Diagnosing Delirium in Geroforensics

Adonis Sfera, MD and Luzmin Inderias, MDPreventing Delirium in Geroforensic Population

Q&APolydipsia or hypodipsia (drinking too much or not enough fluids) may lead to acute delirium True/False

Urinary tract infections may precipitate an exacerbation of schizophrenia True/False

Hypoactive delirium is easily differentiated from major depressive disorder True/False

MemoDelirium is a medical emergency which causes permanent brain damage if not managed quickly and correctly.

Most clinicians currently under-recognize delirium, potentially harming our patients.

Prevention and treatment of delirium requires a true interdisciplinary approach, and is worth the effort as it saves lives!

The goal of this lectureConsider delirium in your differential.

OutlineVignettesDefinitionDelirium in psychiatric inpatientsUncharted territory: delirium in geroforensicsWhy does delirium happenRecognising itRisks and precipitantsPrevention is better than cureHydration and delirium

CASE 1LF is a 63 years old patient with history of schizophrenia and several medical problems including chronic kidney disease with sodium imbalance, HTN and cardiac pacemaker.

In January LF was transferred to the acute hospital due to impaired awareness and cognition which developed over a short period of time, resulting in patients getting agitated and pulling his catheter out.

LFs history and clinical presentation meet the DSM V criteria for acute delirium.

CASE 267 years old female with history of schizoaffective disorder and mild cognitive impairment. Medical problems: hypertension, hyperlipidemia and obesity.

Became combative, agitated and confused with both visual and auditory hallucinations.

PRN medication given consisting of haloperidol, lorazepam, followed by increase in agitation.

Diagnosed with UTI.

DefinitionDelirium is an age-related neurobehavioral syndrome also called acute confusional state or acute brain failure.

Its manifestations consist of fluctuating cognition, deficits of attention, disorganized or violent behavior, altered sleep-wake cycle, hallucinations and delusions.

ENGEL GL,ROMANO J. Delirium, a syndrome of cerebral insufficiency. J Chronic Dis.1959 Mar;9(3):260-77).

The history

Hippocrates (5 BC)Hippocrates referred to delirium as phrenitis from which we derive the word frenzy.

As the motion of the arms I observe the following facts: in acute fevers, pneumonia, phrenitis and headache, if they move before the face, hunt in empty air, pluck nap from the bedclothes, pick up bits and snatch chaff from the walls - all these signs are bad, in fact deadly. Hippocrates (Prognostic, XXII)Phrenitis was replaced with the word delirium in 1769

Delirium in literature

After being rejected by his daughters and exposed to the storm, king Lear becomes delirious, perhaps by cerebral vascular disease. He recovers slightly before his death and is reconciled with his youngest daughter, Cordelia.

The frenzy (delirium)of Orlando FuriosoRenaissance Italian poet Lodovico Ariosto (1516) describes the frenzy (delirium) of Orlando Furioso after not sleeping or eating for three days probably resulting in dehydration and electrolyte imbalance:

He neither sleeps nor eats; though three days pass,Three times the dark descends, he has not stirred.His grief so swells, his sorrow so amassThe madness clouds him, in which long he erred.O miracle,His intellect returned to its pristineLucidity as brilliant as before,As his fair discourse latter witness bore.(Canto XXXIX)

Delirium: DSM-5 Diagnostic Criteria

A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).

B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.

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

D. The disturbances in Criteria A and C are not explained by another preexisting, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as 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 (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.

ICD-10 types of deliriumF00-F09 Organic, including symptomatic, mental disordersF05 Delirium, not induced by alcohol or other psychoactive substancesF05.0 Delirium, not superimposed on dementiaF05.1 Delirium superimposed on dementiaF05.8 Other deliriumF05.9 Delirium unspecifiedF10-19 Mental and behavioral disorders due to psychoactive substance useF1x.03 Acute intoxication, with deliriumF1x.4 Withrowal state with deliriumF1x.40 Without convulsionsF1x.41 With convulsions

Delirium matters, but why?More than 7 million hospitalized Americans suffer from delirium each year.

