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Delirium in the Older Adult Patient: Not Just Altered Mental Status Lisa R. Mack, MD, FACEP...

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Delirium in the Older Adult Patient: Not Just Altered Mental Status Lisa R. Mack, MD, FACEP Assistant Professor Emergency Medicine Emory University, Atlanta, GA June 14, 2003 Georgia College of Emergency Physicians
  • 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???