhysical Exam(head to toe)

FOCAL EXAM:Do appropriate nextstep (e.g.,fevercx)

THEN, review meds& Order other tests

NON-FOCAL EXAM:Review meds

Order addn’l tests

Treat Findings &Manage symptoms

Treat Findings & Manage symptoms

NON-AGITATED PATIENT:

Non-Pharmacologictreatment

AGITATED PATIENT:

Non-Pharmacologic& Pharmacologic tx

Evaluation:Evaluation:Dementia Teaching PointsDementia Teaching Points

1.1. Hx of dementia?Hx of dementia?

2.2. Hx of sundowning?Hx of sundowning?

3.3. Agitated dementia Agitated dementia ≠ delirium≠ delirium

4. Importance of considering dx:4. Importance of considering dx:

DEMENTIA DELIRIUMDEMENTIA DELIRIUM

Evaluation: Physical ExamEvaluation: Physical Exam

• Head to toe:Head to toe:– Vitals Vitals (temp, HR, RR, BP, pulse ox, pain)(temp, HR, RR, BP, pulse ox, pain)– HeadHead (CVA, bleed, meningitis, sz, blind, (CVA, bleed, meningitis, sz, blind,

deaf)deaf)– LungLung (pneumonia, PE, CHF)(pneumonia, PE, CHF)– ChestChest (ischemia, CHF, arrhythmia)(ischemia, CHF, arrhythmia)– AbdAbd (ischemia, impaction, bleed)(ischemia, impaction, bleed)– GUGU (UTI, retention)(UTI, retention)– Extrem (pain, volume status, CVA)Extrem (pain, volume status, CVA)– SkinSkin (pressure ulcer, volume status)(pressure ulcer, volume status)

• No evidence to support routine No evidence to support routine orderingordering

• Order if: Order if: – new focal finding(s) on examnew focal finding(s) on exam– head traumahead trauma– suspicion of encephalitissuspicion of encephalitis– no other identifiable causes foundno other identifiable causes found

Evaluation: Head CT?Evaluation: Head CT?

Evaluation: Medication Evaluation: Medication ReviewReview

• Too little (alcohol or other drug w/d)Too little (alcohol or other drug w/d)– Francis (1990) 1/50pts (2%)Francis (1990) 1/50pts (2%)– Lawlor (2000) 4/71pts (6%)Lawlor (2000) 4/71pts (6%)

• Too much Too much – narcotics, neuroleptics, anticholinergics, narcotics, neuroleptics, anticholinergics,

antiemeticsantiemetics

Francis 1990, Schor 1992, Lawlor Francis 1990, Schor 1992, Lawlor

20002000

Evaluation: Medication ListEvaluation: Medication List

• Antibiotics (aminogly, PCN, ceph, sulfa)Antibiotics (aminogly, PCN, ceph, sulfa)• BenadrylBenadryl• Benzodiazepines (triazolam, alprazolam, diazepam)Benzodiazepines (triazolam, alprazolam, diazepam)• DigoxinDigoxin• GI (Reglan, Bentyl)GI (Reglan, Bentyl)• LithiumLithium• NarcoticsNarcotics• NeurolepticsNeuroleptics• SteroidsSteroids• NSAIDs (Indocin)NSAIDs (Indocin)• H2 Blockers (Cimetidine,…)H2 Blockers (Cimetidine,…)• Parkinsons drugs (Levodopa, Benztropine, Amantadine)Parkinsons drugs (Levodopa, Benztropine, Amantadine)• TricyclicsTricyclics

