confusion and delirium v2email 1217922030035141 9

8/11/2019 Confusion and Delirium v2email 1217922030035141 9

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Confusion over terminology

Confusion

AKA Disorientation

Incoherence

Clouding of consciousness

Delirium


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Delirium: Definition

de lira to wander

clinical syndrome (not disease) characterised by

?


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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


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Delirium: Outcomes Mortality

Delirium in hospital is associated with mortality ratesof 25 33%

Most studies report higher mortality after dischargeeg 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 forcomorbidity, dementia and severity of illness McCusker et al Delirium predicts 12 month mortality. Arch Intern Med.

2002;162:457-463


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Clinical Presentation


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Delirium: Clinical Features

Inattention (95%)

Disorientation

Short term memory impairment

Thinking is disordered Speech rambling and incoherent

Delusions, misperceptions and visual

hallucinations

Distress, anxiety


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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Hypoactive delirium quiet, withdrawn patient, often mistaken for depression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


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Lethargy

Agitation

Day NightNight

Day

Day DayNight Night

PRN

Course of Delirium


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ICD 10 definition

Impairment in consciousness & attention

Global cognitive impairment Psychomotor disturbance

Sleep-wake cycle disturbance

Emotional disturbance


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DSM IV definition

Disturbed consciousness

Disturbed attentionDisturbed cognition

Acute onset

Fluctuating symptoms


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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 milddaytime somnolence but no changes in consciousness, no psychoticsymptoms or perceptual disturbance, and no convincing fluctuations. Shewas not unduly agitated or over-aroused.

She scored 6 out of 10 on the clock-drawing test (CDT), and 22/30 on themini-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 assistancewith everyday household tasks.

At one year the symptoms had not changed.

DSM IVICD 10This CaseCriteria


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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


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Laurila (2003) 425 patients hospital & nursing home

ICD 10DSM IV

81 18

25


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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

FatigueSorensen & Wickbald (2004), J of Clin Nursing, 13


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Risk Factors and Aetiology


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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


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Detection


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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 detectdelirium arising during an admission

Mental status = a vital sign


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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 ofmental state (15.6% Vs. 8.5%)

Rockwood et al (1994) J of Am Ger Soc, 42


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Delirium: Differential DiagnosisMeagher, D J Delirium BMJ 2001; 322: 144 -149

Delirium Dementia Depression

Onset Acute Insidious Variable

Course Fluctuating Steadily progressive Diurnal variation

Consciousness andorientation

Clouded;disoriented

Clear until latestages

Generallyunimpaired

Attention and

memory

Poor short term

memory; inattention

Poor short term

memory withoutmarked inattention

Poor attention but

memory intact

Psychosis present? Common (psychoticideas fleeting,

simple content)

Less common Occurs in smallnumber (psychotic

symptoms complexand moodcongruent)

EEG Abnormal in 80-

90%; generaliseddiffuse slowing in80%

Abnormal in 80-

90%; generaliseddiffuse slowing in80%

Generally normal


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Delirium

Dementia


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Scales (assisted detection)

S l


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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


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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)

Diagnostic Testing: Tools


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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


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The Clock Drawing Test

12

6

39

1011 1

2

4

57

8

Used extensively in assessment of cognitivefunction, 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.


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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

Si l (H d D t )


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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


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0.0

0

0.2

5

0.5

0

0.7

5

1.0

0

S

ensitivity

0.00 0.25 0.50 0.75 1.00

1 - SpecificityArea under ROC curve = 0.8464

ROC curve for Clock Drawing Test using AMTS as gold standard


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Management

B i


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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

D li i I ti ti


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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

Haloperidol


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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

Delirium: Non Pharmacological Mx


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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 andstaff changes)

Delirium: Non Pharmacological Tips


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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


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Prevention

Non Pharmacological Mx: Does it work?


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Non Pharmacological Mx: Does it work?

Cole et al found 227 with incident or prevalentdelirium 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 toimprovement, discharge, mortality!!

Cole MG et al. Systematic detection and multidisciplinary care of delirium in oldermedical inpatients: a randomized trial. CMAJ. 2002; 167(7):753-9.

Delirium: Prevention


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Prospective study involving 852 patients with 426matched pairs compared usual care of elderlygeneral medical patients with those receiving

interventions

Incidence of delirium lower in intervention vs usualcare 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



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Hip Fracture

Marcantonio et al. Pre-op and daily post-op geriatricreview 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


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Extras


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Advance (directives) Decisions


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Advance (directives) Decisions

An advance decision is when someone who has mentalcapacity decides that they do not want a particular type oftreatment if they lack capacity in the future.

A doctor must respect this decision.

If the advance decision says no to treatment which may helpkeep you alive, it must say this clearly and be signed by you.

Another person can sign an advance decision for you butonly if you agree and you can see them sign it.

You are free to make an advance decision if you want to, butno one should force you to make it.


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Pharmacology Of Atypical Antipsychotics


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Zorn SH et al. Interactive Monoaminergic Brain Disorders. 1999:377-393.Schmidt AW et al. Eur J Pharmacol.2001;425:197-201.

Quetiapine

M15-

HT2A

D2

5-

HT2C

5-

HT1A

1

H1

Risperidone

D2

1

5-

HT2A

5-

HT2C

H1

Olanzapine

M1

H1 5-

HT2C

5-

HT2A

D2

1

Ziprasidone

D2

5-HT1D

5-

HT2C

5-HT1A

5-HT2A

1

H1

Clozapine

5-HT2C

M15-

HT2A

H1 1

D2

DSMIV Delirium Symptoms


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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

S e u Sy pto s

DSMIV Delirium Symptoms 2


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Fluctuating clinical picture

Disturbance caused by underlying disorder.

Confirmed by investigations & physicalexamination

Sleep disturbance

Disturbance of psychomotor activity

y p

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