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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

Disorganized ThinkingRambling Illogical conversation

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

Questions???


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