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perioperative delirium
- 1. Perioperative Delirium Tutor: Dr. Choi Nim IC: Tou Weng Ieong (Psychiatry) Date: 2022/04/22
- 2. Content • Case share • Brief Introduction • Diagnosis • Pathophysiology • Risk factor • Assessment • Prevention and management • Summary
- 3. Short case sharing • 37-year-old man • A government-employed, active police • No family history of dementia. • History of alcoholism • Acute onset right upper abdominal pain after dinner • High fever, PE: RUQ tender and murphy sign (+) • Lab: Leukocytosis, mild elevated ALP and total bil. • CT: multiple gallbladder stone with CBD dilatation • Impression: Acute calculous cholecystitis
- 4. Short case sharing • Lap cholecystectomy: uneventfully, minimal blood loss. • POD 1: • Present with acute onset of inattention and fluctuating course of agitation and drowsy • Lab and head CT: unremarkable. • The CAM Diagnostic Algorithm: Suspected delirium • DSM-5 Diagnosis: Hyperactive perioperative delirium DSM-5: The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition delirium CAM: The Confusion Assessment Method
- 5. Short case sharing • Hyperactive perioperative delirium • And history of alcoholism • ECG: sinus rhythm • Haloperidol 0.5 mg IV once • ECG: sinus rhythm, no sign of QT prolongation • Haloperidol 1 mg IV once 30 minutes later then regular at Q12H
- 6. Short case sharing • POD 2: • No more agitation nor inattention • Change Haloperidol IV to oral 1mg morning and 1mg at night • POD 3: • No sign of delirium • Discharge and early psychiatry OPD.
- 7. Definitions • Delirium is defined as a transient, usually reversible, cause of mental dysfunction and manifests clinically with a wide range of neuropsychiatric abnormalities • Any delirium that occurs before or after surgery may be called perioperative delirium • The condition is a medical emergency associated with increased morbidity and mortality rates. JAMA, July 4, 2012—Vol 308, No. 1
- 8. Hospitalized elderly: prevalence of delirium • Prevalent delirium among older patients at hospital admission ranges from 14-24% • The incidence of delirium among older patients arising during admission ranges from 6% to 56% in general hospital populations Arch Intern Med. 2002 Feb 25;162(4):457-63. Am J Psychiatry. 1999 May;156(5 Suppl):1-20. Am Heart J. 2015 Jul;170(1):79-86, 86.e1
- 9. Predisposing factors for delirium Clin Geriatr Med. 2020 May;36(2):183-199. doi: 10.1016/j.cger.2019.11.001.
- 10. Prevalence of perioperative delirium based on hospital setting Setting Incidence of delirium References Abdominal Aortic anyeurism surgery 33-54% Mercantonio et al 1994 Abdominal surgery 5-51% Mann et al 2000 Cataract surgery 4% Milstein et al 2002 Coronary artery bypass graft surgery 37-52% Dyer et al 1995 Elective orthopedic surgery 9-15% Mercantonio et al 1994 Head and Neck Surgery 17% Weed et al 1995 Hip Fracture surgery 35-65% Gustafson et al 1988 Peripheral vascular surgery 30-48% Schneider et al 2002 Urologic surgery 4-7% Dyer et al 1995 Non-intubated ICU patients 30-50% Pun et al 2007 Intubated ICU patients 80% Pun et al 2007 General medical inpatients 15-31% Inouye et al 2007
- 11. High mortality rate • Patient admitted with delirium have a mortality of 11- 26%. • Patients who develop delirium during their admission have a mortality ranging between 22-76%. • V.S.: Septic shock mortality rate: 10-56% Arch Intern Med. 2002 Feb 25;162(4):457-63. Am J Psychiatry. 1999 May;156(5 Suppl):1-20. Am Heart J. 2015 Jul;170(1):79-86, 86.e1
- 12. Negative consequences during hospitalization • Increased hospital length of stay • Increased incidence of falls • Increased incidence of aspiration • Poor recovery from acute medical condition or surgery • Behavior concerns leading to need for increased surveillance • Potential self harm Arch Intern Med. 2002 Feb 25;162(4):457-63. Am J Psychiatry. 1999 May;156(5 Suppl):1-20. Am Heart J. 2015 Jul;170(1):79-86, 86.e1
- 13. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) • Acute Process • Affecting consciousness (alertness/awareness) • Affecting cognition (executive skills) • There is evidence that the disturbance is caused by a medical condition, substance intoxication or withdrawal, or medication side effect • No better explained by an alternative diagnosis. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 5–25. ISBN 978-0-89042-555-8.
