Senior Psychcare

Delirium in Hospitalized Elderly Patients
A. Botts; Clinical Geriatrics; Dec 2010

Introduction
Delirium, defined as an acute confusional state with change in attention and cognition, is a very common ailment which results in substantial morbidity and death amongst elderly persons. It is seen as disturbances of consciousness, reduced environment awareness, and a waxing and declining course. Ten percent to 31% of geriatric sufferers presenting to an emergency division have delirium and 6% to 56% of older patients develop this complication during hospitalization. Delirium leads to many adverse outcomes, including increased period of hospitalization, impaired physical and cognitive recovery at six and twelve months, and mortality rates which are twice as high as that of age-matched control patients. In spite of the common nature and substantial consequences of delirium, around 70% of delirium cases in hospitalized aged individuals are unrecognized.

Risk Factors
Delirium is almost always multifactorial in origins, resulting from standard weakness and stressfull factors. Influencing factors which boost baseline weakness comprise of advanced years, impaired cognitive status, reduced functional status, sensory disability, medical illnesses for example central nervous system disease, and exposure to specific medications. Precipitating aspects for delirium incorporate neurologic/CNS disease, metabolic derangements, trauma, cancer, surgery, disease, environment insults, pain, and treatment issues, such as polypharmacy as well as the usage of certain stressfull medications. Alcoholic beverages and substance withdrawal are common contributors to delirium and really should be considered in all patients. In more mature people, nominal insults may lead to delirium, as many patients possess multiple influencing baseline causes.

Pathogenesis
Although the danger variables for delirium are very well identified, the pathogenesis is actually less clearly understood. Numerous pathogenic mechanisms are likely involved with delirium development, with neurotransmitters and inflammation playing an important role. Cholinergic deficit and dopaminergic excess happen to be strongly correlated with delirium development, but norepinephrine, serotonin, gamma-aminobutyric acid, glutamate, and melatonin instability may also add. Cytokines also seem to be active in the pathogenesis of delirium by simply increasing the permeability of the blood-brain barrier and altering neurotransmission. Particularly, reduced amounts of somatostatin have been recorded in sufferers with delirium who had no overt central nervous system disease. The activation in the sympathetic nerves and hypothalamic-pituitary-adrenocortical axis caused by the stress of sickness or trauma may also contribute to the creation of delirium by adverse effects on hippocampal serotonin receptors.

Diagnosis
Delirium is a clinical analysis, and the doctor has to be acquainted with the normal features of delirium to make a precise diagnosis.

In the Diagnostic and Record Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR), the diagnostic standards for delirium due to multiple etiologies are understood to be follows:

(1) Disturbance of awareness with decreased ability to focus, sustain, or adjust attention;

(2) Alternation in cognition or even the development of a perceptual disturbance that is not better accounted for with a pre-existing, established, or growing dementia;

(3) The disturbance develops over a short period of time and has a tendency to change throughout the day;

(4) There is evidence from the history, physical evaluation, or lab findings that the delirium has more than one etiology.

As noted previously, the development of delirium in aged patients is almost always secondary to multiple etiologies.

The Confusion Assessment Method (CAM) is the most widely used and validated assessment tool for the bedside diagnosis of delirium (Table II). It evaluates for the core aspects of delirium, including acute onset and changing course, poor attention, disorganized thinking, and altered level of consciousness. The CAM has a sensitiveness of 94% to 100% and a specificity of 90% to 95%. Practical queries which they can use at the bedside to evaluate for attention include inquiring patients to narrate the months of the year or days of the week in reverse.

Additional common clinical features of delirium include cognitive deficits, perceptual disturbances such as hallucinations, emotional trouble, and alteration of the sleep-wake cycle. Psychomotor disturbances may also be common in delirium, and sufferers may reveal a hyperactive, hypoactive, or combined presentation. The display of hyperactive delirium ranges from restlessness to constant movement and frustration. Hypoactive delirium may present as slowed movement, paucity of speech, and even unresponsiveness. Hypoactive delirium is not as likely than hyperactive delirium to be identified by medical providers and is linked to higher fatality at 6 months and 1 year. Patients with combined delirium manifest characteristics of both hyperactive and hypoactive delirium.

