Managing Delirium in the Emergency Department. Introduction Not a talk about the agitated patient...

Managing Delirium in the Emergency Department

Introduction

• Not a talk about the agitated patient

• They’re easy and there is lots of literature

- sedate, intubate and let ICU sort it out

Talk about delirium

- emphasis on the emergency department

- very little literature

- big management problem

Introduction

• Managing a patient with delirium is difficult and labour intensive

• A bigger problem is actually recognising that the patient has a delirium

• The 2 groups where we need to have a high index of suspicion are the elderly and the (first presentation) psych patient

Delirium

• Neuropsychiatric Syndrome

- multiple causes

- produce a similar constellation of

symptoms

Delirium Definitions

• A sudden and significant decline in mental functioning not better accounted for by a preexisting or evolving dementia

• Disturbance of consciousness with reduced ability to focus, sustain, and shift attention

DSM-IV Diagnosis • DSM-IV

– A. Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.

– B. A change in cognition or the development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia.

– C. The disturbance develops over a short period of time and tends to fluctuate during the course of the day

– D. There is evidence from the history, PE, or labs that the disturbance is caused by the direct physiologic consequences of a general medical condition

Introduction

• Simplest definition of delirium is “acute brain failure” with a combination of

- behavioural symptoms

- psychological symptoms

- cognitive symptoms

- neurological symptoms

Introduction

• Common presenting problem

> 40% of patients over 65

• Frequently develops during an admission

• Frequently misdiagnosed as psych or dementia

- overlap of symptoms

- dementia predisposes to delirium

Introduction

• Frequently missed all together

• We forget that there are a range of presentations

- agitated delirium

- quiet delirium

- mixed

Why Does Delirium Matter?

• Increased morbidity and mortality

• Increased length of stay

• Increases rate of cognitive decline

• Increased distress to patient and family

- may believe delusions and hallucinations

really happened even after delirium

resolved

Behavioural Symptoms

• Aggressive or agitated

• Quiet and withdrawn

• Screaming / calling out

• Wandering

• Disinhibited

• Altered sleep-wake cycle

Behavioural Symptoms

• Constant questioning

• Hide things / hoarding objects

• Frontal lobe release

- picking at the air / bed clothes

- pulling on IVC or IDC

Psychological Symptoms

• Anxiety

• Paranoid

• Delusions (usually persecutory)

• Hallucinations (usually visual)

- auditory hallucinations: think psych

- visual delusions: think delirium

Cognitive Symptoms

• Can’t focus / inattention

- beware of the “vague historian”

• Can’t shift focus

• Can’t solve problems

• Trouble with abstract thought

• Impaired recent and remote memory

Neurological Symptoms

• Dysphasia

• Dysarthria

• Tremor

Psychiatry and Delirium

• Many of the symptoms of delirium also can occur in a psychiatric illness

- easy to see why there is confusion

• Liason psych are often called to review patients whose delirium has been missed by the treating team

“Psychiatric Symptoms”

• Altered mood

• Altered behaviour

• Altered thought or cognition

• Altered perception

If patients are triaged with these problems,

we jump to the conclusion that is a psych

illness

“Psychiatric Symptoms”

• May be caused by or aggravated by a medical illness (organic illness)

• Incidence is unclear - 10 to 75% range quoted in A&E literature Medical illness is a significant cause of

“psychiatric symptoms”

“Psychiatric Symptoms”

• Unfortunately, medical illnesses often go unrecognized due to inadequate and poorly documented medical assessment in A&E

Tintinelli (1994)

- assessment of: mental state 40 – 80%

LOC 80 – 95%

orientation 70 – 90%

full motor exam 50 - 60%

cranial nerves 20 – 55%

“Psychiatric Symptoms”

• Reeves (2000): still the same problem

• 64 patients with medical illness admitted inappropriately to a psychiatric unit

- full history 66%

- vital signs 90%

- full physical exam 65%

- full mental state exam 0%

“Psychiatric Symptoms”

• Problems with medical assessment are not due to a lack of imaging or esoteric blood tests.