- 14. DSM-V additional features • Psychomotor behavioral disturbances such as hypoactivity, hyperactivity, (or mixed) with increased sympathetic activity, and impairment in sleep duration and architecture • Variable emotional disturbances, may include: • Fear • Depression • Euphoria • Perplexity • Agitation American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 5–25. ISBN 978-0-89042-555-8. Hyperactive Hypoactive Mixed
- 15. Prodromal Phase (Subsyndromal delirium) Prodromal features includes: • Complaints of fatigue • Sleep disturbance (excessive daytime somnolence or insomnia) • Depression • Anxiety • Restlessness • Irritability • Hypersensitivity to light or sound
- 16. Subsyndromal delirium International Journal of Geriatric Psychiatry 2013; 28:771–780 • A state in which patient only have a few criteria for delirium; do not meet full criteria • May precede delirium by a few hours or days • At very high risk for developing “ full blown “ delirium • Associated with negative outcomes intermediate to “ full blown” delirium Figure 3. Individual and Combined Odds Ratio (OR) (and 95% Confidence Intervals (95% CI)) in Studies of Outcomes of Subsyndromal Delirium.
- 17. Development is Multifactorial 1. Older Age 2. Multiple comorbid medical conditions 3. Hx of delirium 4. Pre-morbid cognitive impariment 5. Hx of psychiatric disease 1. Malnutrition 2. Dehydration 3. Sensory deficits 4. An Acute medical problem 5. Disruption of normal sleep/wake cycle 1. Lack of cognitive stimulation 2. Indwelling urinary catheter 3. Medicines that cause delirium 4. Immobilization DELIRIUM + NON-MODIFIABLE MODIFIABLE + =
- 18. Chemical – Hormonal Hypothesis • Cholinergic Deficiency hypothesis • Dopaminergic Excess hypothesis • Contribution of other neuro- transmitter function perturbation: • Norepinephrine • Serotonin • GABA • Glutamate • Melatonin • Cytokines J Gerontol A Biol Sci Med Sci. 1999 Jun;54(6):B239-46. doi: 10.1093/gerona/54.6.b239.
- 19. Mainstream theory in perioperative delirium: TNF-alpha during surgery and anaesthesia in mice Proc Natl Acad Sci U S A 2010 Nov 23;107(47):20518-22. doi: 10.1073/pnas.1014557107. Fig. 1. TNF-α and HMGB-1 measured by ELISA were increased following tibial surgery. (A) Plasma levels of TNF-α were significantly increased after 30 min from skin incision; (B) HMGB-1 was up-regulated after 1 h, peaking at 6 h, and returning to baseline thereafter. Plasma levels of both TNF-α (C) and HMGB-1 (Results are expressed as mean ± SEM (n = 6). *, P < 0.05; **, P < 0.001 versus naive by one-way ANOVA followed by Student-Newman-Keuls test. ND, not determined Tibial surgery Anaesthesia
- 20. Neurofilament light (NFL) • Surgery -> peripheral inflammation + leaky BBB • -> Neuronal damage – release of NFL and tau -> Delirium • NFL is a component of the axonal cytoskeleton tissue • Plasma levels of NFL are sensitive marker of TBI in contact sports. Brain. 2020 Jan 1;143(1):47-54. doi: 10.1093/brain/awz354.
- 21. JAMA, July 4, 2012—Vol 308, No. 1
- 22. Cerebral Perfusion Changes in Delirious Patients Cerebral Perfusion Changes in Older Delirious Patients Using 99mTc HMPAO SPECT
- 23. Brain Gray Matter is reduced following an episode of delirium Crit Care Med. 2012 Jul;40(7):2022-32. doi: 10.1097/CCM.0b013e318250acc0.
- 24. Persistent Cognitive Dysfunction • Signs of delirium may persist for 12 months or longer, particularly in those with underlying dementia • One long-term follow-up study found that after two years, only one-third of patients who had experienced delirium still lived independently in the community. J Gen Intern Med. 2003 Sep;18(9):696-704. J Am Geriatr Soc. 1992 Jun;40(6):601-6.
- 25. Short-term and long-term relationship between delirium and cognitive trajectory Alzheimers Dement. 2016 Jul;12(7):766-75. doi: 10.1016/j.jalz.2016.03.005. Epub 2016 Apr 18.
