Delirium

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Overview of delirium in an older individual

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Delirium

  1. 1. DELIRIUMMARC EVANS M. ABAT, MD, FPCP, DPSGMInternal Medicine-Geriatric Medicine
  2. 2. CASE 81 year old man with diagnosis of Benign Prostate Hypertrophy and Hypertension, came in with history:  3 days prior to admission, low-grade fever and nocturia. Poor sleep. Daughter gave him diphenhydramine for sleep.  Day of admission, became confused, had high grade fever.  No loss of consciousness, vomiting  Past medical history: Hypertension  Personal/ Social History: Smoke tobacco
  3. 3. CASE In hospital, diagnosed to have UTI and acute urinary retention. 6 hours after admission, became combative, agitated, confused. Pulled out IV and insisted on going home.
  4. 4. Questions Diagnosis for acute confusion What are patient’s risk factors for delirium? How will you manage the patient non- pharmacologically? What medications can you use to manage the confusion? What is his prognosis?
  5. 5. Objectives To define the syndrome of delirium. To identify symptoms of delirium. To differentiate delirium from other psychiatric, neurological, and medical conditions. To describe patient prognosis. To discuss basic medical management.
  6. 6. Definition, DeliriumDelirium is a syndrome of acute confusion marked by periods of waxing and waning levels of consciousness, altered psychomotor behavior, and perceptual impairment.
  7. 7. Symptoms Hyperactive Hypoactive Mixed A study of 325 patients in a general hospital identified a 15% incidence of hyperactive delirium, 19% hypoactive and 52% mixed type (Liptzin, Levkoff 1992).
  8. 8. Delirium or Dementia?Delirium Dementia Acute onset  Gradual onset Lasts for hours to  Lasts for months to weeks years MS fluctuates,  MS stable; worse at night sundowning Attention decreased  Normal attention or hyperalert span, alert Language  Word-finding incoherent,slow or difficulty rapid
  9. 9. Differential Diagnosis Delirium vs. mania Delirium vs. acute paranoia Delirium vs. depression Delirium vs. acute psychosis
  10. 10. Etiology1.Infection2. DrugsLong-acting benzodiazepines, meperidine, propranolol, scopolamine, H2-blockers3. Withdrawal StatesAlcohol, benzodiazepines, meprobamate
  11. 11. Etiology4. Hypoperfusion5. Hypoxemia6. MalignancyParaneoplastic phenomenon, pain7. Electrolyte Abnormalities
  12. 12. Etiology8. Painpost-operative,fecal impaction,urinary retention,fracture
  13. 13. Etiology9. Endocrine ProblemsHypo-and hyperthyroidism, hypo-and hyperglycemia10. Sensory deprivation11. Sleep deprivation12. Physical restraints
  14. 14. EtiologyAge over 80 years and male sex are independent risk factors for thedevelopment of delirium in hospitalized patients
  15. 15. EtiologyAn underlying history of dementia (i.e.,Alzheimers, vascular or multi-infarct) is the most significant risk factor for the development of delirium.
  16. 16. Delirium in Hospital A nested case-control study of non- cardiac surgery patients revealed that delirium was positively associated with exposure to meperidine (Odds Ratio (OR), 2.7; 95% confidence interval (CI), 1.3 to 5.5) and to benzodiazepines (OR, 3.0; 95% CI 1.3-6.8).Marcantonio (1994), Brigham and Womens Hospital, Boston
  17. 17. Delirium in Hospital prospective study of orthopedic patients at the same institution, revealed a 26% incidence of post-operative delirium in the 46 patients studied. Drugs such as scopolamine, flurazepam, and propranolol were associated with a relative risk (RR) for delirium of 11.7 (p=.0028).Rogers et al (1989)
  18. 18. Drugs and Delirium S de la Vega. “Confusional States”. Practical Guide to Geriatric Medicine. Ratnaike, Ed. McGraw-Hill 2002. Analgesics  SteroidsCodeine, meperidine,  Antimicrobials indomethacin INH, gentamycin Anti-hypertensives  Anti-parkinsonianClonidine, m-dopa, Bromocriptine, l-dopa propranolol  Digitalis Diphenhydramine  Psychotropics Cimetidine
  19. 19. Drugs with Excess Potential forSevere Outcome in Patients Over Age 65Analgesics Pentazocine or oral meperidine respiratory depression and CNS adverse effects, ex. delirium
  20. 20. Drugs with Excess Potential forSevere Outcome in Patients Over Age 65Anxiolytics Barbiturates, meprobamate, or long-acting benzodiazepines (LABD)(addiction, excess sedation leading to falls and confusion) LABDs may be used for seizure, palsy, withdrawal from SABD
  21. 21. Drugs with Excess Potential forSevere Outcome in Patients Over Age 65Antidepressants Tricyclic AntidepressantsEx. amitriptyline, amoxapine, clomipramine, doxepin• high risk of urinary retention• sedation• anticholinergic side effects
  22. 22. Medical Management Look for reversible medical causes outside of the brain that are amenable to medical treatment. Consult with family members  help focus the extent and aggressiveness of diagnostic tests and medical care.
  23. 23. Non-Pharmacologic Management Nutritional support Aspiration precautions Early rehabilitation NO PHYSICAL RESTRAINTS!
  24. 24. Non-Pharmacologic Management “Therapeutic Untrial”
  25. 25. Pharmacologic Management “atypical” anti-psychotics  Risperidone  Quetiapine  Olanzapine Use lowest possible dose Order a STOP date Haloperidol iv low dose in emergency
  26. 26. PreventionRandomized trial of geriatric interdisciplinary team management in hospitalized patients at risk for deliriumInouye 2000Marcantonio 2001
  27. 27. Case Discussion and Review
  28. 28. CASE 81 year old man with diagnosis of Benign Prostate Hypertrophy and Hypertension, came in with history:  3 days prior to admission, low-grade fever and nocturia. Poor sleep. Daughter gave him diphenhydramine for sleep.  Day of admission, became confused, had high grade fever.  No loss of consciousness, vomiting  Past medical history: Hypertension  Personal/ Social History: Smoke tobacco
  29. 29. CASE In hospital, diagnosed to have UTI and acute urinary retention. 6 hours after admission, became combative, agitated, confused. Pulled out IV and insisted on going home.
  30. 30. Questions Diagnosis for acute confusion? What are patient’s risk factors for delirium? How will you manage the patient non- pharmacologically? What medications can you use to manage the confusion? What is his prognosis? How can you prevent this from recurring?
  31. 31. Review Defined the syndrome of delirium. Identified symptoms of delirium. Differentiated delirium from other psychiatric, neurological, and medical conditions. Described patient prognosis. Discussed basic medical management.
  32. 32. Thank YOU!

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