Evaluation: Medication Evaluation: Medication ListList

• Antibiotics (aminogly, PCN, ceph, sulfa)Antibiotics (aminogly, PCN, ceph, sulfa)• BenadrylBenadryl• BenzodiazepinesBenzodiazepines (triazolam, alprazolam, diazepam) (triazolam, alprazolam, diazepam)• DigoxinDigoxin• GI (Reglan, Bentyl)GI (Reglan, Bentyl)• LithiumLithium• NarcoticsNarcotics• NeurolepticsNeuroleptics• SteroidsSteroids• NSAIDs (Indocin)NSAIDs (Indocin)• H2 Blockers (Cimetidine,…)H2 Blockers (Cimetidine,…)• Parkinsons drugs (Levodopa, Benztropine, Amantadine)Parkinsons drugs (Levodopa, Benztropine, Amantadine)• TricyclicsTricyclics

Evaluation: Medications, Evaluation: Medications, cont’dcont’d

Anticholinergic properties frequently Anticholinergic properties frequently overlooked:overlooked:

Elavil Elavil (amitriptyline)(amitriptyline) Flexeril Flexeril (cyclobenzaprine)(cyclobenzaprine)

Cogentin Cogentin (benztropine)(benztropine) Atarax/VistarilAtarax/Vistaril(hydroxyzine)(hydroxyzine) Bentyl Bentyl (dicyclomine)(dicyclomine) Welbutrin/Zyban Welbutrin/Zyban (bupropion)(bupropion) Ditropan Ditropan (oxybutynin)(oxybutynin) Antivert Antivert (meclizine)(meclizine)

Detrol Detrol (tolterodine)(tolterodine) Ipratropium Ipratropium (atrovent)(atrovent)

Benadryl Benadryl (diphenhydramine)(diphenhydramine) Phenergan Phenergan (promethazine)(promethazine)

Zyprexa Zyprexa (olanzapine)(olanzapine) AtropineAtropineLevsin Levsin (hyoscyamine)(hyoscyamine) QuinidineQuinidine

Evaluation: Additional Evaluation: Additional teststests

• Labs Labs – CBC, lytes, liver, renalCBC, lytes, liver, renal– Consider TSH, B12, cortisol, ammonia, Consider TSH, B12, cortisol, ammonia,

abgabg

• Drug levels (digoxin, etc)Drug levels (digoxin, etc)• Urine tox, Urine tox, UAUA• CXRCXR• EKGEKG • EEGEEG

Evaluation: EEGEvaluation: EEG

• Since 1950’s, recommendations for Since 1950’s, recommendations for EEGsEEGs

• Usually: generalized slowingUsually: generalized slowing• Sensitivity 75%Sensitivity 75%

Management: Non-Management: Non-Pharmacologic Pharmacologic

• CognitionCognition: orientation board (carry pen!) & open : orientation board (carry pen!) & open drapes during daydrapes during day

• SleepSleep: minimize deprivation (no 2am labs, no o/n : minimize deprivation (no 2am labs, no o/n BS/vitals if able, give meds when awake)BS/vitals if able, give meds when awake)

• MobilityMobility: OOB: OOBchair asap, PT/OT, no chair asap, PT/OT, no foley/restraintsfoley/restraints

• VisionVision: glasses: glasses• HOHHOH: get aids; adapt environment; stethoscope : get aids; adapt environment; stethoscope

tricktrick• DehydrationDehydration: po fluids; observe at mealtime; avoid : po fluids; observe at mealtime; avoid

“Boost at nightstand”“Boost at nightstand”• ObservationObservation: Involve family (rotate members) or get : Involve family (rotate members) or get

sitter; move pt to room close to RN stationsitter; move pt to room close to RN station

Management: Non-Management: Non-PharmacologicPharmacologic Restraint Use Restraint Use

• Avoid whenever possible; use only if Avoid whenever possible; use only if needed for patient or staff safetyneeded for patient or staff safety

• Increase risk of falls, injury, agitation Increase risk of falls, injury, agitation & worsened delirium& worsened delirium

• Use only in emergency, for as short a Use only in emergency, for as short a duration as possible with frequent re-duration as possible with frequent re-evaluations, and d/c asapevaluations, and d/c asap

• Absolutely no “sheeting”Absolutely no “sheeting”

Management: Management: PharmacologicPharmacologic

• Few RCT of treating delirium in hosp ptFew RCT of treating delirium in hosp pt• Extrapolation from other populations studied Extrapolation from other populations studied