All hospitalized elderly patients should be assessed for delirium on a daily basis. It's optimal if the examination is conducted 2 or 3 times throughout the day to watch for growing alterations in mental status. If delirium is diagnosed, it is essential to identify and tackle causative components. Initial analysis should include a complete physical examination that includes a review of the individual’s vital signs. Basic workup features a total blood count, serum chemistries, thyroid function studies, urinalysis and urine culture, and chest radiography. With respect to the individual patient, electrocardiography, lumbar puncture, blood cultures, urine toxicology, cardiac enzymes, arterial blood gas, and a blood alcohol level could be warranted. Neuroimaging with computed tomography is generally not really pointed out unless the patient has focal neurologic results on examination, a history of head trauma, or fever associated with encephalopathy, or unless no other reason for the delirium can be determined. All medicines must be carefully examined with the understanding that even long-standing, previously well-tolerated medications can contribute to delirium within the setting of stressfull aspects during hospitalization. It is also vital that you examine for illegal substance use, as withdrawal can promote delirium.

Prevention
Predictive Models Primary prevention steps ought to be utilized in hospitalized senior patients to reduce the regularity and subsequent complications of delirium. Although all hospitalized older people ought to be screened for delirium, prognostic models are helpful for determining those patients that are at specifically large risk.

Four independent baseline risk factors are actually defined as predictors for delirium among elderly hospitalized patients on the medical service: vision disability; certain illness (a composite of nurse rating and a severe Physiology and Chronic Health Evaluation II [APACHE II] score of more than 16); cognitive impairment, defined as a Mini-Mental State Examination (MMSE) score of less than 24; and an elevated blood urea nitrogen (BUN) to creatinine ratio of 18 or more. A risk stratification method was developed by Inouye et al that assigned 1 point for each risk factor. Topics without any points had a low risk (3%-9%) of delirium, while those with 3 to 4 points had the greatest risk of delirium (32%-83%).

Predictive models have also been created for elderly surgical patients. In a study by Marcantonio et al, postoperative delirium was associated with the following independent correlates among elderly persons who underwent noncardiac surgery: age seventy years or older; alcohol abuse; cognitive impairment as determined by the Telephone Interview for Cognitive Status; severe physical functional disability as according to the American Society of Anesthesiologists physical status category system; markedly abnormal serum sodium, potassium, or glucose level; noncardiac pectoral surgery; and aortic aneurysm surgery. Subjects without any risk factors stood a 2% rate of postoperative delirium, which increased to 50% in subjects with three or more risk factors. Inside a more recent study by Rudolph et al, 4 variables were associated with postoperative delirium among patients age sixty years or older who were going through cardiac surgery: low MMSE score (= 23 = 2 points, 24-27 = 1 point); history of cerebrovascular accident/transient ischemic attack (1 point); high Geriatric Depression Scale score (> 4 = 1 point); and abnormal albumin level (1 point). Compared to subject areas without any points, having one point more than doubled the chance of postoperative delirium and having 3 or higher points over quadrupled this risk. In another study, patients age seventy years and older who were going through hip surgery were designated one point for every one of the following delirium risk factors: binocular near vision worse than 20/70 following correction; serious illness, defined as an APACHE II score of higher than 16; MMSE score below 24; or dehydration, as advised by a BUN to creatinine ratio of 18 or higher. Subjects with not one of these threat factors were classified as low danger, individuals with one or two risk factors were classified as intermediate risk, and those with three or four risk aspects were labeled as large risk. Likelihood of postoperative delirium was 3.8% in the low-risk group, 11.1% inside the intermediate-risk group, and 37.1% inside the large-risk group (P < 0.001; relative risk, 98). Researchers reported that cognitive disability at entrance had the greatest predictive value for the development of delirium.16

Nonpharmacologic Prevention
Since most cases of delirium are multifactorial, multicomponent prevention strategies are most reliable in preventing this problem. The Yale Delirium Prevention Test implemented standard protocols aimed at handling 6 risk factors for delirium: cognitive impairment; sleep deprivation; immobility; visual impairment; hearing problems; along with dehydration. Standardized treatment protocols for the management of these danger aspects resulted in a substantial decrease in the development of delirium, from 15% in the usual-care group to 9.9% in the treatment group.

Additionally, the amount and length of delirium episodes among more mature persons within the intervention team had been significantly reduced; nevertheless, the interventions had zero considerable effect on the seriousness or the recurrence of delirium. The particular interventions utilized in the Yale Delirium Prevention Trial were adapted as the Hospital Elder Life Program (HELP), which has been put in place in hospitals throughout the United States, Canada, and Australia. Often implemented mostly by volunteers to minimize financial expense, this system is cost-effective whenever utilized in patients who're at intermediate risk for acquiring delirium. Cost savings among intermediate-risk subjects had been primarily due to savings in nursing expenses, diagnostic processes, and other cost elements, including coronary and extensive treatment units, clinic supplies, surgery and postsurgical fees, rehabilitation services, and physical therapy. Cost-effectiveness was not shown amongst high-risk subjects.

