Geriatric Delirium: Translating Guidelines into Practice Dr. Peter - PowerPoint PPT Presentation

Geriatric Delirium: Translating Guidelines into Practice Dr. Peter Chan, MD, FRCPC Geriatric and Consult-Liaison Psychiatrist Vancouver General Hospital Clinical Professor of Psychiatry University of British Columbia

Learning Objectives  To identify geriatric delirium in long- term care settings  To review the pharmacological and non-pharmacological approaches to managing delirium  To discuss evidence-based preventative measures

Disclosure for Dr. Chan  Speaker honouraria from:  Astra-Zeneca  Eli-Lilly  Janssen-Ortho  Lundbeck  Organon None in past 7 years

Delirium: The Myths 1) Delirium is a cross-sectional diagnosis Requires 24 hour observation  2) Delirium leads to agitation and behaviour problems Watch for “Apathetic” (hypoactive) Delirium  3) Delirium always has an identifiable cause May not find a single cause; multiple factors with  geriatric delirium 4) Delirium is a transient phenomenon May persist or lead to permanent cognitive and/or  functional sequelae in elderly

Delirium (DSM-5) criteria A disturbance in attention (ie: reduced ability to direct, focus, A. sustain, or shift attention) and awareness (reduced orientation to the environment). The disturbance develops over a short period of time (usually B. hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day. An additional disturbance in cognition (eg: memory, C. orientation, language, visual-spatial, perception) The disturbances in A and C are not better explained by D. another pre-existing, established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma. There is evidence from the history, physical examination, or E. laboratory findings that the disturbance is a direct physiological consequences of another general medical condition, substance intoxication or withdrawal, or exposure to toxin, or is due to multiple etiologies.

Screening  Under-recognition, esp. in those:  Over 80 y.o. with hypoactive delirium with visual impairment and/or pre-existing dementia  Inouye et al. Arch Int. Med 2001  No reliable screening tool to differentiate delirium and dementia  Practically, acute-onset and/or fluctuation in cognition/function/abnormal behaviours

How Good Are Long-Term Care Nurses at Screening?  Voyer et al. (J Am Med Direc Assoc 2012; Int J Geri Psyc 2011)  7 LTC Facilities in Montreal and Quebec  N=202 residents  CAM-identified delirium in 21.3% by RA’s  Nursing observation identified 51% of cases identified by Research Assistant  Under-recognition of symptoms varied from 25-66.7% by nursing observation  More likely delirium in mod-severe Dementia; under-recognized if depressive symptoms

Confusion Assessment Method (CAM) (Inouye et al. Ann.Int.Med. Dec.15/90)  acute onset and fluctuation AND  inattention AND  disorganized thinking OR  altered level of consciousness  excellent sensitivity, good specificity

Screening: CAM-Short Form CAM Short Form CAM Algorithm

Delirium, Dementia, Lewy Body Dementia: Cole Am J Geri P 2004 Delirium Dementia Lew y Body Dis Feature Onset Acute Insidious Insidious Duration Hours, Days Months, Years Months, Years Consciousness Variably alert Alert Alert Attention Impaired Intact Frequently impaired Cognitive Fluc. Frequent Infrequent Frequent Symptom Fluc. Frequent Infrequent Infrequent Visual Hallucinate Frequent, Occasional Frequent, complex, transient persistent Thinking Disorganized Impoverished Impoverished Insight May be present Usually absent Usually absent in lucid intervals Parkinsonism Usually absent Occasional Frequent Neuroleptic Infrequent Infrequent Frequent sensitivity EEG Marked slow ing Usually normal or Can show slow ing mild slow ing

Delirium: Subtyping  Hyperactive (agitated)  Differentiate from anxiety  Differentiate from dementia  Hypoactive (apathetic)  Differentiate from depression  Less sleep-wake reversal

General considerations: Diagnosing Geriatric Delirium  24 hr. observation, including sleep-wake cycle  anxiety  new incontinence  unsteady gait, falls  dysarthria/incoherence  mood/affect lability  subtle paranoia and hypervigilance  sleep disturbance Practical tip #1: Ask specifically about vivid dreams or nightmares!

Geriatric Delirium  Predisposing  Precipitating  Perpetuating  Protective/Preventive

Predisposing Factors Inouye, SK et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993; 119:474-481  cognitive impairment  sleep deprivation  immobility  visual impairment  hearing impairment  Dehydration Practical tip #2: Ask about use of visual and hearing aids! Carry a voice amplifier

Differential Dx of Causes: DIMS-R  Practical Tip #3: Check for urinary retention with a bladder scanner!

