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Managing Delirium in the Emergency Department

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Page 1: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Managing Delirium in the Emergency Department

Page 2: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Introduction

• Not a talk about the agitated patient

• They’re easy and there is lots of literature

- sedate, intubate and let ICU sort it out

Talk about delirium

- emphasis on the emergency department

- very little literature

- big management problem

Page 3: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Introduction

• Managing a patient with delirium is difficult and labour intensive

• A bigger problem is actually recognising that the patient has a delirium

• The 2 groups where we need to have a high index of suspicion are the elderly and the (first presentation) psych patient

Page 4: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Delirium

• Neuropsychiatric Syndrome

- multiple causes

- produce a similar constellation of

symptoms

Page 5: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Delirium Definitions

• A sudden and significant decline in mental functioning not better accounted for by a preexisting or evolving dementia

• Disturbance of consciousness with reduced ability to focus, sustain, and shift attention

Page 6: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

DSM-IV Diagnosis • DSM-IV

– A. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.

– B. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia.

– C. The disturbance develops over a short period of time and tends to fluctuate during the course of the day

– D. There is evidence from the history, PE, or labs that the disturbance is caused by the direct physiologic consequences of a general medical condition

Page 7: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Introduction

• Simplest definition of delirium is “acute brain failure” with a combination of

- behavioural symptoms

- psychological symptoms

- cognitive symptoms

- neurological symptoms

Page 8: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Introduction

• Common presenting problem

> 40% of patients over 65

• Frequently develops during an admission

• Frequently misdiagnosed as psych or dementia

- overlap of symptoms

- dementia predisposes to delirium

Page 9: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Introduction

• Frequently missed all together

• We forget that there are a range of presentations

- agitated delirium

- quiet delirium

- mixed

Page 10: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Why Does Delirium Matter?

• Increased morbidity and mortality

• Increased length of stay

• Increases rate of cognitive decline

• Increased distress to patient and family

- may believe delusions and hallucinations

really happened even after delirium

resolved

Page 11: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Behavioural Symptoms

• Aggressive or agitated

• Quiet and withdrawn

• Screaming / calling out

• Wandering

• Disinhibited

• Altered sleep-wake cycle

Page 12: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Behavioural Symptoms

• Constant questioning

• Hide things / hoarding objects

• Frontal lobe release

- picking at the air / bed clothes

- pulling on IVC or IDC

Page 13: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Psychological Symptoms

• Anxiety

• Paranoid

• Delusions (usually persecutory)

• Hallucinations (usually visual)

- auditory hallucinations: think psych

- visual delusions: think delirium

Page 14: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Cognitive Symptoms

• Can’t focus / inattention

- beware of the “vague historian”

• Can’t shift focus

• Can’t solve problems

• Trouble with abstract thought

• Impaired recent and remote memory

Page 15: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Neurological Symptoms

• Dysphasia

• Dysarthria

• Tremor

Page 16: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Psychiatry and Delirium

• Many of the symptoms of delirium also can occur in a psychiatric illness

- easy to see why there is confusion

• Liason psych are often called to review patients whose delirium has been missed by the treating team

Page 17: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

“Psychiatric Symptoms”

• Altered mood

• Altered behaviour

• Altered thought or cognition

• Altered perception

If patients are triaged with these problems,

we jump to the conclusion that is a psych

illness

Page 18: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

“Psychiatric Symptoms”

• May be caused by or aggravated by a medical illness (organic illness)

• Incidence is unclear - 10 to 75% range quoted in A&E literature Medical illness is a significant cause of

“psychiatric symptoms”

Page 19: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

“Psychiatric Symptoms”

• Unfortunately, medical illnesses often go unrecognized due to inadequate and poorly documented medical assessment in A&E

Tintinelli (1994)

- assessment of: mental state 40 – 80%

LOC 80 – 95%

orientation 70 – 90%

full motor exam 50 - 60%

cranial nerves 20 – 55%

Page 20: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

“Psychiatric Symptoms”

• Reeves (2000): still the same problem

• 64 patients with medical illness admitted inappropriately to a psychiatric unit

- full history 66%

- vital signs 90%

- full physical exam 65%

- full mental state exam 0%

Page 21: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

“Psychiatric Symptoms”

• Problems with medical assessment are not due to a lack of imaging or esoteric blood tests.