Inside a potential, randomized test regarding patients age 65 years and older, positive geriatric discussion had been found to be successful within stopping postoperative delirium in people with hip fractures. Geriatricians evaluated sufferers every day during their hospitalization and made specific, protocol-based suggestions, including the treatment of pain, elimination of unnecessary medications, regulation of bowel and bladder functionality, and early mobilization. Delirium occurred in 32% of subjects inside intervention group as compared with 50% of subjects in the usual-care class. Over-all, geriatric consultation decreased the occurrence of delirium instances by one-third and severe delirium cases by one-half.

Pharmacologic Deterrence
A number of reports have focused on the pharmacologic avoidance of delirium within postoperative sufferers. The result of donepezil in lowering postoperative delirium following elective full hip replacement was examined in a randomized, double-blind, placebo-controlled test of 33 senior persons. Patients within the treatment group received donepezil 5 mg every day for 4 days postoperatively. Donepezil did not significantly reduce the occurrence of delirium or the duration of hospitalization in these kind of patients. An additional study evaluated the effect of donepezil on delirium prevention in clients age 50 years or older who were going through optional knee or hip arthroplasty. Subjects in the treatment group took donepezil 5 mg every day for 14 days prior to surgery to acquire a steady state, and continued on the medication for Fourteen days postoperatively. The investigators observed no difference in the incidence or the duration of delirium among the intervention and control groups.

Inside a new study, Gamberini et al evaluated the usage of rivastigmine with the prevention of postoperative delirium within 120 patients, age 65 years or older, pursuing elective heart surgery. Subjects within the treatment group received rivastigmine 1.5 mg Three times every day in the evening before surgery till the evening of postoperative day 6. No significant difference in incidence, duration, or intensity of delirium was found between the intervention and also control teams. The effect of haloperidol prophylaxis may be evaluated in patients, age 70 years and older, undergoing hip surgical treatment. Subjects within the intervention team received haloperidol 0.5 mg 3 times daily from clinic admission until postoperative day 3. Positive geriatric consultation was also supplied to all people.

Haloperidol was not effective in reducing the incidence of postoperative delirium; nevertheless, it is important to remember that the duration and intensity of delirium and the length of hospitalization had been considerably lowered within the intervention group.

Management
Prosperous delirium administration includes handling the fundamental causes, providing supportive treatment, and treating behavior symptoms. Delirium should be considered a medical emergency because of the connected morbidity and fatality, and it usually happens in the setting of significant medical illness. Initial administration should concentrate on ensuring balance of the individual by simply assessing respiratory and circulatory stability and analyzing for feasible life-threatening causes, such as myocardial infarction, cerebrovascular accident, or infection. Subsequent supportive care should include maintaining adequate nutrition and hydration; frequent repositioning and beginning mobilization to prevent stress ulcers; deep vein thrombosis prophylaxis; minimizing the usage of tethers, such as Foley catheters; and staying away from the usage of bodily restraints. Nonpharmacologic measures are first line in the symptomatic treatment of delirium, and include reorienting the individual often, presence of the relatives at the bedside whenever possible, restricting staffing and room changes, and maintaining the sleep-wake routine by minimizing nighttime distractions and ensuring that the person is awake and situated in a bright area during the day.

Pharmacologic treatment of delirium should only be used in patients whose symptoms place themselves or others at risk for harm. Haloperidol, an average antipsychotic agent, has typically been the agent of preference for managing delirium. A randomized, double-blind trial contrasting haloperidol, chlorpromazine, and lorazepam for the medication of delirium in hospitalized people with HIV virus found haloperidol to be better than the other two drugs in these types of individuals. Specifically, haloperidol was successful in enhancing symptoms of delirium and had been identified to possess a very low rate of extrapyramidal unwanted effects. Chlorpromazine was also determined to be effective in reducing symptoms, while lorazepam was determined to be ineffective and also was associated with adverse effects. The effectiveness rate of haloperidol is similar to that of atypical antipsychotic agents. Atypical antipsychotics are quite efficacious in dealing with the behavioral symptoms of delirium, along with risperidone and olanzapine possessing an efficacy of 80% to 85% and 70% to 76%, respectively. Quetiapine has been less typically studied, but additionally appears to be an acceptable treatment option. As compared with haloperidol, the atypical antipsychotics produced fewer adverse effects, such as extrapyramidal symptoms.

