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

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Alcoholic Hepatitis and Delirium Tremens

Alcoholic Hepatitis and Delirium Tremens

Normal liver
Fatty Liver
Alcoholic Hepatitis
Cirrhosis
Acute Alcoholic Hepatitis
Symptoms include
How to assess severe acute alcoholic hepatitis
Management of Alcoholic Hepatitis
TNF and Alcoholic Hepatitis
Management of Alcoholic Hepatits
Delirium Tremens
Treatment
Selecting patients for alcohol withdrawal outpaitent treatment
* Indications: Alchohol dependence with evidence of tolerance and withdrawal
* Contraindications:
o Coexisting acute or chronic illness requiring inpatient treatment
o Current severe withdrawal with DTs
o No possibility for follow up
o Pregnancy
o Seizure disorder or risk of withdrawal seizure
o Suicide risk
* Relative contraindications
o Benzo dependance
o h/o unsuccessful outpatient detozification
o Age>40 years
o Drinking >100g ethanol daily
o Elevated MCV
o Elevated BUN
o Cirrhosis
o Random blood alcohol >200mg/dl
References
Alcoholic Hepatitis and Delirium Tremens.ppt

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Management of Sedation and Delirium in Ventilated ICU Patients

Management of Sedation and Delirium in Ventilated ICU Patients
By:Gabriel Tsao
Stanford University, School of Medicine

Introduction
Presentation Outline
* Sedation in the ICU
o Drug overview
o Sedation assessment
o Drug selection
* Delirium in the ICU
o Incidence and mortality
o Delirium assessment
o Management of delirium

Sedation in Ventilated Patients
* Mechanical ventilation is uncomfortable and anxiety provoking
* Sedation is often necessary for comfort and airway, line, foley, nursing protection
* >85% of ventilated patients receive sedation

Commonly Used Sedatives
Central alpha-agonists
Dexmedetomidine
Fentanyl
Assessing Sedation
Selection of sedative agent
Sedation Use Recommendations
Sedation Interruption
Sedative Dependence
Presentation Outline
* Sedation in the ICU
o Drug overview
o Sedation assessment
o Drug selection
* Delirium in the ICU
o Incidence and mortality
o Delirium assessment
o Management of delirium
Delirium highly prevalent in ICU
Delirium in ventilated patients
Overview of Delirium
Subtypes of Delirium
Assessing Delirium
Pathophysiology Poorly Understood
Treatment of Hyperactive and Mixed Delirium
Other Treatments for Hyperactive/Mixed Delirium
Treatment of Hypoactive Delirium

Management of Sedation and Delirium in Ventilated ICU Patients.ppt

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