(AIDS, NHs, outpatient AD, …)(AIDS, NHs, outpatient AD, …)• Mainstay of tx: antipsychoticsMainstay of tx: antipsychotics

– NOT FDA-approved for use in deliriumNOT FDA-approved for use in delirium– Need to choose type and dose carefullyNeed to choose type and dose carefully– Black box warning of increased mortality w/ use Black box warning of increased mortality w/ use

of antipsychotics in older pts (infectious and of antipsychotics in older pts (infectious and cardiac causes of death)cardiac causes of death)

• See Table in handoutSee Table in handout

Typical: HaloperidolTypical: Haloperidol

Advantages:Advantages: min sedatingmin sedatingless less ↓BP↓BP

Disadvantages: Disadvantages: ↑ ↑ sz risksz risk more EPS side effectsmore EPS side effects

↑↑ QTQT↑↑ risk of Torsadesrisk of Torsades

Dose: Dose: 0.25-0.5mg po, IM, IV *0.25-0.5mg po, IM, IV * *risk of QTc *risk of QTc

prolongation w/ IV prolongation w/ IV

APA APA 19991999

Management: PharmacologicManagement: PharmacologicAntipsychoticsAntipsychotics

Management: PharmacologicManagement: PharmacologicAntipsychotics, cont’dAntipsychotics, cont’d

Atypicals:Atypicals:

Advantages: less EPSAdvantages: less EPS +/- sedation+/- sedation

Disadvantages: Disadvantages: ↓ BP↓ BP weight gainweight gain ↑ ↑ BSBS ↑↑mx mx

(infection, CVS)(infection, CVS)

Management: PharmacologicManagement: PharmacologicAntipsychotics, cont’dAntipsychotics, cont’d

Starting Daily Doses:Starting Daily Doses:Risperidone:Risperidone: 0.25-0.5mg PO 0.25-0.5mg PO

Olanzapine: 2.5-5mg IM,POOlanzapine: 2.5-5mg IM,PO

Aripiprazole: 2-5mg POAripiprazole: 2-5mg PO

Quetiapine: 12.5mg-25 PO bid* Quetiapine: 12.5mg-25 PO bid*

*some concern for QTc prolongation; better *some concern for QTc prolongation; better in PD ptsin PD pts

Management: PharmacologicManagement: PharmacologicBenzodiazepinesBenzodiazepines

Should not be used as first-line agents; Should not be used as first-line agents; may prolong or worsen deliriummay prolong or worsen delirium

Used best if pt is delirious due to w/d Used best if pt is delirious due to w/d of EtOH or benzo’sof EtOH or benzo’s– Consider use in PD, NMSConsider use in PD, NMS– Consider use as second-line, esp if Consider use as second-line, esp if

sedation is desiredsedation is desired

Lorazepam 0.5-1mg PO, IM, IV q4-6hrsLorazepam 0.5-1mg PO, IM, IV q4-6hrs (no adjustment needed (no adjustment needed

for liver or renal dz)for liver or renal dz)

Management: PharmacologicManagement: PharmacologicBottom LineBottom Line

• Try to avoid meds, but if needed:Try to avoid meds, but if needed:– Use haloperidol (or olanzapine) in acute Use haloperidol (or olanzapine) in acute

settings; start low and titrate carefully settings; start low and titrate carefully according to symptoms.according to symptoms.

– Use risperidone, if needed for longer-Use risperidone, if needed for longer-term use (unless PD: quetiapine or term use (unless PD: quetiapine or lorazepam)lorazepam)

– Use lorazepam for w/dUse lorazepam for w/d

Back to case!Back to case!