- 26. Who is at Risk in perioperative delirium? • Elderly • Dementia • Dementia is an underlying issue in 25-50% of delirium cases • CVA • Parkinson’s disease
- 27. Pre-operative screening tool • Screening tools • MoCA, MiniCog, Clock Drawing test • Subjective assessment MCI Sensitivity Specificity MMSE 66% 90% MoCA 94% 40% Mild cognitive impairment (MCI) Montreal Cognitive Assessment (MoCA) Mini-mental state examination (MMSE)
- 28. Precipitants of Perioperative Delirium • Drugs/Toxins – 30% of delirium • Specially drug with anticholinergic effect • Infection • Metabolic • Systems organ diseases • Brain specific issues • Physical disorders
- 29. Delirium Screening Confusion Assessment Method (CAM): • Presence of 1 and 2 • Acute onset and fluctuating course • Inattention • Presence of at least one item from 3 and 4 • Disorganized thinking • Altered level of consciousness Inouye et al. Ann int Med (1990)
- 30. Delirium Screening • Confusion Assessment Method (CAM) • 3 minutes Confusion Assessment Method (3DCAM) • Ultra-Brief CAM • -Months of the Year Backwards, and what is the day of the week? Inouye et al. Ann int Med (1990)
- 31. The Work Up First: • Evaluate medications • 30% of delirium cases are due to medication issues • Anticholinergic/opioid/benzodiazepines/levodopa/H2 blocker/antibiotic/anticovulsants/hypoglcemic agent. • Over the counter medications should NOT be overlooked as a cause • Elderly do NOT have to have a TOXIC LEVEL to be in fact: TOXIFIED
- 32. Lab testing • CBC: To diagnose infection / anemia • Glucose: To diagnose hypoglycemia, DKA, HHS • Thyroid function: Hypothyroidism • Urine/blood drug screening: toxicological causes • Culture/viral test: to diagnose infection • Electrolyte: to diagnose imbalance • Renal and liver function: liver or renal failure • Thiamine and vitamin B-12 levels: deficiency states of these vitamins
- 33. Neuroimaging and EEG • Neuroimaging: • Perform CT scan of the head • MRI of the head may be helpful in the diagnosis of stroke, hemorrhage, and structural lesions • EEG to differentiate other disease: • General medical condition > Posterior dominant rhythm and increased generalized slow-wave activity • alcohol/sedative withdrawal > fast-wave activity • hepatic encephalopathy > diffuse EEG slowing occurs • toxicity/metabolic derangement > Triphasic waves
- 34. Prevention/Treatment Multi-Component Treatment • Orientation protocol • Provision of clocks, calendars, windows with outside views, and verbally re-orienting patients • Cognitive stimulation and mobilization • Patients with cognitive impairment, in particular, may benefit from activity such as regular visits from family and friends • Facilitation of physiology sleep • Night-time noise should be reduced • Ear plugs and melatonin were found to be effective • Managing pain: • pain may be a significant risk factor for delirium
- 35. Antipsychotics as treatment • If potential patient harm is at risk, then trial of antipsychotics is warranted • Haldol (1st) and 2nd generation antipsychotics seems to be equally effective • 2nd generation have less side effects • CAVEAT: • Haldol IV has a black box warning regarding prolonged QT – DO NOT GIVE if you don’t know the baseline QT.
- 37. Effect of antipsychotics on the incidence of adverse effects Ann Intern Med. 2019 Oct 1;171(7):485-495. doi: 10.7326/M19-1860. Epub 2019 Sep 3. Figure 2. Meta-analysis of trials evaluating the effect of antipsychotics on the incidence of adverse effects
- 38. Anti-Psychotics as prophylaxis? Prophylactic Antipsychotic Use for Postoperative Delirium: A Systematic Review and Meta-Analysis Antipsychotics for the Prevention and Treatment of Delirium. Comparative Effectiveness Review Number 219
- 39. Discharge planning • Discharge destination planning • Involve caregivers and family • Do not discharge with delirium (10% hypoactive delirium were discharged in real world data) • Prevent long-term cognitive impairment.
- 40. Summary • Perioperative delirium is common • POD has serious short and long-term poor outcomes • Preoperative screening is critical • Perioperative monitoring and management is essential • Biomarkers suggest inflammatory and neuronal injury may play a role • Multi-component interventions may reduce/prevent delirium • 2nd generation antipsychotic as prophylaxis • Haloperidol for hyperactive delirium • Discharge destination planning for hypoactive delirium
- 41. Reference • Cochrane Database Syst Rev. 2018 Jun; 2018(6): CD005594. • JAMA, July 4, 2012—Vol 308, No. 1 • Arch Intern Med. 2002 Feb 25;162(4):457-63. • Am J Psychiatry. 1999 May;156(5 Suppl):1-20. • Am Heart J. 2015 Jul;170(1):79-86, 86.e1 • Clin Geriatr Med. 2020 May;36(2):183-199. • Alzheimers Dement. 2016 Jul;12(7):766-75. Epub 2016 Apr 18. • Arlington, VA: American Psychiatric Publishing. pp. 5–25. ISBN 978-0-89042-555-8. • International Journal of Geriatric Psychiatry 2013; 28:771–780 • J Gerontol A Biol Sci Med Sci. 1999 Jun;54(6):B239-46. • Proc Natl Acad Sci U S A 2010 Nov 23;107(47):20518-22. • Brain. 2020 Jan 1;143(1):47-54. • J Gerontol A Biol Sci Med Sci. 2006 Dec;61(12):1294-9. • Crit Care Med. 2012 Jul;40(7):2022-32. • Inouye et al. Ann int Med (1990) • Ann Intern Med. 2019 Oct 1;171(7):485-495. Epub 2019 Sep 3. • Antipsychotics for the Prevention and Treatment of Delirium. Comparative Effectiveness Review Number 219
Editor's Notes
- So I am going to share a case, this is a 37 year old alcoholic male patient who suffered from acute onset right upper abdominal pain shortly after dinner. He is febrile and physical examination revealed murphy sign positive. Blood test showed leukocytosis and elevated ALP and cholestasis. Combined with radiology finding support the impression of acute calculos cholecystits.