• The problem is a failure to do a thorough history, examination and mental state examination

ie we aren’t doing the basics

Page 22: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Psych Vrs Delirium

• First presentation of a psych illness is rare over 45 years of age

• Auditory hallucinations are more common

• Even floridly psychotic patients tend to remain orientated to time and place

• Memory is usually intact

• Does not fluctuate over the course of a day

Page 23: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Delirium Vrs Dementia

• Memory deficits, language disturbances and disorganized thinking are common to both diagnoses

• Need to know the patients baseline, what has changed and how quickly it has changed

• Need a good history from multiple sources

Page 24: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Delirium versus Dementia

• DeliriumRapid onsetPrimary defect in attentionFluctuates during the

course of a dayVisual hallucinations

commonOften cannot attend to

MMSE or clock draw

• Dementia

Insidious onsetPrimary defect in short

term memoryAttention often normalDoes not fluctuate during

dayVisual hallucinations less

commonCan attend to MMSE or

clock draw, but cannot perform well

Page 25: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pathophysiology of Delirium

• Systemic pathology leading to a local inflammatory response in the brain with subsequent changes in neurotransmission

- we don’t care

• It involves predisposing factors and precipitating factors

- we do care

Page 26: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pathophysiology of Delirium

Can use predisposing factors to predict who

is at risk of developing delirium

Can use precipitating factors to guide our

management strategies

Page 27: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pathophysiology of Delirium

Predisposing factors- Children and elderly (<10 & > 65)- history of brain disease (dementia, CVA)- history of delirium- impaired vision or hearing- medications (benzo’s; anti-cholinergics)- alcohol dependance- psych history

Page 28: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

• Precipitating factors

- lots

• The main ones are

- underlying medical condition

- substance intoxication

- substance withdrawal

- combination of any or all of these

Pathophysiology of Delirium

Page 29: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pathophysiology of Delirium

Other Precipitating Factors- new medications- invasive procedures (IVC; IDC; NG)- fluid and electrolyte abnormalities

- metabolic disturbances

- change of environment (ED is bad!)

- nutritional deficiencies

Page 30: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pathophysiology of Delirium

• The more precipitants, the greater the chance of developing a delirium

• The more predisposing factors, the fewer precipitating factors are needed to trigger delirium

- In the frail elderly, constipation alone

can trigger delirium

Page 31: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Making the Diagnosis

• Delirium is common

• Delirium is important

• Delirium seems really complicated

• How can I make the diagnosis?

Page 32: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Medical Assessment

• Stable / Unstable

• Danger to Self or Others

• Detailed History

- medical & psychiatric

- from multiple sources

- baseline ADL, cognition, behaviour etc

eg family, ambo’s, bystanders, NH

GP, old notes, CMH team

Page 33: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Clues for an Organic Cause

• Age less than 12 or greater than 40 • Sudden onset (hours to days)• Fluctuating course• Disorientation• Decreased consciousness• Visual hallucinations• No psychiatric history• Emotional lability• Abnormal vitals / physical examination findings • History of substance abuse or toxin exposure

Page 34: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Clues for a Functional Cause

• Age 13 to 40 years• Gradual onset (weeks to months)• Continuous course• Awake and alert• Auditory hallucinations• Psychiatric history• Flat affect• Normal physical examination findings (including

vital signs)

Page 35: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Medical Assessment

• Full physical Examination

- head to toe

eg head / neck / CVS / lungs / abdo

neuro / periphery / skin

- includes vital signs

eg BP, HR, RR, Temp, BSL, RAIR sats

Page 36: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Medical Assessment

• Bedside tests

- mental state exam

- mini mental exam

- EEG

- CAM

Page 37: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Making the Diagnosis

Mini Mental- Useful at separating “normal” from “abnormal”- Not specific for distinguishing delirium from dementia- May be useful as change from baseline- Suggestive if score varies during or between days

Page 38: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Making the Diagnosis

• Mini mental does include tests of attention

- serial 7’s

- spell “world” backwards

Other simple tests

- counting backwards from 20

- days of week backwards

- month of year backwards

Page 39: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

EEG

• Can be diagnostic

- generalised slowing of brain activity

• Significant false positive and negative rate

• Is done on the wards

- but is it useful?

• Not done in A&E

Page 40: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Confusion Assessment Method

Is there evidence of:1) Acute onset and fluctuating course2) Inattention3) Disorganized thinking4) Altered LOC (increased or decreased)

1 and 2 and either 3 or 4 Sens = 95% spec = 90%

Page 41: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Confusion Assessment Method

1) Acute onset & fluctuating course

- is there an acute change from the patient’s baseline?

What are they normally like, what has

changed and when did it change

Page 42: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Confusion Assessment Method

2) Inattention

- did the patient have difficulty keeping track of what was being said?

- can’t focus

- can’t shift focus

- Serial 7’s

- World backwards etc

Page 43: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Confusion Assessment Method

3) Disorganized thinking- rambling conversation- unclear or illogical flow of ideas- Interpret a proverb- “Will a stone float on water?”