More than 60% of delirium cases are not recognized by the health care system.

Predictor of poor prognosis

In hospitalized patients case fatality rates 25% to 35%

Higher hospital costs per day

Source: American Delirium Society https://www.americandeliriumsociety.org/

More reasons60% longer hospital length of stay (LOS)

Reducing delirium LOS by one day: saves $1-2 billion dollars/year

5 times higher nursing home placement

Source: American Delirium Society https://www.americandeliriumsociety.org/

Why is delirium under-recognized?The diagnosis of delirium is missed 33-67% of the time.

Delirium may be the only presentation of severe illness in older patients, for example:

Silent myocardial infarction presents with delirium in up to 40% of cases.

25% of older people have no fever associated with pneumonia, tuberculosis, endocarditis or sepsis, delirium being the only manifestation.

13% of older bacteremic patients are afebrile, but may present with delirium.

EpidemiologyIn the US, the overall prevalence of delirium in the community is 12%.

The incidence of delirium arising during a hospital stay ranges from 6% to as high as 56%.

In geriatric neuropsychiatric patients the incidence is 40-60%.

Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment.Nature reviews Neurology. 2009;5(4):210-220. doi:10.1038/nrneurol.2009.24.

Etiology - multifactorialInfectionPolydipsia, hypodipsia with electrolyte imbalanceMedications adverse effectsHypoperfusionMalignancyPainFecal impactionUrinary retentionSleep deprivationPhysical restraintsEndocrine problems

Delirium: an entity in-between psychiatry and medicine

Delirium in primary psychiatric disorders

The literature regarding delirium in severe psychiatric disorders in is extremely scarce: a total of 8 studies between 1996 and 2014.

The literature regarding delirium in geroforensic population is nonexistent.

This is what we knowIn the past individuals with schizophrenia and schizophrenia-like disorders (SLD) did not live long enough to develop age-related diseases (both medical neuropsychiatric).

Medical complications and suicide contributed to a 20-30% shorter lifespan in this population.

Schizophrenia survivors are a new category of individuals specific for our generation.

Delirium in psychiatric inpatientsPatients with severe psychiatric illness have many risk factors for delirium, such as cognitive impairment (Gill and Mayou, 2000).

Delirium is under-recognized in mental health setting because its symptoms overlap with those of the primary psychiatric illness.

The highest prevalence of delirium was found in individuals diagnosed with bipolar disorder (35.5%), schizoaffective disorder (15.8%), schizophrenia (12.1%)(Ritchie et all. 1996).

Delirium in psychiatric inpatients A recent nationwide retrospective study from Denmark concluded that:

in psychiatric inpatients delirium is associated with elevated mortality.

anticholinergic and sedative-hypnotic agents are the most commonly associated with delirium. the best predictors of delirium are cognitive impairment and a previous history of delirium as 40% of patients with delirium had more than one episode.

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Delirium is frequently misdiagnosed as a psychiatric conditionDelirium is under-recognized in psychiatric patients because its symptoms overlap with those of the primary psychiatric disorder.

A patients experience of deliriumhttp://www.europeandeliriumassociation.com/patient-video.html

Think of delirium in elderly patients with chronic psychosis.

Delirium occurs in many hospitalized older patients and has serious consequences including increased risk for death and admission to long-term care facilities.

Wong et al. JAMA. 2010.

Chronic delirium

Previously delirium been characterized as an acute, severe and reversible condition.

However, symptoms may endure despite treatment or resolution of the precipitating factors, resulting in permanent cognitive impairment.

Novel studies found that 18% of patients had delirium at 6 months.