Medications which may precipitate or perpetuate delirium in the elderly patient Analgesics Anti- Anti- Anti- Anti- Cardiovasc Nauseants Parkinsons Convulsants histamines Chlorpheniramine Scopolamine Amantadine Phenobarbital Beta-blockers Narcotics: (some)  Codeine Diphenhydramine Dimenhydrinate Benztropine Phenytoin  Meperidine (Benadryl  ) (Gravol  ) Trihexyphenidyl Digoxin (Demerol  ) Procyclidine Hydroxyzine  Morphine (Atarax  ) Levo-dopa Bromocriptine Gastrointest Genitourinary Psychiatric Pulmonary Sedatives Other Theophylline Cimetidine Oxybutynin Barbituates Alcohol Some Tricyclic (Ditropan  ) anti-depressants Chloral Hydrate Steroids (TCA) Ranitidine  Amitryptiline Tolterodine (Detrol  )  Doxepin Benzodiazepine Warfarin  Clomipramine Diazepam  Imipramine Lorazepam Solifenacin B-lactam and (Vesicare  ) Oxazepam Quinolone Triazolam Older anti- Antibiotics Alprazolam psychotics Darifenacin (eg: Cipro) (Enablex  )  Chlorpromazine Clonazepam  Thioridazine Flavoxate (Urispas  ) Other: Lithium Trospium (Trosec  )

Reducing the Medication Load  Discontinuing/substituting anticholinergic medications  Diphenhydramine (Benadryl) , Dimenhydrinate ( Gravol), Hydroxyzine (Atarax )  Benztropine (Cogentin), etc.  Urinary anticholinergics  Avoid Amitriptyline (Elavil) Nortriptyline better tolerated  Avoid the use of Cimetidine (Tagamet) in the elderly!  Monitoring the effects of Steroids (Prednisone equivalent ≥ 40mg/d)  Fardet Am J. Psych 2012  Switching Narcotics to (Avoid Meperidine=Demerol):  Hydromorphone (Dilaudid)  Oxycodone  Fentanyl (chronic pain)

Precipitant: Physical Restraints in the Medically Ill Elderly Pitfall #1: Restraints are necessary to prevent morbidity such as falls, and help with managing delirious pts.  Physical restraints increase risk of developing delirium by 4.4x Precipitating Factors in Hospital-Acquired Delirium, Inouye and Charpentier, JAMA 1996; 275: 852-57  Additional morbidities (eg: pneumonia, DVT, stasis ulcers) and mortality risk  In 2001, the Ontario government passed Bill 85, the Patient Restraints Minimization Act Avoid limb or posey restraints in the frail elderly!

Perpetuating Factors in LTC McCusker et al. Environmental factors predict the severity of delirium symptoms in long-term care residents with or without delirium. JAGS 2013  Severity of Delirium Predicted by 6 Factors:  Absence of reading glasses  Absence of aids to orientation  Absence of family member  Absence of glass of water  Presence of bed rails and other restraints....  ....And the prescription of two or more new medications

Pharmacological Management of Delirium  When to use Antipsychotics? (CCSMH’s National Guidelines, 2006: The Assessment and Treatment of Delirium ) “ Psychotropic medications should be reserved for older persons with delirium that are in distress due to agitation or psychotic symptoms, in order to carry out essential investigations or treatment, and to prevent older delirious persons from endangering themselves or others. [D]”

Pharmacological Management of Delirium  “Haloperidol as treatment of choice”  APA Guidelines 1999  Other conventional antipsychotics  Loxapine (Loxapac)  Chlorpromazine (Largactil)  Methotrimeprazine (Nozinan)  Perphenazine  Atypical antipsychotics  Risperidone, Olanzapine, Quetiapine

Atypical vs. Typical Antipsychotics for Delirium “Higher Potency” “Medium Potency” “Lower Potency” • Methotrimeprazine • Loxapine • Haloperidol (Nozinan) • Quetiapine • Olanzapine • Risperidone “Newer Atypicals”: Ziprasidone, Aripiprazole

Haloperidol in Delirium Management  Comparator to atypicals (3 RCT’s in Cochrane)  Prolonged QT c , especially I.V.– baseline ECG  Risk of Extrapyramidal Symptoms, esp. elderly  >4.5 mg/day in Cochrane Review Pitfall #2: Haloperidol is best treatment as best evidence