Learning Objectives Geriatric Delirium: Translating Guidelines into Practice To identify geriatric delirium in long- term care settings To review the pharmacological and non-pharmacological approaches to Dr. Peter Chan, MD, FRCPC managing delirium Geriatric and Consult-Liaison Psychiatrist Vancouver General Hospital To discuss evidence-based Clinical Professor of Psychiatry preventative measures University of British Columbia Delirium: The Myths Disclosure for Dr. Chan 1) Delirium is a cross-sectional diagnosis Speaker honouraria from: Requires 24 hour observation Astra-Zeneca 2) Delirium leads to agitation and Eli-Lilly behaviour problems Janssen-Ortho Watch for “Apathetic” (hypoactive) Delirium Lundbeck 3) Delirium always has an identifiable Organon cause May not find a single cause; multiple factors with geriatric delirium 4) Delirium is a transient phenomenon None in past 7 years May persist or lead to permanent cognitive and/or functional sequelae in elderly Screening Delirium (DSM-5) criteria A disturbance in attention (ie: reduced ability to direct, focus, A. sustain, or shift attention) and awareness (reduced Under-recognition, esp. in those: orientation to the environment). Over 80 y.o. with hypoactive delirium with visual The disturbance develops over a short period of time (usually B. impairment and/or pre-existing dementia hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity Inouye et al. Arch Int. Med 2001 during the course of a day. An additional disturbance in cognition (eg: memory, C. No reliable screening tool to differentiate orientation, language, visual-spatial, perception) delirium and dementia 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. Practically, acute-onset and/or fluctuation in There is evidence from the history, physical examination, or E. cognition/function/abnormal behaviours 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. 1
How Good Are Long-Term Confusion Assessment Method Care Nurses at Screening? (CAM) (Inouye et al. Ann.Int.Med. Dec.15/90) acute onset and fluctuation AND Voyer et al. (J Am Med Direc Assoc 2012; Int J Geri Psyc 2011) inattention AND 7 LTC Facilities in Montreal and Quebec disorganized thinking OR N=202 residents altered level of consciousness CAM-identified delirium in 21.3% by RA’s Nursing observation identified 51% of cases identified by Research Assistant excellent sensitivity, good specificity Under-recognition of symptoms varied from 25-66.7% by nursing observation More likely delirium in mod-severe Dementia; under-recognized if depressive symptoms Delirium, Dementia, Lewy Body Dementia: Cole Am J Geri P 2004 Feature Delirium Dementia Lew y Body Dis Screening: CAM-Short Form Onset Acute Insidious Insidious Duration Hours, Days Months, Years Months, Years Consciousness Variably alert Alert Alert CAM Short Form CAM Algorithm 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 General considerations: Delirium: Subtyping Diagnosing Geriatric Delirium Hyperactive (agitated) Differentiate from anxiety 24 hr. observation, including sleep-wake cycle Differentiate from dementia anxiety new incontinence Hypoactive (apathetic) unsteady gait, falls Differentiate from depression dysarthria/incoherence Less sleep-wake reversal mood/affect lability subtle paranoia and hypervigilance sleep disturbance Practical tip #1: Ask specifically about vivid dreams or nightmares! 2
Predisposing Factors Geriatric Delirium 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 Predisposing cognitive impairment sleep deprivation Precipitating immobility visual impairment Perpetuating hearing impairment Dehydration Protective/Preventive Practical tip #2: Ask about use of visual and hearing aids! Carry a voice amplifier Medications which may precipitate or Differential Dx of Causes: DIMS-R perpetuate delirium in the elderly patient Analgesics Anti- Anti- Anti- Anti- Cardiovasc Nauseants Parkinsons Convulsants histamines Practical Tip #3: Chlorpheniramine Scopolamine Amantadine Phenobarbital Beta-blockers Narcotics: (some) Codeine Diphenhydramine Dimenhydrinate Benztropine Phenytoin Check for urinary Meperidine (Benadryl ) (Gravol ) Trihexyphenidyl Digoxin retention with a (Demerol ) Procyclidine Hydroxyzine Morphine bladder scanner! (Atarax ) Levo-dopa Bromocriptine Gastrointest Genitourinary Psychiatric Pulmonary Sedatives Other Cimetidine Oxybutynin Theophylline Barbituates Alcohol Some Tricyclic (Ditropan ) anti-depressants Chloral Hydrate Steroids Ranitidine (TCA) Tolterodine Amitryptiline (Detrol ) Doxepin Benzodiazepine Warfarin Clomipramine Diazepam Imipramine Lorazepam Solifenacin B-lactam and (Vesicare ) Oxazepam Quinolone Older anti- Triazolam Antibiotics Alprazolam Darifenacin psychotics (eg: Cipro) (Enablex ) Chlorpromazine Clonazepam Thioridazine Flavoxate (Urispas ) Other: Lithium Trospium (Trosec ) Precipitant: Physical Restraints Reducing the Medication Load in the Medically Ill Elderly Discontinuing/substituting anticholinergic medications Pitfall #1: Restraints are necessary to Diphenhydramine (Benadryl) , Dimenhydrinate ( Gravol), prevent morbidity such as falls, and Hydroxyzine (Atarax ) help with managing delirious pts. Benztropine (Cogentin), etc. Urinary anticholinergics Avoid Amitriptyline (Elavil) Nortriptyline better Physical restraints increase risk of tolerated developing delirium by 4.4x Precipitating Avoid the use of Cimetidine (Tagamet) in the elderly! Factors in Hospital-Acquired Delirium, Inouye and Charpentier, Monitoring the effects of Steroids (Prednisone JAMA 1996; 275: 852-57 equivalent ≥ 40mg/d) Additional morbidities (eg: pneumonia, DVT, stasis ulcers) and mortality risk Fardet Am J. Psych 2012 In 2001, the Ontario government passed Bill 85, Switching Narcotics to (Avoid Meperidine=Demerol): the Patient Restraints Minimization Act Hydromorphone (Dilaudid) Oxycodone Fentanyl (chronic pain) Avoid limb or posey restraints in the frail elderly! 3
Perpetuating Factors in LTC Pharmacological Management of McCusker et al. Environmental factors predict the severity of delirium Delirium symptoms in long-term care residents with or without delirium. JAGS 2013 Severity of Delirium Predicted by 6 When to use Antipsychotics? (CCSMH’s National Guidelines, 2006: The Assessment Factors: and Treatment of Delirium ) Absence of reading glasses “ Psychotropic medications should be Absence of aids to orientation reserved for older persons with delirium that Absence of family member are in distress due to agitation or psychotic Absence of glass of water symptoms, in order to carry out essential Presence of bed rails and other investigations or treatment, and to prevent restraints.... older delirious persons from endangering themselves or others. [D]” ....And the prescription of two or more new medications Atypical vs. Typical Pharmacological Management of Antipsychotics for Delirium Delirium “Haloperidol as treatment of choice” APA Guidelines 1999 “Higher Potency” “Medium Potency” “Lower Potency” Other conventional antipsychotics • Methotrimeprazine • Loxapine • Haloperidol Loxapine (Loxapac) (Nozinan) Chlorpromazine (Largactil) • Quetiapine • Olanzapine Methotrimeprazine (Nozinan) • Risperidone Perphenazine Atypical antipsychotics Risperidone, Olanzapine, Quetiapine “Newer Atypicals”: Ziprasidone, Aripiprazole Haloperidol in Delirium Management CPG’s: Delirium Management Comparator to atypicals (3 RCT’s in Country Year Antipsychotic Recommendations Cochrane) Canada (Geriatric 2006 Haldol; alternative Risperidone, Olanzapine, Delirium) Quetiapine Australia 2006 Haldol, Olanzapine, Risperidone Prolonged QT c , especially I.V.– baseline NICE (UK) 2010 Haldol, Olanzapine ECG United States 1999 Haldol Antipsychotic RCT’s number of patients (pooled, 2013) Risk of Extrapyramidal Symptoms, esp. Haldol 258 Chlorpromazine 13 elderly Risperidone 68 >4.5 mg/day in Cochrane Review Olanzapine 125 Quetiapine 60 Pitfall #2: Haloperidol is best treatment as Aripiprazole 21 ( prospective case-matched) best evidence Ziprasidone 30 4
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