Page 44: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

CAM Diagnostic Algorithm

4) Altered level of consciousness - alert (normal), - vigilant (hyperalert), - lethargic (drowsy, easily aroused), - stupor (difficulty to arouse)

Any answer other than “alert” is abnormal

Page 45: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Management

• The key is to identify and treat the underlying causes

Also need to:

- minimise patient anxiety

- prevent harm to the patient

Page 46: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Management: Investigations

• Not to make the diagnosis

• To help guide our treatment

• Often use a “shotgun” approach

• EUC, FBC, LFT, MSU, blood cultures, cardiac biomarkers, CT brain, ABG, ECG, CXR, PR, etc etc etc

Page 47: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Management: Treatment

• Can treat against their will using the mental health act

• Non-pharmacological Strategies

• Pharmacological Strategies

Page 48: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Soapbox Moment

• We used to have a CNC for dementia and delirium but admin in their wisdom has terminated the position

• Each speciality has a CNC who should be involved early in the management of admitted patients with a delirium

Page 49: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Non-pharmacological Treatment

• “A calm, quiet atmosphere, frequent prompts concerning orientation, clear precise communications and a night light are helpful in the management of delirium”

Some dude who has never stepped foot inside an Emergency Department

Page 50: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Non-pharmacological Treatment

• Numerous strategies that aren’t practical in ED (or wards either?)

1)Providing support and orientation

2)Providing an unabiguous environment

3)Maintaining Competence

Page 51: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Non-pharmacological Treatment

In English- Frequent reminders about time and place- Constant reassurance- Staff to wear name tags and indentify

themselves often- Minimise stimuli (noise, lights, procedures)- Place familiar objects in room- Minimise the number of staff involved in care

Page 52: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Non-pharmacological Treatment

• Patients with delirium are unpredictable.

• Unpredictability = bad things happen

- fall; pull out vascaths; abscond; ride

around naked in elevators

• They need a special.

• If none available, place the bed where they can be seen at all times

Page 53: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pharmacological Treatment

• Not Indications

- calling out

- wandering

- convenience of staff

No drug will stop a patient from wandering.

Drugs will help a wandering patient fall

Consider sedating the nurse

Page 54: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pharmacological Treatment

Indications for drug therapy

- relieve patient anxiety

- behaviour putting patient or others at risk

- agitation distressing to patient

Not aiming to sedate the patient

Trying to calm them down

Page 55: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pharmacological Treatment

• No good evidence based studies

• Large range of treatment guidelines

• Are now Australian Best Practice Guideines

Page 56: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Pharmacological Treatment

• Aim to use one drug

• Keep doses to a minimum

• Avoid escalating doses

• Seek expert advice early

• Review medications daily

Page 57: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Benzodiazepines

• Don’t use as a first line agent

- long half life & easy to over sedate

- respiratory depression

- may worsen delirium

- no anti-psychotic actions

- role in alcohol withdrawal & terminal

delirium

Page 58: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Haloperidol

• Haloperidol

- first line in the Australian Guidelines

- widely used (outside of Westmead ED)

- oral, IM or IV

- no agreement in dosing strategy

- “start low, go slow”

Page 59: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Haloperidol Dosing

• 0.5 to 1 mg initially

• repeat in 30 mins to 2 hours if needed

• Maximum 2 to 4 mg / 24 hours

Page 60: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Haloperidol

• Haloperidol in ICU

- 1 , 2 or 5 mg IV

- double dose every 30 minutes till settled

- then give total 24 hr dose as qid on

subsequent days

Page 61: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Second Line Agents

• If after haloperidol, there are prominent psychotic features

- risperidone

- olanzepine

• If after haloperidol, agitation is prominent

- lorazepam

Page 62: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Resperidone

• 0.25 to 0.5 mg PO, Q4 hourly, PRN, maximum 2 mg / day

• Maximum 4 mg / 24 hours

• Side effects include hypotension and sedation

Page 63: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Olanzapine

• Tablets, wafer, IM

• 2.5mg If needed repeat in 4 hours

• Maximum 10 mg / 24 hours

Page 64: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Lorazepam

• 0.5 – 1 mg initially

• If needed repeat in 4 hours

• Maximum 3 mg / 24 hours

Page 65: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Conclusions

• Maintain a high index of suspicion for delirium in elderly patients and possible psych patients

• Remember the red flags for organic & functional illness

• Thorough exam & clear documentation

Page 66: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

Conclusions

• Remember the CAM

• Try to avoid drug therapy

• Calling out and wandering are not indications for drug treatment

Page 67: Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient They’re easy and there is lots of literature - sedate,

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