• The problem is a failure to do a thorough history, examination and mental state examination

ie we aren’t doing the basics

Psych Vrs Delirium

• First presentation of a psych illness is rare over 45 years of age

• Auditory hallucinations are more common

• Even floridly psychotic patients tend to remain orientated to time and place

• Memory is usually intact

• Does not fluctuate over the course of a day

Delirium Vrs Dementia

• Memory deficits, language disturbances and disorganized thinking are common to both diagnoses

• Need to know the patients baseline, what has changed and how quickly it has changed

• Need a good history from multiple sources

Delirium versus Dementia

• DeliriumRapid onsetPrimary defect in attentionFluctuates during the

course of a dayVisual hallucinations

commonOften cannot attend to

MMSE or clock draw

• Dementia

Insidious onsetPrimary defect in short

term memoryAttention often normalDoes not fluctuate during

dayVisual hallucinations less

commonCan attend to MMSE or

clock draw, but cannot perform well

Pathophysiology of Delirium

• Systemic pathology leading to a local inflammatory response in the brain with subsequent changes in neurotransmission

- we don’t care

• It involves predisposing factors and precipitating factors

- we do care

Pathophysiology of Delirium

Can use predisposing factors to predict who

is at risk of developing delirium

Can use precipitating factors to guide our

management strategies

Pathophysiology of Delirium

Predisposing factors- Children and elderly (<10 & > 65)- history of brain disease (dementia, CVA)- history of delirium- impaired vision or hearing- medications (benzo’s; anti-cholinergics)- alcohol dependance- psych history

• Precipitating factors

- lots

• The main ones are

- underlying medical condition

- substance intoxication

- substance withdrawal

- combination of any or all of these

Pathophysiology of Delirium

Pathophysiology of Delirium

Other Precipitating Factors- new medications- invasive procedures (IVC; IDC; NG)- fluid and electrolyte abnormalities

- metabolic disturbances

- change of environment (ED is bad!)

- nutritional deficiencies

Pathophysiology of Delirium

• The more precipitants, the greater the chance of developing a delirium

• The more predisposing factors, the fewer precipitating factors are needed to trigger delirium

- In the frail elderly, constipation alone

can trigger delirium

Making the Diagnosis

• Delirium is common

• Delirium is important

• Delirium seems really complicated

• How can I make the diagnosis?

Medical Assessment

• Stable / Unstable

• Danger to Self or Others

• Detailed History

- medical & psychiatric

- from multiple sources

- baseline ADL, cognition, behaviour etc

eg family, ambo’s, bystanders, NH

GP, old notes, CMH team

Clues for an Organic Cause

• Age less than 12 or greater than 40 • Sudden onset (hours to days)• Fluctuating course• Disorientation• Decreased consciousness• Visual hallucinations• No psychiatric history• Emotional lability• Abnormal vitals / physical examination findings • History of substance abuse or toxin exposure

Clues for a Functional Cause

• Age 13 to 40 years• Gradual onset (weeks to months)• Continuous course• Awake and alert• Auditory hallucinations• Psychiatric history• Flat affect• Normal physical examination findings (including

vital signs)

Medical Assessment

• Full physical Examination

- head to toe

eg head / neck / CVS / lungs / abdo

neuro / periphery / skin

- includes vital signs

eg BP, HR, RR, Temp, BSL, RAIR sats

Medical Assessment

• Bedside tests

- mental state exam

- mini mental exam

- EEG

- CAM

Making the Diagnosis

Mini Mental- Useful at separating “normal” from “abnormal”- Not specific for distinguishing delirium from dementia- May be useful as change from baseline- Suggestive if score varies during or between days

Making the Diagnosis

• Mini mental does include tests of attention

- serial 7’s

- spell “world” backwards

Other simple tests

- counting backwards from 20

- days of week backwards

- month of year backwards

EEG

• Can be diagnostic

- generalised slowing of brain activity

• Significant false positive and negative rate

• Is done on the wards

- but is it useful?

• Not done in A&E

Confusion Assessment Method

Is there evidence of:1) Acute onset and fluctuating course2) Inattention3) Disorganized thinking4) Altered LOC (increased or decreased)

1 and 2 and either 3 or 4 Sens = 95% spec = 90%

Confusion Assessment Method

1) Acute onset & fluctuating course

- is there an acute change from the patient’s baseline?

What are they normally like, what has

changed and when did it change

Confusion Assessment Method

2) Inattention

- did the patient have difficulty keeping track of what was being said?

