Delirium in the Older Adult Patient: Not Just Altered Mental StatusLisa R. Mack, MD, FACEPAssistant Professor Emergency MedicineEmory University, Atlanta, GAJune 14, 2003

Georgia College of Emergency PhysiciansSt. Simons Island, Georgia

GoalFor you to recognize delirium as a specific disease entity and to begin ruling it in or out in your patients with AMS

ObjectivesIdentify the 4 risk factors for deliriumIdentify the 4 features of the CAM diagnostic algorithm and the criteria for diagnosing deliriumIdentify the top 3 causes of deliriumState the pharmacological treatment for delirium

Delirium?Case 1: Patient dozes off when youre trying to talk to himCase 2: Mr. P. keeps picking at his bed clothes as you try to talk to himCase 3: The nurse asks you to prescribe something to stop Mrs. B from being agitated, but when you go in to see her she looks fine

DefinitionOlder adult= age > 65Delirium= A disturbance of consciousness and an acute change in cognition or perception3 types:Hyperactive (22-30%)Hypoactive (24-26%)Mixed (42-46%)

Why Important?In 2000, a consensus panel identified delirium as 1of 3 target conditions for quality improvement in older patients*Missed diagnosis in up to 67% of pts.Up to 55% of ED patients*Prevalence in ED is 9.6 % *Bundled as AMS by ED physicians

*Sloss, EM, et al. J Am Geriatric Soc. 2000*Hustey, FM et al. Academic EM 2000*Elie, M. Et al. CMAJ 2000

Why Important? cont.Under-recognized as a disease entityCase 1, 2, 3Increased morbidity/mortality*Increased costsMajority of causes are reversiblePotentially preventable

*Kakuma, R et al. J Am Ger Soc. April 2003

Prevention1993 Inouye identified 4 independent and cumulative risk factors:Vision impairmentSevere illness (APACHE II score

Prevention cont.1999, Inouye et al NEJM: A multicomponent intervention to prevent delirium in hospitalized older patients.-Delirium developed in 9.9% ofinterventional group vs 15% control -Improvement in cognition and reduction inuse of sleep medication were significant-Delirium prevented, but no impact on severityor recurrence once it developed

What we know:Intervention before onset reduces delirium*A validated assessment tool exists (CAM); 95-100% sens.; 89-100% spec. +

So why are we frequently missing the diagnosis?

*Inouye, SK et al. NEJM 1999; AGS Mtg May 2003 few studies ongoing+Ely, EW et al.Crit Care Med 2001; Monette, J et al General Hosp Psych 2001

Barriers to diagnosisIndividual patient presentationThe presentation of severe illness in older peopleDifferential diagnosisVascular dementia may present w/acute cognitive declineHypoactive delirium may be mistaken for depression

The DiagnosisDelirium is a clinical diagnosisThe criteria: Confusion Assessment Method (CAM)InattentionAcute onset and fluctuating symptomsAltered level of consciousnessDisorganized thinking

Must have 1 and 2 and either 3 or 4

Inattention Inability to shift attention (Perseverance)Inability to focusSimple test:Recite the days of the week backwardDigit span test (repeat 5 numbers forward without errors)

Acute onset/fluctuatingSxs usually present for

Altered Level of ConsciousnessHyperactive vs hypoactiveAlert (normal)VigilantLethargic (drowsy, but easily aroused)StuporComa

Disorganized ThinkingRamblingIllogical conversation

ManagementRecognize and treat the underlying causeModify the environmentControl the symptoms

EtiologiesTop 3 causes:InfectionMetabolic disturbancesMedications-anticholinergics-opiates

Etiologies cont.AMICVADrug withdrawal

The work-up therefore reflects the above: CBC,Chem, U/A, CXR, ECG, +CT scan, +Drug screen

EnvironmentKeeping patient oriented to time/placeAdequate lighting, routine sleep timesInvolving friends/family

Symptom controlFirst-line treatment= HaloperidolLeast anticholinergic activityRapid onsetDose: 0.25- 0.5 mg, max 5mg/24hrBDZs= first-line tx in ETOH w/drawalLorazepam 0.25-1 mg, titrate

Symptom control cont.Haloperidol plus lorazepamSynergistic effectAllows for lower doses of haloperidol and therefore reduced extrapyramidal effects

Note: BDZs can actually cause a paradoxical reaction of agitation

SummaryDelirium is misdiagnosed in up to 55% of ED patientsThe 4 risk factors of delirium are:The 4 features of the CAM are:The top 3 causes of delirium are:The drugs used to control symptoms are:

Take Home PointsDelirium is not a just AMSED physicians need to recognize delirium as a distinct disease entityED physicians need to recognize risk factors for delirium to assist in prevention

Questions???