Morning Report

Steve Hart4/19/2006

Case Presentation

77 y/o AAF with ESRD presents to ED with lower extremity weakness x 1-2 days and elevated blood pressure.

Feeling generally weak, now unable to ambulateOff BP meds for about a week

“BP controlled with Dialysis”

HeadachesPoor visionSome SOB and coughingPer social worker and daughter, mental status changed from baseline

PMHxHTNGlaucomaCataractAnemiaRecent AV graft infection

Social HxLives at home with daughterQuit smoking in 50’s

Allergies – noneMeds

LisinoprilAranespXalatin eye dropsPhosloNephrocapsZocorAspirin

VitalsT 97.1 HR 79 R 14 BP 175/69 Pox 98% 2L

Physical ExamGen – Alert, oriented? Female, HEENT – PERRLA, EOMI, MMMNeck – JVD, nl thyroidChest – bilateral rhonciCV – RRR, nl S1 and S2, no edema, no bruitsAbd – soft, NT/ND, no HSMExt – no E/C/CNeuro – equal/symetric +1 reflexes., CN intact, nl

cerebellar signs, +5 strength in UE, -5 in LE Neg Rhomberg

Labs

138 96 7

3.7 33 2.5

90 13.6

5.3 218

41.5 Ca 9.7

CKMB 1.8

Trop I 0.05

EKG NSR, No ST changes

CXR NAD

UA: 1.006, 8.5, prot 100, occ bact, LE large, 27 WBC

Diff: N65 L20 M10

Imaging

Head CTSmall vessel disease with age indeterminate infarcts in internal capsule. Possible subacute on old?

MRI Headmoderate deep and sub-cortical ischemic white matter changes – non acuteBilateral patchy ischemic foci in the lentiform nucleus and pons. No intracranial mass lesionremote micro hemorrhage in the right posterior inferior aspect of the thalamus

Problem List

Geriatric

Weakness, ambulatory only with assistance - new

Recent decline in mental status

HTN, uncontrolled

ESRD

UTI

Impaired vision

SOB, hypoxic

Small vessel disease, lacunar infarcts

Hospital Course

Day 1Started on routine SQ heparin and pepcid on admissionMI ruled out with serial enzymes and EKGsCultures negative, no empiric antibiotics

Remained afebrile

SOB and hypoxia relieved with dialysisBlood pressure poorly controlledNeurology consulted for mental status changes

Hospital Course

Mental Status quickly deterioratedHallucinationsFluctuating mental status

Alert but not oriented at timesUnable to concentrateTangential thought

“sundowning” Patient placed in restraints

Delirium

Delirium

Definitionreduced ability to focus, sustain, or shift attention change in cognition or the development of a perceptual disturbance Acute onset (hours to days)Identifiable cause

Epidemiology

At admission prevalence 14-24% Hospitalization incidence 6 to 56%15-53% geriatric patients post-op70-80% older patients in ICU60% nursing home will have at some time83% of geriatric patients prior to death

Delirium….Why should I care?

Mortality rate in hospitalized patients 22-76% One year mortality rate is 35-40%Prolongs hospital courseIncreased cost of care in hospitalIncreases likelihood of disposition to nursing home, functional decline and loss of independence

More reasons to care

Strong association with underlying dementiaFrequently, patient may never return to baseline or take months to over a year to do soDelirium is often the sole manifestation of serious underlying disease

Pathophys

EEG shows diffuse cortical slowingNeuropsyc and imaging

Disruption of higher cortical functionPrefrontal cortexSubcortical structuresThalamusBasal gangliaFrontal and temporoparietal cortex fusiform cortexLingual gyriEffect greatest on non-dominant side.

InvolvesNeurotransmissionInflammationChronic stress

Pathogenesis

NeurotransmissionCholinergic deficiency

Anticholinergics can precipitate deliriumSerum anticholinergic activity increased in those with deliriumCholinesterase inhibitors can reverse this effect

Dopaminergic excessNeuropeptides, endorphins, serotonin, NE, GABA may play a role.

Pathogenesis

Pathogensis

CytokinesInterleukins and interferonsOften elevated in DeliriumHave known strong CNS effectsPrimary role – sepsis, bypass surgeries, dialysis, cancers

Pathogensis

Chronic stressUntreated pain / analgesia are strong risk factorsElevated cortisol assoc with delirium

Risk Factors

Underlying brain diseaseDementiaStrokeParkinson’s

Advanced AgeSensory ImpairmentBladder Caths

Differential

Psychiatric IllnessDepressionmania

DementiasNonconvulsive status epilepticus

Especially in ICU

Wernicke’s aphasiaOccipital lesions

(cortical lesions and confabulations)

Bifrontal lesions (tumors or trauma)

Diagnosis

Clinical

Step #1 – Recongnize the disorder

Step #2 - Uncover underlying medical illness

Recognize

Often unrecongnized, >70% of cases

Behavioral or cognitive issues often wrongly attributed to age, dementia or other mental disorders

determine acuity of change in mental status.if no historian available, one should assume acute and delirious until proven otherwise

Recognize

Disturbance in consciousness and alterned congnitionConsciousness

Attention – poorSubtle loss of mental clarity initially

Patient “isn’t acting right”

DistractabilityTangential or disorganized thought

Acute/subacute onsetFluctuating course throughout a day

Recongnition

CongitionMemory lossDisorientationDifficulty with language and speechPerceptual disturbances

DelusionsHallucination

Assessment

Formal mental status evaluation in all geriatric patients (ie. MMSE or CAM)

Arouse all older patients daily to evaluate hypoactive form of delirium

Search for causes of delirium

D Drugs, Drugs and toxins, tooE Eyes, earsL Low O2 states (MI, ARDS, PE, CHF, COPD,

stroke, shock)

I InfectionR Retention (of urine or stool). RestraintsI IctalU Underhydration, UndernutritionM Metabolic (hypo/hyper glycemia, calcemia,

uremia, liver failure, thyroid disorders)

Causes

Other Causes

Foley catheterInvasive procedureSleep deprivationPain

Drugs

Accounts for 30% of all casesCommon culprits

Anti-histaminesAnti-cholinergicsAntibioticsSome antidepressantsDopamine agonistsHypoglycemicsBenzosOpiates

Patient

Poor visionEvidence of old and recent strokesInfection - UTIRestraintedMultiple medications

Pepcid started on admission

ESRDHypoxia

Treatment

Correct all identifiable causesDelirium is usually multifactorialCorrection of multiple causes is often necessary for recovery

Pharmacologic – if neededAntipsychoticsAvoid benzos except with ETOH withdrawl

Orient Patients Provide clocks, calenders, windows, structured activitiesHearing aides, glasses

The End – Questions/Comments?