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Overview of Confusion & Delirium for Clinicians (July 2007)
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Overview of Confusion & Delirium for Clinicians (July 2007)

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This is a brief overview of delirium originally given as a talk for nurse in Kettering, UK, 2007.

This is a brief overview of delirium originally given as a talk for nurse in Kettering, UK, 2007.

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  • 1. Delirium & Confusion
  • 2. Confusion over terminology • “Confusion” – AKA Disorientation – Incoherence – Clouding of consciousness – Delirium
  • 3. Delirium: Definition • de lira “to wander” • clinical syndrome (not disease) characterised by ?
  • 4. Scope of the Problem • 10-15% delirious on admission (Inouye 1997, Lipowski 1987) • 5-40% incident delirium in hospital (Francis 1992) • Settings – 11-43% post-operatively (Bryson 2006) – 70-87% in the ICU (Pisani 2006) – > 70% in terminal CA (Massie 1987)
  • 5. Delirium: Outcomes - Duration • More persistent than previously realised • Up to one week in 60% • two weeks in 20% • four weeks in 15% • more than four weeks in 5% • Delirium still present at 6 months – O'Keeffe S The prognostic significance of delirium in older hospital patients J of the Am Geriatr Soc 1997;45(2):174-8
  • 6. Delirium: Outcomes Mortality • Delirium in hospital is associated with mortality rates of 25 – 33% • Most studies report higher mortality after discharge eg 39% vs 23% at two years – Francis J Prognosis after hospital discharge of older medical patients with delirium. J Am Geriatr Soc 1992;40(6):601-6 • Hazard ratio of 2.11 at 1 year adjusted for comorbidity, dementia and severity of illness – McCusker et al Delirium predicts 12 month mortality. Arch Intern Med. 2002;162:457-463
  • 7. Clinical Presentation
  • 8. Delirium: Clinical Features • Inattention (95%) • Disorientation • Short term memory impairment • Thinking is disordered • Speech rambling and incoherent • Delusions, misperceptions and visual hallucinations • Distress, anxiety
  • 9. Delirium: Clinical Features • Hyperactive delirium – Repetitive behaviours e.g. plucking at sheets, wandering, verbal and physical aggression • Hypoactive delirium – quiet, withdrawn patient, often mistaken for depression • Mixed pattern
  • 10. Lethargy Agitation Day Night Night Day Day DayNight Night PRN Course of Delirium
  • 11. ICD 10 definition Impairment in consciousness & attention Global cognitive impairment Psychomotor disturbance Sleep-wake cycle disturbance Emotional disturbance
  • 12. DSM IV definition Disturbed consciousness Disturbed attention Disturbed cognition Acute onset Fluctuating symptoms
  • 13. A Case That Breaks the Rules • Ms EM, a 27 y/o with Hodgkins, two months post-natal • EM experienced disturbed sleep-wake cycle, disorientation, distractibility, and a sub-acute onset of confusion over seven days. There was also mild daytime somnolence but no changes in consciousness, no psychotic symptoms or perceptual disturbance, and no convincing fluctuations. She was not unduly agitated or over-aroused. • She scored 6 out of 10 on the clock-drawing test (CDT), and 22/30 on the mini-mental state examination (MMSE). • On the Delirium Rating Scale she scored 11 out of a possible 32. Functionally, she stopped working and driving, and required assistance with everyday household tasks. • At one year the symptoms had not changed.
  • 14. QualifyingQualifyingNoCausative agent EssentialQualifyingNoRapid onset and fluctuation of symptoms Not requiredEssentialYesEmotional disturbance Not requiredQualifyingYesImpairment of abstract thinking or comprehension QualifyingQualifyingYesMemory impairment QualifyingQualifyingYesDisorientation Not requiredQualifyingNoIncreased or decreased motor activity Not requiredQualifyingYesDisturbance of sleep-wake cycle QualifyingNot requiredYesDisorganized thinking/incoherent speech QualifyingQualifyingNoPerceptual disturbances EssentialEssentialYesImpairment of attention QualifyingEssentialNoClouding/disturbance of consciousness DSM-IVICD-10This CaseCriteria
  • 15. Laurila (2003) 425 patients hospital & nursing home ICD 10 DSM IV 81 18 25
  • 16. Prodromal Symptoms • Prospective & descriptive observational study • 6 hours before meeting DSM IV criteria • Behavioural symptoms noticed • Urgent calls for attention • Anxiety • Disorientation • Decreased psychomotor activity Other literature – Altered sleep pattern – Fatigue Sorensen & Wickbald (2004), J of Clin Nursing, 13
  • 17. Risk Factors and Aetiology
  • 18. Risk factors for incident delirium Predisposing RR • Vision imp. 3.5 • Severe illness 3.5 • Dementia 2.8 • Dehydration 2.0 Precipitating RR • Restraints 4.4 • Malnutrition 4.0 • >3 new med.s 2.9 • Bladder catheter 2.4 • Iatrogenic event 1.9 Inouye et al,Ann Med 2000;32:257-263
