Delirium: Prevention, Assessment and Management during the COVID-19 Pandemic

David Conn - Baycrest & U. of Toronto

May 2020

ECHO Ontario: Care of the Elderly

Faculty/Presenter Disclosure

• Faculty: David Conn

• Relationships with commercial interests:– Grants/Research Support: None

– Speakers Bureau/Honoraria: None

– Consulting Fees: None

Disclosure of Commercial Support

• This program has NOT received financial support other

than the support of the MOHLTC

• This program has NOT received in-kind support

• Potential for conflict(s) of interest:

None to be disclosed

Mitigating Potential Bias

The information presented in this CME program is based on

recent information that is explicitly ‘‘evidence-based’’.

This CME Program and its material is peer reviewed and all

the recommendations involving clinical medicine are based

on evidence that is accepted within the profession; and all

scientific research referred to, reported, or used in the

CME/CPD activity in support or justification of patient care

recommendations conforms to the generally accepted

standards

By the end of the session participants will:

• Be able to list key precipitating factors for Delirium

• Be able to select appropriate screening tools

• Be able to describe some strategies to prevent delirium

• Be aware of the association between COVID-19 and delirium

• Be able to outline management approaches in the current circumstances

DSM-5 Criteria for Delirium

A. A disturbance in attention and awareness (reduced orientation)

B. Develops over a short period, represents a change from baseline and tends to fluctuate in severity during the course of a day

C. An additional disturbance in cognition (e.g. memory, disorientation, language, visuospatial ability or perception)

D. A and C are not better explained by another pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal (e.g. coma)

E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies.

Maldonado, 2017

Categories

• HYPOACTIVE delirium (lethargic, somnolent, sluggish) - more often not recognized as they don’t cause a “disturbance”; may be seen as depressed;

• HYPERACTIVE delirium (agitated, hallucinating, inappropriateness);

• MIXED - combination of both

Maldonado, 2017, Int J Ger Psych

12

RNAO, 2016

Epidemiology – Older Individuals

• Community – 1-2% prevalence• Emergency room ~ 10%• At time of hospital admission (medical) – ~ 10-20%; during

stay another ~ 5-10% will develop• Post-operative ~ 10-15% (hip fracture ~ 40-50%)• LTC facilities – poorly studied; incidence ? • High rates in special populations- Palliative care/ advanced

cancer (80%+); ICU (70%);

• Retrospective cohort study

• 1571 residents from 12 Ontario LTC Homes

• Incidence of 40% over 32 months.

• Dementia, pain and antipsychotics associated with development of delirium

• Note – recent Spanish study: 18% incidence over 1 year(Perez-Rios et al., 2019)

Predisposing Factors

• Demographic – increasing age

• Cognition – dementia/ cognitive impairment, history of prior delirium, depression

• Function – impairment/ disability

• Sensory impairment – vision & hearing

• Intake – dehydration, malnutrition

• Drugs – number, psychotropics, alcohol misuse

• Coexisting conditions – severe medical illness

J Gen Intern Med 1998, 13:204-12

Precipitating• Drugs – psychotropics, narcotics, anticholinergics,

number, withdrawal (e.g., alcohol, benzodiazepines)

• Intercurrent illness – infections

• Surgery – orthopedic, cardiac

• Physiological – e.g. abnormal sodium

• Organ failure - hypoxia

• Environment/ interventions – ICU, use of restraints, catheterization

• Psychological - sleep deprivation, stress, inadequate pain control

What is our understanding of the underlying pathophysiology of delirium ?

Acute Brain Failure (delirium)Underlying mechanisms

Maldonado (2017)

• Neuronal aging

• Neuroinflammation

• Oxidative stress

• Neuroendocrine dysfunction

• Circadian dysregulation

• Neurotransmitter dysregulation

• Network Disconnectivity

Mechanisms of Delirium (Flacker & Lipsitz 1999)

Medications

Alcohol withdrawal

Medications

Medical illness

Surgical illnessMedications

Stroke

Cholinergic

Activation

Cholinergic

Inhibition

GABA

Activation

Hepatic Failure

Benzodiazepine and

Alcohol Withdrawal

Glutamine

Activation

Hepatic failure

Alcohol withdrawalCortisol

ExcessSerotonin

Deficiency

Serotonin

Activation

Cytokine

Excess

Dopamine

Activation

Medications

Substance withdrawal

Delirium

Surgical illness

Medical Illness

Tryptophan depletion

Phenyalanine elevationGlucocorticoids

Cushings Syndrome

Surgery Stroke

Under-recognition

• Often unrecognized by nurses and physicians; why?– Fluctuating course

– Overlap with dementia

– Lack of formal cognitive assessment

– Neglecting to determine the acuity of the change in cognition

– Under appreciation of its importance/ consequences

– Ageism (expectation; “Aren’t all older persons in hospital confused?”)