Standard and atypical antipsychotic drugs carry black-box warnings from the Food and Drug Administration (FDA) concerning an increased risk of death whenever applied to senior patients treated for dementia-related psychosis. These warnings, issued for atypical antipsychotics in 2005 and typical antipsychotics in 2008, are supported by numerous reports. In a retrospective cohort investigation of 22,890 patients age 65 years or older, standard antipsychotics had been of a considerably greater modified chance of death as compared to atypical antipsychotics through the 180-day review period. The highest boost in the modified risk of death for typical antipsychotics occurred within the initial 40 days of treatment and when given at increased doses.

A population-based, retrospective cohort study that evaluated the use of antipsychotic agents and death involving 259 community-dwelling adults and rest home residents, age 66 years or older, with dementia discovered a statistically significant elevated chance of death at 30 days among both community-dwelling participants and nursing home residents with new usage of atypical antipsychotics. Standard antipsychotic use had been associated with a higher possibility of death through the 180-day study period. A recent investigation evaluating the effect of the FDA black-box caution for typical and irregular antipsychotic medication use found a general reduction in use; decreased usage was most significant for atypical antipsychotics in elderly patients with dementia.

Despite the FDA warnings and research conclusions, antipsychotic medications are often found in elderly people with delirium who present a danger to theirselves or others. In such cases, health care suppliers should have a comprehensive dialogue of the feasible benefits and dangers of antipsychotic treatment with the patient’s specified choice maker. Antipsychotics should be used in the smallest effective dose for the smallest duration possible.

Lorazepam is a second-line treatment for delirium and really should be used only in sufferers with sedative/alcohol revulsion, Parkinson’s disease, or neuroleptic malignant syndrome. Even among these select patients, however, lorazepam should be used with significant caution, as there is a risk of elevated confusion and paradoxical exhilaration.

Prognosis
Regardless of using suitable management choices, delirium continues to result in higher morbidity and mortality amongst a significant number of patients. Persistent delirium, defined as continued evidence of delirium during the time of hospital discharge, is much more typical amongst elderly persons, affecting around 39% of older patients. Right after hospital discharge, 44.7% still experienced delirium at 30 days and 32.8% at 3 months. Independent risk elements for continual delirium include standard dementia, visual disorder, functional impairment, large comorbidity, as well as the use of physical restraints. Persistent delirium is part of adverse outcomes. In a study of sufferers over age sixty five years with hip fractures, delirium dogging 30 days following clinic discharge was associated with a heightened decrease in activities of daily living and ambulation, and an increased occurrence of new nursing home placement or death in comparison with similar subjects who didn't have delirium. In a study of 433 contributors age 70 years and older, 83.3% of people with persistent delirium died or had been admitted to a rest home 1 year right after hospitalization. Although these bits of information did not meet the requirements for statistical importance, these were clinically significant, as only 67.7% of subjects in whom delirium had resolved by discharge and 41.5% of subjects who never had delirium deceased or had been admitted to a nursing home after 12 months of follow-up.

While dementia is definitely a well-recognized risk aspect for delirium, it today appears that delirium might increase the risk for the expansion of cognitive disorder.

Inside a study published in 2008 of patients age 60 years or older who went through elective, noncardiac surgery, delirium had been associated with a heightened incidence of early postoperative cognitive dysfunction 1 week postoperatively; however, there was clearly no relationship found between postoperative delirium and long-term postoperative cognitive dysfunction at 3 months. In yet another study, an evaluation of patients who went through heart surgery conducted 1-to-1.5 years following surgery saw a medically—although not statistically—substantial increase in the incidence of memory and focus issues amongst subjects who developed postoperative delirium. A prospective study demonstrated delirium being related to decreased MMSE scores 1 year following hospitalization, following adjustment for comorbidity, severity of illness, and other covariates, in individuals age 65 years and older who had been admitted to a medical services.

Conclusion
Delirium impacts up to 56% of hospitalized senior patients,1 and frequently leads to significant adverse outcomes, such as higher duration of hospitalization, reduced activities of daily living, increased occurrence of institutionalization following hospitalization, and death. All geriatric clients ought to be evaluated for delirium during the time of hospital programs, and a delirium reduction program needs to be initiated for all patients. If delirium does grow, assessment and management of causative factors must be implemented. Nonpharmacologic surgery, including frequent reorientation, family presence, and minimisation of sleep-wake disruptions, will be the basis of symptom control. Pharmacologic therapy is suitable when symptoms of delirium place the patient or others in danger of harm. Haloperidol is the standard first-line agent, but untypical antipsychotics are actually established to have similar efficacy.