Overview of delirium in an older individual

1. DELIRIUM
MARC EVANS M. ABAT, MD,
FPCP, DPSGM
Internal Medicine-Geriatric
Medicine

2. CASE
 81 year old man with diagnosis of Benign
Prostate Hypertrophy and Hypertension, came in
with history:

3 days prior to admission, low-grade fever and
nocturia. Poor sleep. Daughter gave him
diphenhydramine for sleep.

Day of admission, became confused, had high
grade fever.

No loss of consciousness, vomiting

Past medical history: Hypertension

Personal/ Social History: Smoke tobacco

3. CASE
 In hospital, diagnosed to have UTI and
acute urinary retention.
 6 hours after admission, became
combative, agitated, confused. Pulled out
IV and insisted on going home.

4. Questions
 Diagnosis for acute confusion
 What are patient’s risk factors for
delirium?
 How will you manage the patient non-
pharmacologically?
 What medications can you use to manage
the confusion?
 What is his prognosis?

6. Objectives

To define the syndrome of delirium.

To identify symptoms of delirium.
 To differentiate delirium from other
psychiatric, neurological, and medical
conditions.

To describe patient prognosis.
 To discuss basic medical
management.

7. Definition, Delirium
Delirium is a syndrome of acute confusion
marked by periods of waxing and waning
levels of consciousness, altered
psychomotor behavior, and perceptual
impairment.

8. Symptoms
 Hyperactive
 Hypoactive
 Mixed
 A study of 325 patients in a general
hospital identified a 15% incidence of
hyperactive delirium, 19% hypoactive and
52% mixed type (Liptzin, Levkoff 1992).

9. Delirium or Dementia?
Delirium Dementia
 Acute onset  Gradual onset
 Lasts for hours to  Lasts for months to
weeks years
 MS fluctuates,  MS stable;
worse at night sundowning
 Attention decreased  Normal attention
or hyperalert span, alert
 Language  Word-finding
incoherent,slow or difficulty
rapid

10. Differential Diagnosis
 Delirium vs. mania
 Delirium vs. acute paranoia

Delirium vs. depression
 Delirium vs. acute psychosis

11. Etiology
1.Infection
2. Drugs
Long-acting benzodiazepines, meperidine,
propranolol, scopolamine, H2-blockers
3. Withdrawal States
Alcohol, benzodiazepines, meprobamate

12. Etiology
4. Hypoperfusion
5. Hypoxemia
6. Malignancy
Paraneoplastic phenomenon, pain
7. Electrolyte Abnormalities

13. Etiology
8. Pain
post-operative,
fecal impaction,
urinary retention,
fracture

14. Etiology
9. Endocrine Problems
Hypo-and hyperthyroidism, hypo-and
hyperglycemia
10. Sensory deprivation
11. Sleep deprivation
12. Physical restraints

15. Etiology
Age over 80 years and male sex are
independent risk factors for the
development of delirium in hospitalized
patients

16. Etiology
An underlying history of dementia (i.e.,
Alzheimer's, vascular or multi-infarct) is
the most significant risk factor for the
development of delirium.

17. Delirium in Hospital
 A nested case-control study of non-
cardiac surgery patients revealed that
delirium was positively associated with
exposure to meperidine (Odds Ratio (OR),
2.7; 95% confidence interval (CI), 1.3 to
5.5) and to benzodiazepines (OR, 3.0;
95% CI 1.3-6.8).
Marcantonio (1994), Brigham and Women's Hospital,
Boston

18. Delirium in Hospital
 prospective study of orthopedic patients at
the same institution, revealed a 26%
incidence of post-operative delirium in the
46 patients studied.
 Drugs such as scopolamine, flurazepam,
and propranolol were associated with a
relative risk (RR) for delirium of 11.7
(p=.0028).
Rogers et al (1989)

19. Drugs and Delirium
S de la Vega. “Confusional States”. Practical Guide to
Geriatric Medicine. Ratnaike, Ed. McGraw-Hill 2002.
 Analgesics  Steroids
Codeine, meperidine,  Antimicrobials
indomethacin INH, gentamycin
 Anti-hypertensives  Anti-parkinsonian
Clonidine, m-dopa, Bromocriptine, l-dopa
propranolol  Digitalis
 Diphenhydramine
 Psychotropics
 Cimetidine

20. Drugs with Excess Potential for
Severe Outcome in Patients Over Age
65
Analgesics
 Pentazocine or oral meperidine
 respiratory depression and
 CNS adverse effects, ex. delirium

21. Drugs with Excess Potential for
Severe Outcome in Patients Over Age
65
Anxiolytics
 Barbiturates, meprobamate, or long-acting
benzodiazepines (LABD)
(addiction, excess sedation leading to falls
and confusion)
 LABDs may be used for seizure, palsy,
withdrawal from SABD

22. Drugs with Excess Potential for
Severe Outcome in Patients Over Age
65
Antidepressants
 Tricyclic Antidepressants
Ex. amitriptyline, amoxapine, clomipramine,
doxepin
• high risk of urinary retention
• sedation
• anticholinergic side effects

23. Medical Management
 Look for reversible medical causes outside
of the brain that are amenable to medical
treatment.
 Consult with family members
 help focus the extent and aggressiveness of
diagnostic tests and medical care.

24. Non-Pharmacologic
Management
 Nutritional support
 Aspiration
precautions
 Early rehabilitation
 NO PHYSICAL
RESTRAINTS!

25. Non-Pharmacologic
Management
“Therapeutic Untrial”

26. Pharmacologic Management
 “atypical” anti-psychotics
 Risperidone
 Quetiapine

Olanzapine
 Use lowest possible dose
 Order a STOP date
 Haloperidol iv low dose in emergency

27. Prevention
Randomized trial of
geriatric
interdisciplinary team
management in
hospitalized patients
at risk for delirium
Inouye 2000
Marcantonio 2001

28. Case Discussion and
Review

29. CASE
 81 year old man with diagnosis of Benign
Prostate Hypertrophy and Hypertension, came in
with history:

3 days prior to admission, low-grade fever and
nocturia. Poor sleep. Daughter gave him
diphenhydramine for sleep.

Day of admission, became confused, had high
grade fever.

No loss of consciousness, vomiting

Past medical history: Hypertension

Personal/ Social History: Smoke tobacco

30. CASE
 In hospital, diagnosed to have UTI and
acute urinary retention.
 6 hours after admission, became
combative, agitated, confused. Pulled out
IV and insisted on going home.

31. Questions
 Diagnosis for acute confusion?
 What are patient’s risk factors for
delirium?
 How will you manage the patient non-
pharmacologically?
 What medications can you use to manage
the confusion?
 What is his prognosis?
 How can you prevent this from recurring?

33. Review

Defined the syndrome of delirium.

Identified symptoms of delirium.
 Differentiated delirium from other
psychiatric, neurological, and medical
conditions.

Described patient prognosis.
 Discussed basic medical management.

34. Thank YOU!