Poll: Which delirium screening tool is most often used in your setting ?

• Confusion assessment method (CAM)

• Delirium symptom interview

• Nursing delirium screening scale

• Another tool

• General assessment rather than a specific tool

Screening InstrumentsCCSMH recommends…

• The Confusion Assessment Method is recommended for screening on acute medical/surgical wards and in the ER [C]

• The Delirium Symptom Interview is additionally recommended in complex cases [C]

• Clinical Institute Withdrawal Assessment (CIWA-Ar) is recommended for monitoring symptoms of alcohol withdrawal [C]

Index episode of delirium

Prior delirium

Prior cognitive

impairment Medical

comorbidity

Increased length

of stay

Increased mortality

rate

Increased

institutionalization

Persistent cognitive

impairment

Possible Delirium Outcomes And Key Related

Factors (Adapted from Trzepacz et al, 2002)

Delirium & COVID-19

Poll: Name one factor that might increase the risk of delirium in people who have severe illness

caused by COVID-19

Helms et al. (2020). Strasbourg, France.

COVID-19: Risk factors for deliriumKotfis et al, 2020

• Direct CNS invasion by virus

• Induction of CNS inflammatory mediators

• Secondary effects of other organ systems failure

• Effects of sedatives

• Prolonged mechanical ventilation

• Immobilization

• Environmental factors e.g. isolation

Delirium and COVID-19 in the ICU (Kotfis et al., 2020)

Poll: How often can delirium be prevented in hospitals ?

• 90% of the time

• 65% of the time

• 50% of the time

• 33% of the time

• 15% of the time

YALE DELIRIUM PREVENTION TRIAL RESULTS (Inouye et al. 1999)

Outcome Intervention

Group

(N=426)

Usual Care Group

(N=426)

Matched OR

(CI)

or p-value

Incident delirium, n (%) 42 (9.9%) 64 (15.0 %) .60 (.39-.92)

p= .02

Total delirium days

No. delirium episodes

105

62

161

90

p=.02

p=.03

Delirium severity score 3.9 3.5 p=.25

Recurrence rate 13 (31.0%) 17 (26.6%) p=.62

Preventing Delirium amidst COVID-19: Recommendations and Tools for HELP Programs

Here, we provide information for HELP Programs to assist with delirium prevention when (1) HELP staff are allowed

in rooms; (2) no HELP staff are allowed in rooms

Intervention

(1) HELP ELS/ELNS visit allowed (2) No visits: Provide “Hospital Kit” (materialsand instructions) for patients in

quarantine/isolation [see next page forinstructions on assembling the Hospital Kit]

Early mobilization • Walking with patient – laps around the room

• Move regularly from bed to chair

• Range of motion exercises—instruct patient toaugment walking or if walking not possible

• Instructions: (1) Safe Walking and Range ofMotion Exercises; (2) Use of stress balls andexercise bands

• Equipment: Stress balls for squeezing (stressrelief and strengthening) and exercise bands

Therapeutic activities • Provide usual choices of therapeutic activitiesfrom HELP resources that patient enjoys

• If feasible, help patients call or FaceTime withfamily and loved ones

• Activities and Instructions: Word searches andcrossword puzzle

Orientation • If none in room, bring in mini-whiteboard withdate, location, team members, and schedule

• Provide calm, orienting communication

• “My Orientation Card” with same info as is onthe whiteboard in a HELP patient’s room

Vision and hearing impairment

• Use HELP vision and hearing protocols

• For vision-impaired patients, consider verballyreading through handouts in the “Hospital Kit”

• Adaptive equipment such as large buttontelephone. Provide magnifying glasses (properprotocol for disinfecting)

Feeding assistance/dehydration

• Encourage patients to drink six 8oz glasses offluids/day

• Note card in Hospital Kit with information onhydration, nutrition, sleep, mobility, etc.

Nighttime relaxation and sleep

• Review sleep hygiene (no caffeine after 2p.m.)

• Provide warm milk or herbal tea

• Conduct relaxation exercises from 6-ftdistance

• “Relaxation Exercise” notecard

• “What Should I Know About Sleep?” notecard

• Eye mask, ear plugs to reduce distractions

Addressing agitation and fear (related to delirium or fear of providers with PPE)

Try verbal de-escalation procedures before jumping to antipsychotics or other pharmacological methods. See the handout “Verbal De-Escalation” for your use, includes pocket card.

[Staff only]

Reproduced by The American Geriatrics Society Inc. with permission.

