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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Hypoactive delirium quiet, withdrawn patient, often mistaken for depression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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Delirium: Prevention
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
Delirium: Prevention
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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