- can’t focus

- can’t shift focus

- Serial 7’s

- World backwards etc

Confusion Assessment Method

3) Disorganized thinking- rambling conversation- unclear or illogical flow of ideas- Interpret a proverb- “Will a stone float on water?”

CAM Diagnostic Algorithm

4) Altered level of consciousness - alert (normal), - vigilant (hyperalert), - lethargic (drowsy, easily aroused), - stupor (difficulty to arouse)

Any answer other than “alert” is abnormal

Management

• The key is to identify and treat the underlying causes

Also need to:

- minimise patient anxiety

- prevent harm to the patient

Management: Investigations

• Not to make the diagnosis

• To help guide our treatment

• Often use a “shotgun” approach

• EUC, FBC, LFT, MSU, blood cultures, cardiac biomarkers, CT brain, ABG, ECG, CXR, PR, etc etc etc

Management: Treatment

• Can treat against their will using the mental health act

• Non-pharmacological Strategies

• Pharmacological Strategies

Soapbox Moment

• We used to have a CNC for dementia and delirium but admin in their wisdom has terminated the position

• Each speciality has a CNC who should be involved early in the management of admitted patients with a delirium

Non-pharmacological Treatment

• “A calm, quiet atmosphere, frequent prompts concerning orientation, clear precise communications and a night light are helpful in the management of delirium”

Some dude who has never stepped foot inside an Emergency Department

Non-pharmacological Treatment

• Numerous strategies that aren’t practical in ED (or wards either?)

1)Providing support and orientation

2)Providing an unabiguous environment

3)Maintaining Competence

Non-pharmacological Treatment

In English- Frequent reminders about time and place- Constant reassurance- Staff to wear name tags and indentify

themselves often- Minimise stimuli (noise, lights, procedures)- Place familiar objects in room- Minimise the number of staff involved in care

Non-pharmacological Treatment

• Patients with delirium are unpredictable.

• Unpredictability = bad things happen

- fall; pull out vascaths; abscond; ride

around naked in elevators

• They need a special.

• If none available, place the bed where they can be seen at all times

Pharmacological Treatment

• Not Indications

- calling out

- wandering

- convenience of staff

No drug will stop a patient from wandering.

Drugs will help a wandering patient fall

Consider sedating the nurse

Pharmacological Treatment

Indications for drug therapy

- relieve patient anxiety

- behaviour putting patient or others at risk

- agitation distressing to patient

Not aiming to sedate the patient

Trying to calm them down

Pharmacological Treatment

• No good evidence based studies

• Large range of treatment guidelines

• Are now Australian Best Practice Guideines

Pharmacological Treatment

• Aim to use one drug

• Keep doses to a minimum

• Avoid escalating doses

• Seek expert advice early

• Review medications daily

Benzodiazepines

• Don’t use as a first line agent

- long half life & easy to over sedate

- respiratory depression

- may worsen delirium

- no anti-psychotic actions

- role in alcohol withdrawal & terminal

delirium

Haloperidol

• Haloperidol

- first line in the Australian Guidelines

- widely used (outside of Westmead ED)

- oral, IM or IV

- no agreement in dosing strategy

- “start low, go slow”

Haloperidol Dosing

• 0.5 to 1 mg initially

• repeat in 30 mins to 2 hours if needed

• Maximum 2 to 4 mg / 24 hours

Haloperidol

• Haloperidol in ICU

- 1 , 2 or 5 mg IV

- double dose every 30 minutes till settled

- then give total 24 hr dose as qid on

subsequent days

Second Line Agents

• If after haloperidol, there are prominent psychotic features

- risperidone

- olanzepine

• If after haloperidol, agitation is prominent

- lorazepam

Resperidone

• 0.25 to 0.5 mg PO, Q4 hourly, PRN, maximum 2 mg / day

• Maximum 4 mg / 24 hours

• Side effects include hypotension and sedation

Olanzapine

• Tablets, wafer, IM

• 2.5mg If needed repeat in 4 hours

• Maximum 10 mg / 24 hours

Lorazepam

• 0.5 – 1 mg initially

• If needed repeat in 4 hours

• Maximum 3 mg / 24 hours

Conclusions

• Maintain a high index of suspicion for delirium in elderly patients and possible psych patients

• Remember the red flags for organic & functional illness

• Thorough exam & clear documentation

Conclusions

• Remember the CAM

• Try to avoid drug therapy

• Calling out and wandering are not indications for drug treatment