Delirium & Confusion

Confusion over terminology

• “Confusion”

– AKA Disorientation– Incoherence– Clouding of consciousness– Delirium

Delirium: Definition

• de lira “to wander”

• clinical syndrome (not disease) characterised by

?

Scope of the Problem

• 10-15% delirious on admission (Inouye 1997, Lipowski 1987)

• 5-40% incident delirium in hospital (Francis 1992)

• Settings– 11-43% post-operatively (Bryson 2006)

– 70-87% in the ICU (Pisani 2006)

– > 70% in terminal CA (Massie 1987)

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

Delirium: Outcomes Mortality

• Delirium in hospital is associated with mortality rates of 25 – 33%

• Most studies report higher mortality after discharge eg 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 for comorbidity, dementia and severity of illness– McCusker et al Delirium predicts 12 month mortality. Arch Intern Med.

2002;162:457-463

Clinical Presentation

Delirium: Clinical Features

• Inattention (95%)• Disorientation • Short term memory impairment • Thinking is disordered• Speech rambling and incoherent• Delusions, misperceptions and visual

hallucinations • Distress, anxiety

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• Hypoactive delirium– quiet, withdrawn patient, often mistaken for depression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

Lethargy

Agitation

Day Night NightDay

Day DayNight Night

PRN

Course of Delirium

ICD 10 definition

Impairment in consciousness & attentionGlobal cognitive impairmentPsychomotor disturbanceSleep-wake cycle disturbanceEmotional disturbance

DSM IV definition

Disturbed consciousnessDisturbed attentionDisturbed cognitionAcute onsetFluctuating symptoms

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 mild daytime somnolence but no changes in consciousness, no psychoticsymptoms or perceptual disturbance, and no convincing fluctuations. She was not unduly agitated or over-aroused.

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

• At one year the symptoms had not changed.

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

Laurila (2003) 425 patients hospital & nursing home

ICD 10DSM IV81 18

25

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– Fatigue

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

Risk Factors and Aetiology

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

Mechanisms

• Nearly all speculative

• Metabolic deficits difficult to measure

Detection

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 detect delirium arising during an admission

• Mental status = a “vital sign”

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 of

mental state (15.6% Vs. 8.5%)

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

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 andmemory

Poor short termmemory; inattention

Poor short termmemory withoutmarked inattention

Poor attention butmemory intact

Psychosis present? Common (psychoticideas fleeting,simple content)

Less common Occurs in smallnumber (psychoticsymptoms complexand moodcongruent)

EEG Abnormal in 80-90%; generaliseddiffuse slowing in80%

Abnormal in 80-90%; generaliseddiffuse slowing in80%

Generally normal

Delirium

Dementia

Scales (assisted detection)

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

• Operationalized DSM-III criteria

1. Acute Onset and2. Fluctuating course and3. Inattention, Plus:

• Disorganized speech or• Altered level of consciousness

- Inouye SK, Ann Int Med 1990

Confusion Assessment Method (CAM)

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

The Clock Drawing Test

12

6

39

1011 1

2

4

578

•Used extensively in assessment of cognitive function, 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;18:129-133Int J Geriatr Psychiatry 2000;15:548-561

Draw a clock face. Set the time at 10 past 11.

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

Simple screen (Henderson Data)

Clock drawing test

sensitivity 0.92 (0.86 – 0.98)specificity 0.73 (0.64 – 0.83) PPV 0.61NPV 0.95

Kappa = 0.57 z = 5.43 p < 0.001

0.00

0.25

0.50

0.75

1.00

Sen

sitiv

ity

0.00 0.25 0.50 0.75 1.001 - Specificity

Area under ROC curve = 0.8464

ROC curve for Clock Drawing Test using AMTS as gold standard

Management

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 IncAm J Geriatr Psychiatry 2004;12;7-21

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

• 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

• Correct sensory deficits (glasses and hearing aids)

• Communication, simple instructions, avoid jargo

• Re orientation (calendars, clocks, schedules)

• A quiet, stable environment (Minimise room and staff changes)

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

Prevention

Non Pharmacological Mx: Does it work?

• Cole et al found 227 with incident or prevalent delirium 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 to improvement, discharge, mortality!!

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

Delirium: Prevention

• Prospective study involving 852 patients with 426 matched pairs compared usual care of elderly general medical patients with those receiving interventions

– Incidence of delirium lower in intervention vs usual care 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: PreventionHip Fracture

• Marcantonio et al. Pre-op and daily post-op geriatric review 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

• 126 patients > 65 y/o for hip fracture repair

• Pre-op and daily post-op geriatric review or usual care

– Delirium: 32% vs 50% (NNT = 6) RR 0.6– Severe delirium: 12% vs 29% (NNT = 6) RR0.4– Those without dementia benefited most

– Marcantonio et al. Reducing Delirium after Hip Fracture J Am GeriatrSoc 2001;49: 516-22

Delirium: Prevention Hip Fracture

Extras

Mental Capacity Act (2005)

• Premise: everyone can make their own decisions.• Give the person all the support they can to help them

make decisions.• No-one should be stopped from making a decision

just because someone else thinks it is wrong or bad.• Anytime someone does something or decides for

someone who lacks capacity, it must be in the person’s best interests

• When they do something or decide something for another person, they must try to limit your own freedom and rights as little as possible.

Advance (directives) Decisions

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

• A doctor must respect this decision.

• If the advance decision says no to treatment which may help keep you alive, it must say this clearly and be signed by you. Another person can sign an advance decision for you but only if you agree and you can see them sign it.

• You are free to make an advance decision if you want to, but no one should force you to make it.

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

Quetiapine

M15-

HT2AD2

5-HT2C

5-HT1A

α1

H1

Risperidone

D2

α1

5-HT2A

5-HT2C

H1

Olanzapine

M1

H1 5-HT2C

5-HT2A

D2

α1

Ziprasidone

D2

5-HT1D

5-HT2C

5-HT1A

5-HT2A

α1

H1

Clozapine

5-HT2C

M15-

HT2A

H1 α1

D2

Pharmacology Of Atypical Antipsychotics

• 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

DSMIV Delirium Symptoms

• Fluctuating clinical picture

• Disturbance caused by underlying disorder.

• Confirmed by investigations & physical examination

• Sleep disturbance

• Disturbance of psychomotor activity

DSMIV Delirium Symptoms 2