Delirium in the Elderly

Serena Chao, MD, MSc

Department of Medicine-Geriatrics Section
May 2008 CRIT
5/10/08
Incidence Among Elderly
Patients is HIGH
1/3 of patients presenting to ER
1/3 of inpatients aged 70+ on general med units
Incidence ranges 5.1% to 52.2% after noncardiac
surgery (Dasgupta M et al. J Am Geriatr Soc 2006;54:1578-89)
Highest rates after hip fracture and aortic surgeries
Delirium: Increased Mortality
One-year mortality: 35-40%
Independent predictor of higher mortality up to
1 year after occurrence
Hazard Ratio between 2 and 3
Elderly medical inpatients: Adjusted for dementia,
comorbidity, clinical severity, APACHE II score,
admitting service (med vs. geri), demographic variables
(McCusker J et al. Arch Intern Med. 2002; 162:457-463)

Mechanically ventilated MICU & CCU patients: Adjusted

for coma, age, Charlson Comorbidity Index, APACHEII
score, SOFA, admitting diagnosis of sepsis or ARDS,
sedative and narcotic use (Ely EW et al. JAMA. 2004; 291:1753-62)
Delirium: Increased Risk of
Functional decline
New nursing home placement
Persistent cognitive decline:
18-22% of hospitalized elders with complete
resolution 6-12 months after discharge
CAVEAT: Many subjects with preexisting
cognitive impairment
(Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003;
18:696-704)
Diagnosis: Call it what it is
DELIRIUM: ICD-9 code 780.09

MS or mental status change:

No ICD-9 code
Diagnosis: Confusion Assessment
Method (CAM)
Inouye SK et al. Ann Intern Med. 1990; 113: 941-948

(1) Acute change in (3) Disorganized

mental status with a thinking
fluctuating course
(2) Inattention OR

AND (4) Altered level of

consciousness

Sensitivity: 94-100%, Specificity: 90-95%

How to Distinguish
Delirium from Dementia
Features seen in both: Key features of
Disorientation delirium:
Memory impairment Acute onset
Paranoia Impaired attention
Hallucinations Altered level of
Emotional lability consciousness
Sleep-wake cycle
reversal
Assume it is Delirium until
Proven Otherwise

Delirium may be the only

manifestation of life-threatening
illness in the elderly patient
A Model of Delirium

A multifactorial syndrome that arises from an

interrelationship between:
Predisposing factors a patients underlying
vulnerability
AND
Precipitating factors noxious insults
Predisposing Factors
i.e. baseline underlying vulnerability

Baseline cognitive Visual impairment

impairment Hearing impairment
2.5 fold increased risk Functional impairment
of delirium in dementia
patients Depression
25-31% of delirious Advanced age
patients have History of ETOH abuse
underlying dementia
Male gender
Medical comorbidities:
Any medical illness
Precipitating Factors
i.e. noxious insults

Medications Infections
Bedrest Medical illnesses
Indwelling bladder Urinary retention and
catheters fecal impaction
Physical restraints ETOH/drug withdrawal
Iatrogenic events Environmental
Uncontrolled pain influences
Fluid/electrolyte
abnormalities
Some drug classes that are
associated with delirium
Medications with psychoactive effects:
3.9-fold increased risk
2 or more meds: 4.5-fold
Sedative-hypnotics: 3.0 to 11.7-fold
Narcotics: 2.5 to 2.7-fold
Anticholinergic drugs: 4.5 to 11.7-fold
Risk of delirium increases as number of meds
prescribed rises
Prevention of Delirium:
It can be done!
Find patients with 1 to 4 of the following
predisposing characteristics:
Visual impairment (worse than 20/70 corrected)
Severe illness
Cognitive impairment (MMSE<24/30)
High BUN/Cr ratio (>18)
(Inouye SK et al. Ann Intern Med. 1993; 119:474-481)
Prevention=Good Hospital Care for the
Elderly Patient (Inouye SK et al. NEJM. 1999;340:669-76)

RISK FACTOR INTERVENTION

Cognitive impairment Orientation protocol, cognitively
stimulating activities 3x/day

Sleep deprivation Nonpharmacologic protocol, noise

reduction, schedule adjustments

Immobility Ambulation or active ROM

exercises; minimize equipment

Visual impairment Glasses or magnifying lens,

adaptive equipment

Hearing impairment Portable amplifying devices,

earwax disimpaction

Dehydration Early recognition and volume

repletion
A Multicomponent Intervention to
Prevent Delirium (Inouye SK et al. NEJM. 1999;340:669-76)

Outcome Interv. Usual care Statistical

(n=852) group group analysis
st
1 9.9% 15% OR=0.60
delirium (95% CI
0.39 to 0.92)
episode
Total days 105 161 P=0.02
delirium
# delirium 62 90 P=0.03
episodes
Keys to Effective Management
Find and treat the underlying disease(s) and
contributing factors
Comprehensive history and physical
Including neurological and mental status exams
Choose lab tests and imaging studies based on
the above
Review medication list
Always Try Nonpharmacologic
Measures First
Presence of family members
Interpersonal contact and reorientation
Provide visual and hearing aids
Remove indwelling devices: i.e. Foley catheters
Mobilize patient
A quiet environment with low-level lighting
Uninterrupted sleep
Management: Hyperactive,
Agitated Delirium
Use drugs only if absolutely necessary: harm,
interruption of medical care
First line agent: haloperidol (IV, IM, or PO)
For mild delirium:
Oral dose: 0.25-0.5 mg
IV/IM dose: 0.125-0.25 mg
For severe delirium: 0.5-1 mg IV/IM repeated q30 min
until calm
Patient will likely need 2-5 mg total as a loading dose
Maintenance dose: 50% of loading dose divided BID
May use olanzepine and risperidone
(Lonergan E et al. Cochrane Database Syst Rev. 2007 Apr 18; (2): CD05594)
What about Ativan (lorazepam)?

Second line agent

Reserve for:
Sedative and ETOH withdrawal
Parkinsons Disease
Neuroleptic Malignant Syndrome
AVOID RESTRAINTS AT ALL COSTS:
Measure of LAST(!!!) resort
Take Home Points: Delirium in
the Elderly
A multifactorial syndrome: predisposing
vulnerability and precipitating insults
Delirium can be diagnosed with high sensitivity
and specificity using the CAM
Prevention should be our goal
If delirium occurs, treat the underlying causes
Always try nonpharmacologic approaches
Use low dose antipsychotics in severe cases