- So urgent operation was day at the same day uneventfully. However, shortly after the operation, he became agitated and inattention to daily activity, sometime he is better and sometime doesn’t and later even progress to drowsy. Beside these syndrome, his vital sign is stable. So we ask urgent blood test and head CT to rule out organic lesion which suggested otherwise unremarkable. We use an screening tool called CAM to elevate delirium and later he was diagnosed with hyperactive perioperative delirium.
- Given that the patient is agitated and had the comorbidity of alcoholism, haloperidol tranquilizer started with low dose and repeated it with double dose. No QT prolongation was noted.
- After all the sedation, the patient has no more agitation and regain fully function. And he was discharged eventually.
- So delirium is defined as a acute onset, reversible mental dysfunction with wide range of presentation. And occurs before or after surgery is defined as perioperative delirium. Because it associated with increasing morbidity and mortality so early diagnosis and resolution of symptoms are the thing that improve our patients outcomes and thus delirium should be considered a medical emergency
- the geriatric population is particularly prone to delirium upon presentation to the hospital, the rate of prevalent delirium among older patients ranges from 14 to 24 %, whereas following the admission the development of incident delirium among older patients during the hospitalization ranges anywhere from six to fifty six percent
- Predisposing factors for either delirium or peiroperative delirium , i've highlighted in red the central column which is for surgery, you can see that dementia and any sort of cognitive impairment are increasing by up to four fold, any previous history of an episode of delirium or functional impairment or visual impairment all of those things are likely to increase the risk of suffering from postoperative delirium
- This slide may account for some of that variation, so the prevalence rates basically depend on not only the population being study but the setting in the hospital, for example the prevalence rates of general medical patients ranges anywhere from 15 to 31 percent increasing to as high as 50 percent in cardio thoracic surgical patients, orthopedic surgery is 15% but hip fracture as high as 65%, vascular surgery is about 40-50%, and to an unbelievable 80 percent in intubated icu patients
- so when you look at the literature the mortality rate associated with acute delirium is 11 to 26 percent in people that get admitted with delirium And the population that develops delirium while they're in the acute care situation range from 22 to 76% If you look back to the mortality rate of other critical disease or syndrome such as septic shock, the mortality rate is around 10-56%, so delirium is much greater then it.
- Why does delirium has a higher mortality rate than septic shock, because when patient get into delirium status it often indicated that this patient had multiple underline problem that require medical attention, beside, patient is delirious has a longer length of stay, higher incidence of fall and aspiration, poor recovery after surgery and behavior concern that can potentially self harm, these issues combined together may increase the mortality rate. /////////////////////// https://www.youtube.com/watch?v=ahs6aHN_R6k&t=747s 05:43
- According to the diagnostic manual of mental disorder, the definite diagnose of delirium need to fulfill all these five criteria, it need to be an acute process this is something that affects cognitive ability or executive skills and it definitely affects the ability of awareness, need to have the evidence of medical source, and no other better explanation .
- in addition to that delirium can be further classified into three subtype such as hypoactive, hyperactivty or mixed delirium, they can also presented with emotional feature such as depressed, agitation, fear, etc, these are very common presentation to delirium
- In the prodromal phase of delirium or so called sub-syndromal delirium early symptoms occur, before all criteria have been met and it's easy to ignore, Patient often say thing like I just don't want to do physical therapy today, I don't really want visitors, I'm having trouble sleeping , I'm a little anxious.