American Delirium Society https://www.americandeliriumsociety.org/

Post-delirium cognitive impairmentMost patients demonstrate persistent difficulties and only rarely return to premorbid levels of functioning

Even young patients experience post-delirium cognitive impairment.

https://www.youtube.com/watch?v=x0QlOesVP9A&feature=youtu.be

Differential diagnosisDelirium vs. DementiaDelirium vs. maniaDelirium vs. acute paranoiaDelirium vs. depressionDelirium vs. psychosis

Delirium, dementia and exacerbation of psychosisClinical featureDeliriumDementiaExacerbation of psychosisOnsetacuteslowacuteCircadian coursefluctuatingstablestableLevel of consciousnessaffectedsparedsparedAttentionimpairedimpairedmay be impairedCognitionimpairedimpairedmay be impairedHallucinationsusually visualoften absentusually auditoryDelusionspoorly systematizedoften absentsustained and systematizedPsychomotor activityincreased or reducedoften normalvariableInvoluntary movementsAsterixis, myoclonus, tremorabsentabsentEEGabnormalabnormalUsually normal

Clinical type of delirium Symptoms Resembles

HyperactiveIncreased arousalRestless,Agitated May be aggressiveManiaPsychotic decompensation HypoactiveDecreased alertnessSlow speechApatheticDepressionMixedCombination of the aboveRapid cycling

Delirium risk factorsPredisposing factorsPrecipitating factorsDementiaRestraintsDehydrationDehydrationCo-morbidityMore than 5 medicationsSensory impairmentBladder catheter

Delirium in the geroforensic populationForensic detainees represent a special population.

Schizophrenia predisposes to dementia

- Patients with schizophrenia and schizophrenia-like psychoses develop late life dementia more often than the general population.

-Cognitive impairment is a feature of schizophrenia.

-Kraepelin used the term dementia praecox to describe schizophrenia.

-Over 25% of elderly with schizophrenia have moderate to severe cognitive impairment.

RaghavakurupRadhakrishnan,RobertButler,LauraHead. Dementia in schizophrenia. Advances in Psychiatric TreatmentMar 2012,18(2)144-153;DOI:10.1192/apt.bp.110.008268

The number of inmates over the age of 65 has more than doubled between 2007 and 2013 Source: Bureau of Justice Statistics

Geroforensic population more predisposed to delirium than nonforensic seniors forensic detainees age more rapidly than the general populationmaintained on higher doses of psychotropic drugs lowering medication dosages often delayed to avoid relapse of aggression more likely to have history of unhealthy life styles and of drugs or alcohol addictionobesity more likely: altered volume of distribution of antipsychotic drugs more likely hepatitis c, altering albumin level and hepatic drug metabolism

Why care about delirium in geroforensic population?

Forensic institutions house individuals with severe psychiatric disorders and significant history of violence maintained on psychotropic drugs for extended periods of time which predisposes this population to adverse effects.

Psychotropic drugs may impair both the hydration status and thermoregulation, predisposing for medication adverse effects.

Drug adverse effects

Dementia and aging are the main risk factors for delirium.

Patients with dementia-delirium co-morbidity present with a mortality risk of 65%.

Dementia and aging are crucial for the development of medication adverse effects which occur in over 15% of older patients at an annual cost of 20 billion .

Pretorius RW,Gataric G,Swedlund SK,Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician.(2013) 87(5):331-6.

Medication adverse effects as risk factors of delirium in psychiatric inpatientsAnticholinergic medicationsECTLithium-antipsychotic combinationHigh doses of low potency antipsychotic drugs(Huang et al. 1998)Non-psychiatric medications including antibiotics

Delirium may be a complication of treatment or discontinuation of treatment with psychotropic drugs (Kruszewski et al. 2009)(Lin and Ceo 2010).

Medications and aging

The effects of medications in older adults is a new field of study, even though more than one-half of all prescription medications are dispensed to persons older than 60.

Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician. (2013) 87(5):331-6

TheBeers Criteria for Potentially Inappropriate Medication Use in Older AdultsA guideline for healthcare professionals to help improve the safety of prescribing medications for older adults.

It emphasizes risk-benefit ratio, polypharmacy, drug-drug interactions and adverse drug reactions.

