Delirium. This is probably the favorite subject of all geriatrician (with falls) and it is in fact one of the most important to know if you want to be called a « care for the elderly » person. I heard so many different presentations on the subject, but the one from this week was the best. This is a summary of the « Giant geriatric seminar » done by Dr Dan Liberman.
First, he showed us how prevalent deliriums are (more than I thought!). I verified this information and these approximations are accurate.
Epidemiology: prevalence of delirium in various wards:
- ER: 10-20%
- General Internal medicine: 30-50%
- General surgery: 50-70%
- Intensive care unit: 80-90%
Then, he asked us what are the more dramatic complications of delirium (now I am all ears!)
Complications of delirium:
- Increasing risk of falls
- Increasing functional decline
- More institutionalization
- Increased LOS in hospital
- Increased long term cognitive impairment
- And of course, increased mortality.
He presented this study done in a family medicine hospital ward that compared the % of mortality in delirious patient versus non-delirious patient at 1 and 6 months (1):
|1 month||6 months|
Predisposition factors: (anything that have a LR>3)(2)
- Cognitive impairment <24/30 on MMSE
- Decreased vision <20/70
- Severe illness (High APACHE score)
- Dehydration (increased BUN)
Precipitating factors: (anything that have a LR>3)
- Physical restraints
- Malnutrition (decreased albumin)
You know the incredible lists of predisposition or precipitating factors that usual books/presenters give? Nobody can remember all of these. The items of the present list are actually significantly contributing to delirium. That is more helpful, it means you have an actual target when facing delirium (among other things I know, wait for it).
Diagnosis of delirium: Confusion Assessment Method (CAM) algorithm
You need to have these 2 items: Acute onset/fluctuating AND Inattention
Plus, either one of these: Disorganized thinking OR Altered level of consciousness
Easy one, I knew that! But, how do you evaluate inattention? My short answer, if you are not able to do a neurological exam because the patient does not follow your order= inattention. There is other testing: the 100-7 calculation, asking the days of the week, the months of the year backward, spelling the word world backward. This is very practical! Also, if your patient falls asleep while talking to you, either you are very boring or he is inattentive! The sensitivity of CAM is about 94%, which is acceptable for a screening tool. Inter-ratter reliability is measured with a kappa of 0.7-1.0 (3). These are all good reasons to use it. On the plus side, it is so easy to use!
Utility of CT-Scan:
1-2% of time, the CT-scan will explain the reason why the patient is delirious (bleeding, stroke, mass).
2-4% if you can find an abnormality on the neurological exam.
And how many in the emergency department we do for these patients? I found this retrospective study done in Boston in 2014 that presented exactly these numbers. 1714 head CT were done, 398 had the clinical indication of delirium, 2.7% of findings in the absence of fall, known brain process or new neurological findings (Bortinger 2014). This other study did state that in absence of neurological findings, head trauma or falls the CT will not offer an answer to the acute confusion state (4). But for that, you have to be able to actually do a good neurological exam that could be difficult in delirious patient. I think that what we should understand from this is if you have a patient with an acute confusion state without obvious trauma or neurological findings but your workup is somehow negative, a CT could be considered but not as an “no brainer” delirium workup.
Treatment of delirium (I know delirium is not a disease itself it is a symptom of an acute process or multifactorial events…)
- Find and treat the cause
- Orientation (yourself, do not just ask the date they get it wrong and then you leave, reorient them, nurses, volunteers, and most importantly, family members)
- Optimize hearing and vision (It is amazing how many patient does not have their own glasses)
- Decrease iatrogenic (Foley (VERY FEW PEOPLE NEEDS IT), catheter, DVT prophylaxis, avoid unnecessary testing, etc.)
- Optimize sleep (room with window, good sleep hygiene, avoid sleeping pills, use melatonin?)
- Pain control
- Hydration and alimentation (Make sure they eat and are well hydrated)
Remember the precipitating and predisposing factors list? It is all in the treatment plan. There you go! And in fact, it is the same actions that you should take to prevent delirium in elderly.
Now, melatonin. Every geriatrician I talked in the last week are very fond of melatonin. You have to take it 2 hours prior to sleep, and take it for at least one week to have an actual effect. I could not find good specific randomized controlled trial about melatonin in elderly sleeping disturbance. Is it miraculous? No. But it does help in so-many-neurotransmettors-brain-depleted elderly (Yes it is a thing!). The most important thing: no serious adverse effects. Bottom line: it is worth the trial.
Here I though it was an actual good solution to agitation in delirious patient. NOT. Try everything else (calming voice tone, family members, music, reorientation, photos, etc). And IF (big IF) it does not work then you could use antipsychotic rx. There is a black box warning about all antipsychotics for elderly because they increase mortality. They are all the same. Some has more effect on the QT (Haldol, Seroquel), some are more sedative (Seroquel), some are more anticholinergique (Seroquel, haldol), some has more metabolic effects (zyprexa). You have to know their actual pharmacologic profil before using them. Make sure you have an EKG and some electrolytes measurement prior their use.
Antipsychotic in prevention? One study in orthopaedics showed that Risperdal could prevent delirium (they really don’t want to deal with delirium!). A small Spanish study showed a possible role for gabapentin in delirium (Spanish study…).
This concludes my small summary of delirium. I hope this was not too confusing!
- Cole MG, Primeau FJ. Prognosis of delirium in elderly hospital patients. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne. 1993 Jul 1;149(1):41-6. PubMed PMID: 8319153. Pubmed Central PMCID: 1485278.
- Inouye SK. Delirium in older persons. The New England journal of medicine. 2006 Mar 16;354(11):1157-65. PubMed PMID: 16540616.
- Wei LA, Fearing MA, Sternberg EJ, Inouye SK. The Confusion Assessment Method: a systematic review of current usage. Journal of the American Geriatrics Society. 2008 May;56(5):823-30. PubMed PMID: 18384586. Pubmed Central PMCID: 2585541.
- Hardy JE, Brennan N. Computerized tomography of the brain for elderly patients presenting to the emergency department with acute confusion. Emergency medicine Australasia : EMA. 2008 Oct;20(5):420-4. PubMed PMID: 18973639.