- Around 62% of patient will present one of these features before they meet to full diagnostic criteria of delirium, it may represent the prodromal phase of a delirium episode or the tail end of a resolving delirium episode patients with Subsyndromal delirium are at very elevated risk for delirium and is also associated with negative outcomes that are associated with full-blown delirium
- so this figure is demonstrating the usefulness of predictive models for development delirium utilizing complex interrelationships between risk factor, let's say for example a patient with advanced age ,pre-existing cognitive impairment or multiple medical conditions, in combination to exposure with the precipitating factor such as the development of acute medical conditions, presence of modifiable risk factors in the hospital, many of which are iatrogenic and include things such as medications, complications of invasive procedure, immobilization malnutrition, dehydration, use of bladder catheters, sleep deprivation, etc So all this non-modifiable and modifiable factor combined together might significantly increase the risk of delirium
- the precise pathophysiologic mechanisms underlying delirium have not been definitively identified , there are a number of hypotheses which have been put with focus on, such as the roles of neurotransmission, neuroinflammation and alteration of permeability of the blood-brain barrier , unfortunately none of these hypotheses have resulted in a single effective pharmacological treatment to prevent or treat extend delirium /////////////////////////////////////////// https://www.youtube.com/watch?v=ahs6aHN_R6k&t=747s 23:43
- a few years ago a very convincing study of perioperative delirium showed in mice who had tibial surgery and anesthesia, they got a pronounced inflammatory response with TNF alpha in mice who underwent surgery and anaethesia, but in Anaesthesia there was no response no inflammatory response at all, leading us to think that there must be something happening with respect to the surgery
- Also there is a new biomarker called nfl or neurofilament light it's basically that's kind of a core protein of the axons It is being used for biomarker studies of neurodegenerative disease, people who have delirium had a much higher level in nfl, so indication that there might have been a greater brain damage from baseline to post-operative day one And the NFL is also a very good severity indicator or score, the more severe of delirium, the change in neural injury biomarker is greater
- In microscopic: this is just a hypothetical cartoon about delirium in terms of pathophysiology, let say if somebody is undergoing surgery so there‘s this inflammation in the periphery , the TNFalpha increase, and that basically goes into the bloodstream and weakened the blood brain barrier Normal the blood brain barrier protect you from toxic and cleanup all the toxic by microglial cells. unfortunately when they get activated they also release inflammatory mediators so in a way there's even more inflammation in the brain, so the hypothesis is that this inflammation causes neuronal temporatory dysfunction, if the delirium it is not being treated, it will become a permanent damage of the brain
- Just now we talk about the mechansim in microscopic, but how about in the brain structure: so this is the SPE-CT, the functional scan of delirium patient, you can see a widespread pattern of both decreased and increased regional cerebral blood flow in acutely delirious patients now the areas of hyper perfusion do not suggest some sort of compensatory mechanism and increase in activity in different brain regions thus disrupting network level functions on the brain And it is the reason why we call delirium is a acute brain dysfunction.
- Another study showed delirious patient is associated with hippocampal and frontal lobe volume reductions observed at hospital discharge and at three-month follow-up, and these figures also showed that the greater the duration of delirium the greater the loss of brain volume in these areas, So it isnt only causing short term acute brain dysfunction but also long-term cognitive impairment as well.
- we tend to think of delirium as an acute event but in fact many of them of cognitive decline for up to 12 months after that acute event, and some studies suggest one third of the patient can decline after 24 months
- this is some more work, the performance of delirium patient after the surgery kind of rebounded back before 3 months, but then by three years postoperatively you can see that those with delirium have declined considerably greater than the normal people
- who is at risk for delirium and this is going to become really important because we need to be proactive so the elderly people who have brain damage from CVA, parkinsonian diseases and most importantly the demented population in the acute care setting 25 to 50 percent are in the demented population
- Preoperative cognitive state is a key risk factor for delirium but cannot be estimated objectively in medical or surgical emergencies. In contrast to emergency surgery, elective surgery allows preoperative cognitive and further assessments. And now many studies suggest a basic risk assessment including a cognitive screen such as MoCA can help to stratify patients to provide targeted prevention and management strategies
- actually we know precipitate delirium and they fall into six broad categories and we need to be aware of is the drugs and toxins, 30% of the causes of delirium boil down to the medications that we gave the patient or the patient's gave themselves so most the time is drug that with anticholinergic effect but things like metabolic diseases, the calcium disorders, hyponatremia hypo and hyper glycaemia, infectious processes. All of this is the common cause of delirium
