Delirium in the Older Adult Patient:
Not Just Altered Mental Status
Lisa R. Mack, MD, FACEPAssistant Professor Emergency Medicine
Emory University, Atlanta, GAJune 14, 2003
Georgia College of Emergency Physicians
St. 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
Objectives
1. Identify the 4 risk factors for delirium
2. Identify the 4 features of the CAM diagnostic algorithm and the criteria for diagnosing delirium
3. Identify the top 3 causes of delirium
4. State the pharmacological treatment for delirium
Delirium?Case 1: Patient dozes off when you’re
trying to talk to him…Case 2: Mr. P. keeps picking at his bed
clothes as you try to talk to him…Case 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 perception 3 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 entity Case 1, 2, 3
Increased 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 impairment Severe illness (APACHE II score <16)
Cognitive impairment Dehydration
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 diagnosis Individual patient presentationThe presentation of severe illness in
older peopleDifferential diagnosis
Vascular dementia may present w/acute cognitive decline
Hypoactive delirium may be mistaken for depression
The Diagnosis Delirium is a clinical diagnosis The criteria: Confusion Assessment
Method (CAM)1. Inattention2. Acute onset and fluctuating symptoms3. Altered level of consciousness4. Disorganized 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 backward Digit span test (repeat 5 numbers forward
without errors)
Acute onset/fluctuatingSxs usually present for <2 weeksMay fluctuate over the course of
minutes to hours (Ask caregiver)
Altered Level of Consciousness
Hyperactive vs hypoactive Alert (normal) Vigilant Lethargic (drowsy, but easily aroused) Stupor Coma
Management
1. Recognize and treat the underlying cause
2. Modify the environment
3. Control the symptoms
Etiologies
Top 3 causes:
1. Infection
2. Metabolic disturbances
3. Medications-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/place
Adequate lighting, routine sleep times Involving friends/family
Symptom controlFirst-line treatment= Haloperidol
Least anticholinergic activity Rapid onset Dose: 0.25- 0.5 mg, max 5mg/24hr
BDZs= first-line tx in ETOH w/drawal Lorazepam 0.25-1 mg, titrate
Symptom control cont.
Haloperidol plus lorazepam Synergistic effect Allows 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 “AMS”ED physicians need to recognize
delirium as a distinct disease entityED physicians need to recognize risk
factors for delirium to assist in prevention