©1999 Hospital Elder Life Program, LLC.

www.ccsmh.ca;

www.rgptoronto.ca/resources/covid-19/39

Management-Non-pharmacological

• Treatment of all potentially correctable, contributing causes should be done in a timely, effective manner [D]– Maintain cardiovascular stability

– Temperature control

– Adequate oxygenation

– Fluid and electrolyte balance

– Control glucose levels,

– Maintain normal elimination pattern (avoiding continuous catheterization)

– Correct micronutrient deficiencies

Management-Non-pharmacological

• Prevent older persons from harming themselves or others using the least restrictive measures [D]

• Suggested environmental strategies include:– Avoid sensory deprivation or overload [C]

– Adequate lighting in room [C]

– Use of clocks, calendar, chart of day’s schedule [C]

– Avoid room changes [C]

– Use of familiar objects [D]

– Avoid putting delirious patients in the same room together [D]

rgptoronto.ca

COMMUNICATION TIPS FOR CLINICIANS CARING FOR OLDER ADULTS EXPERIENCING DELIRIUM DURING THE COVID-19 PANDEMIC

Isolation protocols and the use of personal protective equipment such as gowns, gloves, and masks can

make people feel even more fearful and confused. People with hearing loss may have difficulty

understanding what care providers are saying through a mask and may require written communication.

GENERAL COMMUNICATION TIPS

Non-verbal communication is critical to successful interactions. Remember to SMILE, they will hear it in

your voice even if they can’t see your face and will be reassured.

Thank you to the many delirium experts across Ontario

COVID-19

SAMPLE SCRIPT FOR PEOPLE WITH CONFUSION

COMMUNICATION TIPS FOR PEOPLE WITH AGITATION

It is very important for staff who feel confident and have training to try and de-escalate a person who may be experiencing agitation. If you appear anxious or fearful, it may escalate the person further. Stay calm, maintain a safe distance from the person in order to make them feel safe, have a colleague present for support and assistance, as needed, but only one clinician should talk to the person.

April 1, 2020

Stay calm, slow down and be patient.

Maintain eye contact and position yourself so the patient can see you.

Introduce yourself, call the patient by name, and explain your role/what you are going to do.

Listen actively and keep your language and instructions simple.

Engage and empathise.

“Hello, ___________ (use preferred name). My name is ______________, and I am your _________(role). You are admitted in ____________ because you got sick. I am here to help you and make sure you are comfortable.” Explain the task and ask for permission to proceed before approaching the patient or touching them, e.g., “The doctor has ordered these medicines for you to help you feel better. Can I give them to you now?

Verbally engage: Engage the person’s attention by calling their name in a gentle tone of voice: “Hello ____________ (use preferred name). I am ____________, your _______.

Establish a collaborative relationship: “I can see you are upset. I want to help you.”

Verbally de-escalate: “It’s okay. I am sorry you are upset. I am here to help you and keep you safe. How can I help you?” Repeat your message, if needed, as the upset person may not be able to hear and/or respond the first time.

1

2

3

Pharmacologic Management

• Psychotropic medications should be reserved for those in significant distress due to agitation or psychotic symptoms, in order to carry out essential investigations or treatment, and/or to prevent older delirious persons from endangering themselves or others. [D]

• In the absence of psychotic symptoms causing distress to the patient, treatment of hypoactive delirium with psychotropic medications is not recommended [D]

Pharmacologic Management

• Antipsychotics are the treatment of choice to manage the symptoms of delirium (with the exception of alcohol or benzodiazepine withdrawal delirium). [B]

Ref: Breitbart et al, 1996.RCT Haldol vs. CPZ vs. lorazepam in pts with AIDSHaldol & CPZ had better outcomes than lorazepam.

Pharmacologic Management

• When pharmacotherapy is indicated, low dose, short term therapy with haloperidol or an atypical antipsychotic can be considered [B]

(Grover et al. 2011 RCT hal=olanz=risp. Tahir et al. 2010 RCT Quetiapine vs Placebo. Quetiapine had sig. faster recovery)

Pharmacologic Management

• Initial dosages of haloperidol are in the range of 0.25 mg- 0.5 mg od-bid.

• Baseline ECG is recommended prior to starting haloperidol. For prolongation of QTc to greater than 450 msec or >25% over baseline, consider cardiology consult and discontinuing haloperidol. [D]

Pharmacologic Management

• Benzodiazepines as monotherapy are reserved for older persons with delirium caused by withdrawal from alcohol/sedative-hypnotics. [B]

• As benzodiazepines can exacerbate delirium, their use in other forms of delirium should be avoided. [D]

• Cholinesterase inhibitors: Promising as a potential Rx but RCTs have been unsuccessful.

Key Points

• Delirium represents acute brain failure.

• Multiple precipitating factors to consider.

• Use of screening tools e.g. CAM is optimal

• Patients with severe COVID-19 illness are at high risk of developing delirium for many reasons - needs further study !

• Preventative strategies can reduce incidence of delirium

• Optimal treatment of underlying causes is critical

• Management includes non-pharmacological / environmental approaches

• Use of psychotropic medications should be reserved for those in severe distress or in danger of harming self or others

Thank you!