- So how to screen delirium for the patient with high risk or with suspicious feature of delirium, so here is a screening tool called confusion assessment method there's four criteria, and you need to have the two core criteria which is first acute onset and fluctuating course, we talked about fluctuating course you‘re going to see them in the morning they might be fine and they might not be so fine in the afternoon acute onset so often where the confusion arises is that if case you have patient who has history of dementia, it is very easy to be missed as dementia syndrome, so you have to talk with the family members about the patient baseline functioning and most of the time they will tell you my mom has dementia but this is not my mother, than you got the diagnosis. another thing is inattention, if you're talking to them they kind of drift off or they start falling asleep because they're very inattentive, there is one way to test for inattentive is to ask them to subtract 7 from 100. then presence of at least one item from three and four of the criteria, so disorganized thinking not knowing where they are, altered level of consciousness so they might be a little bit stumbling or drowsy
- There are some simplified version of screening tool adapted from confusion assessment method, such as three-minute confusion assessment method and even a ultra simpified version called ultra-brief CAM. there's two questions that you can actually ask that might be with highest sensitivity to give you a clue as to whether somebody might be delirious that is month of the year backwards and what is the day of the week So these are really commonly used tools for doctors don't have too much time
- So we have identified the delirious patient, the first thing you are going to do is not try to give any medication to treat delirium unless the patient is very agitated or presented with self-harm behaviors Instand is find out the cause of delirium and most of the time is related to the drug. Anticholinergic is the most common cause, others such as opioid, H2 blocker, antibiotic, hypoglycemic agent and near to all the medication that can pass through the blood brain barrier can cause delirium, Once you identify these medication, you can hold the medication if possible but do not be overlooked as a cause
- So after the suspected medication is withhold, routine blood test showed be done in addition with thyroid function test and vitamin level, basically these lab test can rule out 90% of medical issues that causing delirium
- Radiology study usually involve chest and abdominal x-ray and head CT or MRI is indicated if the patient’GCS dropped or present with any feature of focal neurological sign to rule out structural brain lesion EEG has been very useful in differential diagnosis to rule out alcohol withdrawal, hepatic encephalopathy and toxic derangement
- So how do we prevent and treat delirium, so it is multi modality thing not only depend on medication or solving the medical issues of the delirious patient, keeping these people oriented is the priority, you can bringing in a personal items for them or asking family members stay with the patienet, another thing that really makes people more subject to delirium is no sensory input, for example, taking away patient glasses or hearing aid is a sure reason to make patient become delirious, in psychiatry we called it sensory deprivation, so we need to resume their sensory as soon as possible. also to keep control of their circadian rhythm, reduce all the Night-time noise and provide ear plugs to them. managing pain is really important because pain does not go well for cognitive functioning . All these component were found to be very effective in delirious patient.
- antipsychotics for treatment so it is recommended if patients are harm to themselves, some studies would suggest that the typical and atypical antipsychotics are equally efficacious at treatment but they really preferred second generations because of decreased side-effect profile The most dangerous and troublesome side effect of 1st generation is QT prolongation So it is recommended to do ECG before and after you give 1st generation of antipsychotics If there are any sign of QT prolongation, then 2nd generation is preferred
- So how do we use haloperidol as a tranquilizer The most safer way to decrease the risk of QT prolongation is to start with lose dose then gradually increase the dose Initally we can give 0.5mg IM then repeat 0.5mg 30 minutes later, then increase to 1mg if refractory and go on. The maxium dose of IM haldol can up to 100mg But more than 45mg/day increase the risk of EPS Other 2nd generation such as quetiapine is more useful for pateint with insmonia and risperidone is more useful in hypoactive delirium, so you can use it case by case
- It has been believed that haloperidol has more cardiac side effect than second generation. However in recent study provide evident suggested, potentially harmful cardiac effects particularly prolongation of the QT interval tended to occur more frequently with second-generation antipsychotics versus placebo or haloperidol. So nowaday treating delirum, the first line treatment is still haloperiol.
- What about antipsychotics for prophylaxis, it started in 2005 people started to give 0.5mg of oral Haldol thiamine and folate to high-risk patient before surgery, and until ten years ago a meta-analysis concluded that antipsychotic is good as delirium prophylaxis, it can decrease the incidence of delirium but cannot improve the severity of symptoms of delirium or the duration And they also found that second generation of antipsychotic is better than haldolperiol as prophylatic. in other words if you're going to use a 2nd generation anti-psychotic you're going to have to start that medication before they become delirious
- discharge destination planning it should involve family and friends if possible or caregivers because the likelihood of poor compliance with post-operative orders Moreover its about 10% of hypoactive delirium patients are sent home all the time still with delirium so post discharge rehabilitation and follow up in OPD for congitive function for high risk patient is necessary to reduce the risk of longterm congitive repairment.