• 75yo W admit 75yo W admit 2d ago2d ago w/ COPD, bronchitis w/ COPD, bronchitis• Intern reports: o/n she pulled out her IV, thought she was a homeIntern reports: o/n she pulled out her IV, thought she was a home• X-cover ordered X-cover ordered Prosom 1mgProsom 1mg & po abx & po abx• Currently, pt w/o c/o. Currently, pt w/o c/o. Doesn’t recall events of previous night.Doesn’t recall events of previous night.• PE: sleepy, arouseablePE: sleepy, arouseable

37.6 148/62 88 20 37.6 148/62 88 20 93%2L93%2LLungs w/ faint wheeze bilatLungs w/ faint wheeze bilatRest w/o changeRest w/o changeLabs Labs WBC 13.2, diff PWBC 13.2, diff P; H/H stable; H/H stable

Na 133Na 133, BUN 26, Cr , BUN 26, Cr 1.21.2• A/P A/P #1) COPD—cont #1) COPD—cont nebsnebs, , steroidssteroids, po , po abxabx

#2) HTN—stable on meds#2) HTN—stable on meds #3) Confusion—add #3) Confusion—add risperdal 1mg QHS prnrisperdal 1mg QHS prn #3) #3) DispDisp—await PT/OT—await PT/OT

Teaching PointsTeaching Points

1.1. Ask: What do you think caused last Ask: What do you think caused last night’s events?night’s events?

– Was a h/o dementia missed?Was a h/o dementia missed?(dementia/delirium relationship; role of MMSE; (dementia/delirium relationship; role of MMSE;

further family hx)further family hx)

– Was her PE different at the time x-cover Was her PE different at the time x-cover was called?was called?(systematic evaluation/head-to-toe)(systematic evaluation/head-to-toe)

– Did we start or alter dose of any Did we start or alter dose of any medications?medications?(nebs, steroids, abx)(nebs, steroids, abx)

Teaching Points, cont’dTeaching Points, cont’d

2.2. Ask: Is she delirious now?Ask: Is she delirious now?– Discuss use of CAMDiscuss use of CAM

(comfort of tool; dx of delirium in chart)(comfort of tool; dx of delirium in chart)

– Discuss outcomes of deliriumDiscuss outcomes of delirium(increases: LOS, healthcare costs, mx, d/c to (increases: LOS, healthcare costs, mx, d/c to LTCF)LTCF)

– Discuss use of Prosom (and other Discuss use of Prosom (and other benzo’s) in deliriumbenzo’s) in delirium

Teaching Points, cont’dTeaching Points, cont’d

3.3. Ask: Is there anything we should do Ask: Is there anything we should do today to follow-up on her confusion?today to follow-up on her confusion?

– Discuss further studies that may or may Discuss further studies that may or may not be needednot be needed(CXR? UA? Repeat Na?)(CXR? UA? Repeat Na?)

– Discuss the non-pharmacologic Discuss the non-pharmacologic measures that should be put into place measures that should be put into place (orient board, fluids, mobility, drapes, HS nebs (orient board, fluids, mobility, drapes, HS nebs & labs)& labs)

– Discuss use of risperidone (and other Discuss use of risperidone (and other antipsychotics) in deliriumantipsychotics) in delirium

Recommended ReadingRecommended Reading

• Inouye SK. Delirium in older persons. NEJM Inouye SK. Delirium in older persons. NEJM 2006;354:1157-652006;354:1157-65

• Schneider LS et al. Effectiveness of atypical Schneider LS et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s antipsychotic drugs in patients with Alzheimer’s disease. NEJM 2006;355:1525-38.disease. NEJM 2006;355:1525-38.

• Sink KM et al. Pharmacological treatment of Sink KM et al. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA neuropsychiatric symptoms of dementia. JAMA 2005;293:596-608.2005;293:596-608.

• Breitbart W et al. Agitation and delirium at end of Breitbart W et al. Agitation and delirium at end of life. JAMA 2008;300(24)2898-2910.life. JAMA 2008;300(24)2898-2910.

• Martins S. Delirium in elderly people: a review. Martins S. Delirium in elderly people: a review. Front Neuro 2012;3(101)1-12.Front Neuro 2012;3(101)1-12.