  • 19. Mechanisms • Nearly all speculative • Metabolic deficits difficult to measure
  • 20. Detection
  • 21. Delirium: Detection • Delirium often missed • 32 – 67% of delirious patients are not diagnosed • Cognitive assessment should be standard – MMSE or AMTS • Serial testing to monitor progress and to detect delirium arising during an admission • Mental status = a “vital sign”
  • 22. Educational intervention => recognition Rockwood et al (1994) • Simple educational intervention at monthly grand ward • Diagnosed 3% pre intervention (187 pts) • Diagnosed 9% post intervention (247 pts) • Frequent comments on various aspects of mental state (15.6% Vs. 8.5%) Rockwood et al (1994) J of Am Ger Soc, 42
  • 23. Delirium: Differential Diagnosis Meagher, D J Delirium BMJ 2001; 322: 144 -149 Delirium Dementia Depression Onset Acute Insidious Variable Course Fluctuating Steadily progressive Diurnal variation Consciousness and orientation Clouded; disoriented Clear until late stages Generally unimpaired Attention and memory Poor short term memory; inattention Poor short term memory without marked inattention Poor attention but memory intact Psychosis present? Common (psychotic ideas fleeting, simple content) Less common Occurs in small number (psychotic symptoms complex and mood congruent) EEG Abnormal in 80- 90%; generalised diffuse slowing in 80% Abnormal in 80- 90%; generalised diffuse slowing in 80% Generally normal
  • 24. Delirium Dementia
  • 25. Scales (assisted detection)
  • 26. Scales • Delirium Rating Scale Revised 98 (DRS-R-98) • Brief Psychiatric rating Scale (BPRS) • Mini Mental State Examination (MMSE) • Clinical Global Improvement (CGI) • Medical notes, prescription charts and investigations • Actimeter
  • 27. • Operationalized DSM-III criteria 1. Acute Onset and 2. Fluctuating course and 3. Inattention, Plus: • Disorganized speech or • Altered level of consciousness - Inouye SK, Ann Int Med 1990 Confusion Assessment Method (CAM)
  • 28. Diagnostic Testing: Tools Sensitivity Specificity • CAM* .46-.92 .90.92 • Delirium Rating Scale .82-.94 .82-.94 • Clock draw+ .87 .93 • MMSE (24 cutoff) .52-.87 .76-.82 • Digit span test .34 .90 *validated for delirium & capable of distinguishing delirium from dementia
  • 29. The Clock Drawing Test 12 6 39 10 11 1 2 4 57 8 •Used extensively in assessment of cognitive function, especially as a screen for dementia •Administration is quick, easy and non-threatening •Several studies assessing its validity as a screen for delirium with conflicting results •Multiple scoring methods, >12 reported in the literature J Geriatr Psychiatry Neurol 2005;18:129-133 Int J Geriatr Psychiatry 2000;15:548-561 Draw a clock face. Set the time at 10 past 11.
  • 30. The Clock Drawing Interpretation Scale 1. There is an attempt to indicate a time in any way. 2. All marks or items can be classified as either part of a closure figure, a hand, or a symbol for clock numbers. 3. There is a totally closed figure without gaps (closure figure). 4. A “2” is present and is pointed out in some way for the time. 5. Most symbols are distributed as a circle without major gaps. 6. Three or more clock quadrants have one or more appropriate numbers:12-3, 3-6 etc. 7. Most symbols are ordered in a clockwise or rightward direction. 8. All symbols are totally within a closure figure. 9. An “11” is present and is pointed out in some way for time. 10. All numbers 1-12 are indicated. 11. There are no repeated or duplicated number symbols. 12. There are no substitutions for Arabic or Roman numerals. 13. The numbers do not go beyond the number 12. 14. All symbols lie about equally adjacent to a closure figure edge. 15. Seven or more of the same symbol type are ordered sequentially. 16. All hands radiate from the direction of a closure figure center. 17. One hand is visibly longer than another hand. 18. There are exactly two distinct and separable hands. 19. All hands are totally within a closure figure. 20. There is an attempt to indicate a time with one or more hands. (Score “1” per Item) Score Only if Symbols for Clock Numbers are Present: Score Only if One or More Hands are Present: J Am Geriatr Soc 1992;40:1095-1099
  • 31. Simple screen (Henderson Data) Clock drawing test sensitivity 0.92 (0.86 – 0.98) specificity 0.73 (0.64 – 0.83) PPV 0.61 NPV 0.95 Kappa = 0.57 z = 5.43 p < 0.001
  • 32. 0.000.250.500.751.00 Sensitivity 0.00 0.25 0.50 0.75 1.00 1 - Specificity Area under ROC curve = 0.8464 ROC curve for Clock Drawing Test using AMTS as gold standard
  • 33. Management
  • 34. Basics 0. Assessment, investigate, document 1. Treat cause 2. Supportive care • Maintain proper nutrition, hydration and safety (prevention aspiration, ducubitus ulcers, falls etc) 3. Pharmacologic • Antipsychotic medications (haloperidol, respiridone, olanzapine etc.) • Benzodiazepines do not play a role (except in alcohol withdrawl related delirium) 4. Nonpharmacologic • Interpersonal contact (reorientation) • Environmental (clocks, windows, provide hearing aids, glasses, minimizing room changes etc.) Moore & Jefferson: Handbook of Medical Psychiatry, 2nd ed., Copyright © 2004 Mosby Inc Am J Geriatr Psychiatry 2004;12;7-21
