Instructor: Sally Rigler, MD, MPH
Reviewed by: Anne Walling, MB, ChB
Specific Learning Objectives:
Before reviewing the learning objectives and content, please take the Pre-Test in Angel. You must do this before you can proceed with the module. The answers are given in the Post-Test that completes the module.
Please review this module before our class session. We will apply the tasks in the Skills Objectives to several cases during our class discussion.
Students will acquire a high index of suspicion for delirium among hospitalized older adults and internalize an understanding of its impact on mortality, morbidity, and functional capacity.
Students will reflect delirium-prevention concepts as part of clinical care.
Students will integrate an understanding of the contributions of multiple health care providers in the prevention and treatment of delirium.
Delirium is a rapidly-developing disorder of disturbed attention that fluctuates with time. Although the clinical presentation of delirium differs considerably from patient to patient, the characteristic features of the diagnosis are:
- Reduced level of consciousness and difficulty focusing, shifting, or sustaining attention.
- Cognitive change (deficit of language, memory, orientation, perception) that is not better explained by dementia.
- Symptoms develop rapidly (hours to days) and vary during the day
- Evidence can usually be found (signs and symptoms) of underlying medical condition or conditions.
(from the DSM-IV)
NOTE:
The management of delirium is based on confirming the diagnosis, addressing the precipitating causes, managing the acute symptoms, and minimizing the risk of complications. (see algorithm in Inouye SK. Delirium in Older Persons. NEJM 2006;35:1163)
- Use history from informants and patient (plus screening tools such as MMSE if appropriate and possible to administer) to confirm the diagnosis of acute change in mental status not explained by dementia, depression, mania, psychosis. Remember delirium can be hyperactive OR hypoactive in the elderly
- Evaluate for underlying medical conditions (CHF, UTI etc) using history, physical examination and laboratory data. Treat as indicated.
- Review medication list in detail, including non-prescription substances, for any that can be safely stopped (especially psychoactive medications or opiates).
- Supportive care (airways, hydration, nutrition, nursing care).
- Non-pharmacologic treatment [quiet safe environment, familiar people and objects, clear communication ( eyeglasses, hearing aids as needed), aids to orientation, avoid restraints, catheters, I/Vs etc].
- Pharmacologic treatment only for severe distressing or disruptive agitation (low doses of neuroleptic and/or benzodiazepine, with short half-life) .
- Ensure follow-up. Alert caretakers to need for early recognition of change in status to prevent recurrence of delirium.
Delirium:
- Acute onset
- Level of arousal fluctuates during different observations
- Can't maintain attention
- May incorrectly perceive things in environment
- Speech/thinking is disorganized, disorientation common
- Sleep cycle is disturbed
- Psychomotor activity may be increased or decreased
Dementia:
- Onset is insidious (except in stroke-related dementia)
- Normal level of alertness
- Confusion does not fluctuate rapidly
- Sleep cycle stable (though may develop day-night reversal)
- Speech may gradually deteriorate to anomia and aphasia, but does not develop abrupt incoherent speech
In patients undergoing elective surgery, delirium increased all complications from 2% to 15%, mortality from 0.2% to 4%, hospital stay from 7 to 15 days, and risk of being discharged to an institution from 11% to 35%,
Delirium is one of the most common preventable adverse events in care of elderly patients and is increasingly used as a quality of care indicator. An estimated 30-40% of cases are preventable.
Prevention depends on:
- Prevention/early recognition and aggressive treatment of precipitating conditions (includes pain, constipation).
- Attention to environmental and sensory deprivation factors in hospitalized or ill elderly patients.
- Avoidance of instrumentation, restraints and other associated factors.
- Adequate hydration, nutrition, rest, social support.
- Attention to appropriate medications (especially avoiding opiates, anticholinergics, sedatives).
- Individualize care orders, especially avoid “PRN pain” standing orders.
- Suspect delirium in all “change of status” situations.
Scoring systems to identify hospitalized older adults at most risk of delirium are available. The one you must know is the Confusion Assessment Method, or CAM:
For a diagnosis of delirium, the CAM requires:
- Presence of acute onset and fluctuating course
and
- Inattention
and either
- Disorganized thinking or altered level of alertness
You will receive more information during class discussion about each case. These are just brief introductions. Please think about what some of the possible contributors are to each case of delirium in each different context below, and be ready to discuss in class.
Case 1
A is an 81 year old man in the hospital s/p surgical procedure for head and neck cancer. His current issues are pneumonia, anemia, new PEG tube, deconditioning weakness, hypertension and diabetes mellitus. The nurse calls to tell you that he spent the night wandering the unit in a wheelchair, disoriented, difficult to redirect, easily distracted. This morning, he is lethargic and confused.
Mr. B is a 78 year old man who underwent an uneventful elective total knee arthroplasty 3 days ago. The nurse calls to tell you that he is ‘‘talking out of his head’ since her 3 p.m. shift started. There has been no prior history of this behavior reported on prior shifts.
Mrs. A is an 86 year old female with Alzheimer’s dementia who has been living in the same nursing home for the last two years. The nurse calls to tell you “she’s more confused than usual, and more agitated today.”
Mr. C is an 80 year old man fell on the ice and suffered a subtrochanteric fracture. His PMH includes dyslipidemia, hypertension, depression & anxiety, and his family mentions they’ve been worried about “some mild memory problems” for about a year. He become floridly confused on the second post-op day.
©
The University of Kansas Medical Center