The criteria are used in geriatrics clinical care to monitor and improve the quality of healthcare.

The "Beers Criteria" contains lists of medications that pose potential risks outweighing potential benefits for people 65 and older.

By using Beers criteria practitioners may prevent harmful side effects, including those that could be life-threatening.

Source: American Geriatric Society http://www.americangeriatrics.org

Antibiotics and delirium: a recent link A recent study demonstrated that antibiotic toxicity can represent an unrecognized cause of delirium in hospital patients, with manifestations observed in three distinct phenotypes: 1. encephalopathy accompanied by seizures or myoclonus arising within days after antibiotic administration (caused by cephalosporins and penicillin);

2. encephalopathy characterized by psychosis arising within days of antibiotic administration (caused by quinolones, macrolides, and procaine penicillin)

3. encephalopathy accompanied by cerebellar signs and MRI abnormalities emerging weeks after initiation of antibiotics (caused by metronidazole).

Shamik Bhattacharyya, R. Ryan Darby, Pooja Raibagkar,L. Nicolas Gonzalez Castro, Aaron L. Berkowitz. Antibiotic-associated encephalopathy. Neurology (2016) vol. 86no. 10963-971. doi:http://dx.doi.org/10.1212/WNL.0000000000002455

UTI and schizophreniaNovel study: urinary tract infections 29 times more likely in schizophrenia relapse.

Most likely mechanism: delirium

Miller BJ,Graham KL,Bodenheimer CM,Culpepper NH,Waller JL,Buckley PF. A prevalence study of urinary tract infections in acute relapse of schizophrenia. J Clin Psychiatry.2013 Mar;74(3):271-7. doi: 10.4088/JCP.12m08050.

The UTI-delirium connection

The bottom line

Under-recognition of delirium in geroforensic institutions translates into poorer health care outcomes in spite of higher medical spending.

Aging and hydrationHomer: old age is like a dried olive branch.

Aristotle: one should know that living beings are moist and warm . . . However old age is dry and cold.

Galen: Aging is associated with a decline in innate heat and body water.

Galens most pertinent observation was that dehydration is difficult to diagnose, and this remains true today.

Dehydration and morbidity Dehydration is a predisposing factor for delirium

Dehydration has been associated with increased mortality rates among hospitalized older adults.

Dehydration is one of the ten most frequent diagnoses responsible for hospitalization in the United-States.

Dehydration has been associated with impaired cognition, acute confusion, falls and constipation.

The cost associated with dehydration in the US is estimated at $1.14 billion a year.

Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician. (2013) 87(5):331-6

Hydration, cognition and psychopathologyPersistent subclinical dehydration is associated with anxiety, panic attacks, and agitation. Fluctuation in tissue hydration results in inattention, hallucinations, and delusions.

Severe dehydration leads to somnolence, psychosis, and unconsciousness (loss of awareness of the surroundings).

CNS symptoms are present when dehydration results in a 1% loss of body water and are very prominent at 5% loss.

Breitbart W and Alici Y. Agitation and delirium at the end of life: we couldnt manage him. JAMA. 2008;300(24):2898-2910.

Polydipsia or hypodipsiaPolydipsia and hypodipsia (drinking to much or not enough water) are encountered in individuals with history of schizophrenia or schizophrenia-like psychosis. Both predispose to electrolyte imbalance and delirium. Both are regulated by the same brain area, the subfornical organ (SFO).

The thirst center: subfornical organ (SFO)

Adonis Sfera,Michael Cummings, Carolina Osorio. Dehydration and cognition in geriatrics: a hydromolecular hypothesis. Front. Mol. Biosci., 12 May 2016 |http://dx.doi.org/10.3389/fmolb.2016.00018

Further research in geroforensic delirium

It is necessary to answer the question: which individuals require low dosage regimens of psychotropic drugs in order to avoid age-related adverse effects and which need and can tolerate larger doses to avoid relapses into aggressive behavior?