  • 35. Delirium: Investigation • Routine • FBP • U&E • Glucose • Calcium • Liver function tests • Cardiac enzymes • Urinalysis and MSU • O2 saturation • CXR • Consider • ECG • TFT • Arterial blood gases • B12 and folate • CT brain • EEG
  • 36. Haloperidol • Rosen H, (1979) Haloperidol Vs Thioridazine • Tsuang M, (1971) Haloperidol Vs Thioridazine • Thomas et al (1992) Haloperidol Vs Droperidol • Brietbart et al (1996) Haloperidol, CPZ & Lorazepam
  • 37. Delirium: Non Pharmacological Mx • Correct sensory deficits (glasses and hearing aids) • Communication, simple instructions, avoid jargo • Re orientation (calendars, clocks, schedules) • A quiet, stable environment (Minimise room and staff changes)
  • 38. Delirium: Non Pharmacological Tips • Avoid sleep disruption • Encourage mobility and self care • Avoid restraints and bed rails • Involve family where possible • Meaningful personal items • A view to the outside
  • 39. Prevention
  • 40. Non Pharmacological Mx: Does it work? • Cole et al found 227 with incident or prevalent delirium amongst 1925 patients in 5 general medical units • Randomised to usual care or geriatrician and nurse consultation & follow up • No significant differences in LOS, time to improvement, discharge, mortality!! • Cole MG et al. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ. 2002; 167(7):753-9.
  • 41. Delirium: Prevention • Prospective study involving 852 patients with 426 matched pairs compared usual care of elderly general medical patients with those receiving interventions – Incidence of delirium lower in intervention vs usual care group (9.9% vs 15%) – Total days of delirium (105 vs 160) – Number of episodes of delirium (62 vs 90) – No difference in severity of delirium or recurrence rates – Major effect of interventions was to prevent the primary episode of delirium Inouye et al N Engl Med 1999;340:669-76
  • 42. Delirium: Prevention Hip Fracture • Marcantonio et al. Pre-op and daily post-op geriatric review 126 elderly patients (RCT) • Oxygen, fluid/electrolytes • pain, medication review/reduction • bowel and bladder function • nutrition, early mobilisation and rehabilitation • prevent/detect/treat post op complications • environmental stimuli • treat delirium
  • 43. • 126 patients > 65 y/o for hip fracture repair • Pre-op and daily post-op geriatric review or usual care – Delirium: 32% vs 50% (NNT = 6) RR 0.6 – Severe delirium: 12% vs 29% (NNT = 6) RR0.4 – Those without dementia benefited most – Marcantonio et al. Reducing Delirium after Hip Fracture J Am Geriatr Soc 2001;49: 516-22 Delirium: Prevention Hip Fracture
  • 44. Extras
  • 45. Mental Capacity Act (2005) • Premise: everyone can make their own decisions. • Give the person all the support they can to help them make decisions. • No-one should be stopped from making a decision just because someone else thinks it is wrong or bad. • Anytime someone does something or decides for someone who lacks capacity, it must be in the person’s best interests • When they do something or decide something for another person, they must try to limit your own freedom and rights as little as possible.
  • 46. Advance (directives) Decisions • An advance decision is when someone who has mental capacity decides that they do not want a particular type of treatment if they lack capacity in the future. • A doctor must respect this decision. • If the advance decision says no to treatment which may help keep you alive, it must say this clearly and be signed by you. Another person can sign an advance decision for you but only if you agree and you can see them sign it. • You are free to make an advance decision if you want to, but no one should force you to make it.
  • 47. Zorn SH et al. Interactive Monoaminergic Brain Disorders. 1999:377-393. Schmidt AW et al. Eur J Pharmacol.2001;425:197-201. Quetiapine M1 5- HT2AD2 5- HT2C 5- HT1A α1 H1 Risperidone D2 α1 5- HT2A 5- HT2C H1 Olanzapine M1 H1 5- HT2C 5- HT2A D2 α1 Ziprasidone D2 5-HT1D 5- HT2C 5-HT1A 5- HT2A α1 H1 Clozapine 5- HT2C M1 5- HT2A H1 α1 D2 Pharmacology Of Atypical Antipsychotics
  • 48. • Disturbance of Consciousness – Reduced clarity of awareness of the environment – Reduced ability to focus, sustain, or shift attention. • A change in cognition – Memory deficit – Disorientation – Language disturbance • Perceptual disturbance – Illusions – Visual Hallucinations – Auditory hallucinations DSMIV Delirium Symptoms
  • 49. • Fluctuating clinical picture • Disturbance caused by underlying disorder. • Confirmed by investigations & physical examination • Sleep disturbance • Disturbance of psychomotor activity DSMIV Delirium Symptoms 2

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