- so in summary peri-operative delirium is common and has serious short and long-term poor outcomes So we need to be screening pre-operatively it's essential we need to monitor and manage during the intra and or whole perioperative period Study suggest neuroinflammation and neuronal injury may play a role in perioperative delirium multi-component interventions may reduce or prevent delirium and ultimately And recent study suggest second antipsychotic can reduce to incident for high risk patient Haloperidol as a tranquilizer is remain to be a standard treatment for hyperactive delirium Make a discharge destination planning is necessary in order to prevent long-term cognitive impairment for hypoactive delirium
- Haloperidol Versus Second-Generation Antipsychotics One RCT, with low risk of bias, compared the second-generation antipsychotic, ziprasidone, with haloperidol and reported no between-group differences in short-term mortality, defined as mortality while in hospital or up to 30 days after randomization
- https://www.youtube.com/watch?v=TDLsq2m6zgY&t=2336s the literature makes a big difference about mobilization strapping these people into beds and keeping them down has definitely been correlated with the chances of them becoming delirious and when I say like that strapping them into beds we don't strap people into beds but we do this I put s CDs on their legs I put a Foley in their bladder I put a rectal tube in their rectum I put an IV sometimes in both arms and then I put that that the spo2 monitor on their finger so we don't intend to strap them down but we have you know just trying to get somebody out of bed with four or five lines in them oh you're scrap down pretty well so we have definitely impacted these people's mobility alright and we talked about these things already managing pain is really important if you let these people's pain stay out of control for some reason that does not go well for our cognitive functioning
- https://www.youtube.com/watch?v=ahs6aHN_R6k&t=747s 13:26
- https://www.youtube.com/watch?v=ahs6aHN_R6k&t=747s 6:12
- so this is a study coming to us from the American geriatric Society really looking at the duration of delirium and how does that affect mortality and this is a very busy slide we're not going to read the whole thing but the bottom line is this that your patients with a cute delirium the longer they have that delirium the worse it gets for them and so this is a state that looked at you know a follow-up post acute hospitalization at two weeks four weeks 12 weeks and 26 weeks and the longer your delirium goes the higher your mortality rates go these patients had a three-time higher mortality rate who even when you match for age severity of disease cool more reds everything just the delirium itself gives you a three-time increase in their mortality
- https://www.youtube.com/watch?v=TDLsq2m6zgY&t=2336s
- https://www.youtube.com/watch?v=TDLsq2m6zgY&t=2336s
- https://www.youtube.com/watch?v=TDLsq2m6zgY&t=2336s
- https://www.youtube.com/watch?v=TDLsq2m6zgY&t=2336s
- so can we predict who is at highest risk for delirium and the answer is yeah we we actually have some tools at our disposal so this is the mini cog it's a three-minute test I did this for clinical purposes to a patient a week and a half ago he was had heavy cognitive decline and it took me five minutes to get him on board with doing this test and it's very simple so it's painless it boils down to these two steps you asked them to memorize three words chair table spoon whatever interestingly when you look at the studies they validated these word choices so they know that these were choices work and they prefer that you use these word choices I think any three words or three items would probably do so you ask them mr. Smith remember these three words for me and then you have them draw clockface and have them put the the hands of the clock to 10:00 after 11:00 and then after they're done with that task then you ask them well what were those three words again can you can you bring them back to me and the way that you scored that out is if they remember all three words they pass there's no evidence of a cognitive issue if they can get one or two words right and they ace that clock face they're okay if they can't do the clock face and recall more than one or two words that suggests they're very high risk for dementia or cognitive decline and if they can't get any of them and then they probably definitely have an issue when they look at this as a validation tool what they find is that this is somewhere between 76 and 95 percent sensitive to picking up at-risk populations for delirium and with a p-value of less than 0.001 so pretty reasonable tool and it only takes just three minutes so we could totally with the three minutes screen at risk populations to say I think that this person is somebody that we need to have a high suspicion that they're going to have a delirium issue in our Hospital
- so how are we gonna make this diagnosis of delirium in the acute care setting so here's a tool that I want to offer you this has been validated this is the confusion assessment method for the ICU the thing I like about this assessment is it was designed for people who may or may not be verbal even if you're innovated as long as you're alert you can you as long as they're alert you can use this on them if you're not alert I can't help you with that so it starts with an assessment of their alertness so this is the richmond agitation sedation scale and when you look at zero i'm hoping everybody in the room is about an RA SS of zero we're all alert and we're calm and we can pay attention if you're not then i'll medicate you later and as long as you're above a negative three which means you're you'll at least respond to voice then you can proceed on with doing the km ICU assessment on them if they're below that if they're just too sedate this is not the tool for you and you're gonna have to come back after you've gotten that patient's level of consciousness up
- people can be delirious because they're having a seizure but they're not tonic-clonic so we don't start to think about it so you can never say that a patient is is not having a seizure when you're working them up for delirium or mental status changes so that's something important to keep in mind and the other important role of the EEG is the things that cause delirium may have profoundly different appearances on an EEG hyperactivity and sharp waves would certainly be much more likely to be due to alcohol and benzodiazepine withdrawal whereas diffuse cortical slowing is probably more in line what we normally see with people who just have metabolic delirium or infectious delirium that sort of thing
