Delirium in the Elderly

Delirium in the Elderly
By:Bree Johnston MD MPH
UCSF Division of Geriatrics

Case Study
Atypical Presentations
Learning Objectives
* Recognize that delirium is a common presentation of disease in the elderly
* Recognize that delirium is associated with adverse outcomes
* Know how to distinguish between delirium and other diagnoses (dementia, depression)
* Identify risk factors for delirium and strategies for risk reduction
* Discuss management strategies, recognizing the limitations of current data
Definition
* “an acute disorder of attention and cognition” (de lira “off the path”)
* Standard definition not use until 1980 with publication of DSM III
* Other terms used include organic brain syndrome, metabolic encephelopathy, toxic psychosis, acute mental status change, exogenous psychosis, sundowning
Pathophysiology
Delirium Risk Factors
* Age
* Cognitive impairment
* Male gender
* Severe illness
* Hip fracture
* Fever or hypothermia
* Hypotension
* Malnutrition
* High number of meds
* Sensory impairment
* Psychoactive medications
* Use of lines and restraints
* Metabolic disorders:
* Depression
* Alcoholism
* Pain

Delirium Risk Model
Baseline Risk Group
Precipitating Factor Group
Surgical Prediction Rule
Clinical Prediction Rule for Post-surgical Delirium
Differential Diagnosis
* CNS pathology
* Dementia, particularly frontal lobe
* Other Psychiatric disorders
o Psychosis
* Depression: 41% misdiagnosed as depression Farrell Arch Intern Med 1995
o Bipolar disorder
* Aconvulsive status epilepticus
* Akathisia
* Overall, 32-67% missed or misdiagnosed

Diagnosis
Diagnostic Tools
Delirium versus Dementia
Medications and Delirium
Searching for the cause
103 treatment and 111 controls
Intervention: Surgery as soon as possible & geriatric evaluation pre and post op vs usual care
Outcomes Treatment Control
Possible Benefit From:
* Preoperative psychiatric assessment followed by nursing reorienation (33% vs 14%)
* Postoperative reorienation (87% vs 6%)
* Preoperative education about delirium (78% vs. 59%)
* Pre and post operative psychiatric intervention (13% vs 0)
Can Interventions Prevent Delirium?
Intervention Protocol
* Cognition Orientation, activities
* Sleep Bedtime drink, massage, music, noise reduction
* Immobility Ambulation, exercises
* Vision Visual aids and adaptive equipment
* Hearing Portable amplifiers, cerumen disimpaction
* Dehydration BUN, volume repletion
Preventing Delirium post Hip fracture
* Protocols for:
o Fluid/electrolytes
o Pain treatment
o Eliminating unnecessary medications
o Bowel/bladder function
o Nutrition
o Mobilization
o CNS oxygenation
o Prevention of complications (MI, PE, UTI, pneumonia)
o Environmental stimuli
o Treatment of agitated delirium
Delirium in Hip fracture
Severe delirium, cumulative incidence
Delirium, cumulative incidence
Delirium at discharge
Interventions that May Help
Drug therapy
Drug Therapy of Delirium
Neuroleptics
Use of Haloperidol
Atypical neuroleptics
Benzodiazepines
Other agents
Delirium in the ICU
Sedation in the ICU
Prevention is the Best Medicine

Delirium in the Elderly.ppt