- so how did the se patients present, when we think about the presentation of delirium we typically think about sun downing and we think about just confused grandma type people and there really has three different classical presentations there's the very hypoactive the withdrawn I don't want to get up and do anything and I don't want to do exercise today they just kind of withdraw into themselves and they're quiet and unless you really pick at these people it's pretty easy to ignore the signs of delirium in that population the next presentation that we see is the hyperactive their psychomotor or just goes way up and these people are angry they're up they're pacing they're tearing out lines they're doing bad things hard to ignore those people and then mixed and that's probably the most common thing that we see you know like a bad mullet it's all business in the front party in the back these people it's pretty quiet during the day but when the Sun Goes Down it's really hard to ignore and anybody who works the night shifts or has ever been a house officer can tell you we've seen this population before so very common presentations
- this is the ubiquitous up to date slide with more facts that you guys can ever memorize I'm not going to read that to you I know you guys read faster than I do but it's there for your reading the point is those six categories have a lot of sub diagnosis ease that can get you into trouble
- this one I built for you though this is my attempt to look at every medications that has an anticholinergic effect because remember when we start getting out Sedo choline that's when we would predict we're going to start to have trouble with these patients and look at these medications that we use commonly I've probably taken care of at least three patients that I've given either nortriptyline or amitriptyline to this week alone all of our anti-nausea medications all of our smooth muscle relaxants there's a lot of medications benadryl 'he's notorious when I was a resident they just hammered homes stopped giving benadryl to our elderly patients at night because you're making a big mess they go crazy and they can't be please stop doing it this list just keeps piling on and no matter what flavor of medicine we practice here I'm pointing to some medications that you guys probably are prescribed or used or given and so there's lots of them
- The nuts and bolts of what we understand from a neuro hormonal aspect are as follows this is an imbalance between a cetyl choline and dopamine and so these people have too little acetylcholine in their system they did a study looking at preoperative surgical patients and what they found is those who had the lowest levels of acetylcholine were definitely the most likely to become delirious during the course of their stay here and when you look at things like hypoxia hypoglycemia thymine deficiencies these are all things that we would all agree make us much more likely to become delirious and those things also have this in common they all decrease levels of acetylcholine in our system so we know that this imbalance between acetylcholine and dopamine makes a big difference in who will be subject to delirium and who won't and when you think about how many anti cholinesterase affecting medications are on the mark many of them are which are over-the-counter it's not that hard for patients to get into trouble with the dopamine and acetylcholine systems
- so number one is it does involve the cortical and subcortical structures of the brain we started doing EEG s on patients in the 1940s and what we found is when you look at brainwave activity you can clearly see a cortical dysfunction on those EEG s and sometimes you can even use those to tease out what flavor of delirium these patients have like for example when somebody becomes delirious because of a withdrawal symptom those EEG have some very specific characteristics to them
- https://www.youtube.com/watch?v=WtdIhavXe2E 16:37 first of all pre-operative cognitive assessment pre-operative cognitive impairment is the strongest predictor of a patient experiencing post-operative delirium pre-operative screening should be mandatory for anyone 65 years or more coming in for surgery and this may allow us the opportunity to prevent delirium and further cognitive decline
- https://www.youtube.com/watch?v=WtdIhavXe2E 12:49 this is uh some best practices from our perioperative neurotoxicity working group 12:42 a number of years ago uh from miles berger and um just to highlight that 12:48 um you'll see the the bottom there eeg based intraoperative brain monitoring to 12:54 titrate anesthetic administration that was based on the fact that although 13:00 there's little evidence to suggest that eeg based monitoring can reduce delirium 13:07 or post-operative delirium the group decided that it was probably 13:14 something that should be done with respect to titrating anesthetic anyway
- https://www.youtube.com/watch?v=WtdIhavXe2E 11:27
- https://www.youtube.com/watch?v=WtdIhavXe2E 5:31
- so assuming that you've 21:25 got that level of a consciousness 21:26 appropriate then we're gonna follow a 21:29 pattern and I think that this is 21:30 probably easier there just to show you 21:32 the worksheet itself so is this patient 21:34 anything different than their baseline 21:37 she was she's aware but she's agitated 21:40 she's off of her baseline how many times 21:43 have we been told by the family well 21:45 she's just not herself you're like what 21:47 do you mean well I don't know but I know 21:48 my mom and this is not how my mom acts 21:51 but they can't put it on this one thing 21:55 you know but off of her baseline so if 21:57 you're off your baseline and if you have 22:00 troubles with attention and this is 22:03 where you they don't have to be verbal 22:05 for this so what they do with this test 22:06 is they're gonna read out a series of 22:09 letters and every time you hit a you 22:12 need to respond to that and so if 22:13 they're intubated you just have them 22:14 squeeze your hand every time I be 22:18 and every time they squeeze 22:19 appropriately you know they're oriented 22:21 so if they make more than two errors 22:23 then they're having difficulty following 22:25 you and maintaining attention so that 22:29 brings us so you have to have both of 22:30 those things so if you check the first 22:32 two boxes you're well on your way 22:34 because you only have to have one more 22:36 box check thereafter so if they're 22:39 having trouble with altered levels of 22:41 consciousness or if they're having 22:43 issues of cognition or disorganized 22:46 thinking either one of those two things 22:48 then you've met the criteria to say this 22:51 patient is delirious so and they have a 22:54 bunch of yes-or-no questions will a 22:56 stone float on water is one pound more 22:58 than two pounds that sort of thing or 23:00 you can have them hold their fingers up 23:03 you know show me two fingers now now 23:05 show me two fingers on your other hand 23:07 yeah can they pay attention enough to be 23:10 able to follow those commands for you so 23:12 it's a pretty simple screening test for 23:14 delirium