Oct 6 - Postop Delirium in the Older Person (Brymer)

8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)

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Post-operative deliriumin the Older Person

Presented by: C. Brymer, M. Dasgupta, L. VanBussel & H. Park

(Slides prepared by: M. Dasgupta, MD, FRCP,Laurie McKellar RN(EC), BScN, GNC(C)

Lisa Van Bussell, MD, FRCP(C))


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Frequent duties of a clinical clerkrotating through surgery:

Do an admission Hx and PE on an elderlyindividual about to go through a surgicalprocedure: This should help in determining the risk for

future problems that may develop (e.g. post-op complications, including delirium)

Being paged to manage a confusedperson who has had a surgical procedure(all the residents are busy in the OR)


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Case Scenario

You are called (at 3:00 AM) to assess a

confused patient who is post-op day # 3following a hip fracture repair

Staff insist that he is a danger to himself andneeds something now

How to approach this all-too-commonscenario? Could this have been prevented?


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Basic objectives

To be aware of how to diagnose delirium

To be able to appreciate when someone is

at risk for developing post-op delirium

To have an approach to management of thedelirious patient


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Outline - delirium (peri-operative): Epidemiology: frequency, pathophysiology, impacts/ consequences

Diagnosis: definition and manifestations, collateral history, needfor inter-Disciplinary Team (IDT) approach

Risk factors for surgical patient: Patient factors operative/anesthetic factors post-operative/medical factors

Delirium prevention

Management of the delirious patient: Non-pharmacologic interventions Pharmacologic interventions

Discussion of cases


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Surgery in the older adult: Older people account for about 40% of elective

surgeries and 50% of emergent surgicalprocedures

Older people are at increased risk for post-

operative medical complications (e.g. cardiaccomplications, etc..)

Delirium is in the top three most common post-operative complications (Seymour and Vaz,1989; Liu et al.,2000)


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Delirium Unlike other typical medical/post-operative

syndromes:

There is no unifying pathophysiologic explanationunderlying the delirious state

It represents a common set of symptoms that canaccompany virtually any acute condition (etiologicallynon-specific)

Brain malfunction in response to multiple factors

Occurs in medical, surgical & psychiatric patients-EXTREMELY COMMON


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Pathophysiology of Delirium- We really dont know why delirium happens

BUT.. (Van der Mast, Neurol 1998; Marcantonio et al., 2006): It is associated with neurotransmitter alterations

(e.g. anticholinergic activity, altered serotonin

synthesis, catecholamine, ie dopamine activity)

Also implicated: altered melatonin levels, post-oppain and endorphins, cortisol

Neurotransmitter abnormalities may result frommultiple pathophysiologic processes


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Associated with bad consequences:

Immediate impacts of delirium:

Difficult to care for

People can get more sick (due to abovefactors)

length of hospital stay, cost

Highly distressing for patients who recall it.(Breitbart et al ( 2002 )

risk for short and long-term

functional decline, dementia,institutionalization and death (Dolan et al.,2000; Marcantonio et al., 2000; Lundstrom et al., 2003)


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Delirium- What is it? DSM- IV-TR (Diagnostic and Statistical

Manual of Mental disorders, 2000) diagnostic

criteria for delirium (clinical diagnosis): Disturbance of consciousness or awareness (reduced ability

to focus/ sustain or shift attention)

Change in cognition (e.g. memory, disorientation, language)

or development of a perceptual disturbance that is notbetter accounted for by a preexisting, established orevolving dementia

Disturbance develops over a short time period (usuallyhours-days) and fluctuates during the day

Evidence from history, physical examination or laboratoryfindings that the disturbance is caused by the directphysiological consequence of a general medical condition


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Delirium- What is it? Confusion Assessment Method (CAM) is a

bedside diagnostic tool

CAM algorithm includes 4 key features of delirium:

1) acute onset and fluctuating course

2) inattention

3) altered LOC

4) disorganized thinking

Delirium should be suspected if features1 and 2 and either 3 or 4 are present

Inouye, S. et al (1990). Annals of Internal Medicine, 113(12)


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Delirium- Clinical Manifestations

Hyperactivity and/or Hypoactivity

NOTE: Delirium is often misdiagnosed

as dementia &/ or depression

Resistive to medical and care needs

e.g. refusing physical exam, tests, medications,pulling out IV/central lines/foley catheters/chest

tubes, removing leads, oxygen, etc. Refusing bathing, eating, drinking, ambulation,

OT/PT interventions


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Delirium- Clinical Manifestations

Behavioural changes:

calling out, moaning, crying, physical aggression,hallucinations/paranoia, attempting to escape (highrisk for falls), altered sleep

Cognitive changes: disorientation, non-sensical speech, not following

commands, etc.


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Delirium- complexity of diagnosis Overlapping features between delirium, dementia

& depression, and all 3Ds can co-exist

If person has altered mental status, alwaysassume delirium until proven otherwise.Delirium is a medical emergency.

Differentiating the 3Ds clinically : onset, course,progression, duration, awareness, alertness,attention, orientation, memory, thinking &

perception (New Zealand Guidelines Group (1998). Guidelines for theSupport and Management of People with Dementia.)

Slide is content from the London 3Ds 2008 Workshop (Screening)


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Assessment of Clinical features of delirium, dementia & depression

(adapted in RNAO BPG Screening for Delirium, Dementia and Depression in Older Adults( 2003)from: New Zealand Guidelines Group (1998) Guidelinefor the Support and Management of People with Dementia.)

Feature Delirium/ Acute Confusion Dementia Depression

Onset Acute/subacute depends on cause, often attwilight

Chronic, generally insidious,depends on cause

Coincides with life changes, oftenabrupt

Course Short, diurnal fluctuations in symptoms;worse at night in the dark & on awakening

Long, on diurnal effects,symptoms progressive yetrelatively stable over time

Diurnal effects, typically worse in themorning; situational fluctuations butless than acute confusion

Progression Abrupt Slow but even Variable, rapid-slow but uneven

Duration Hours to less than 1 month, seldom longer Months to years At least 2 weeks, but can be severalmonths to years

Awareness Reduced Clear Clear

Alertness Fluctuates; lethargic or hypervigilant Generally normal Normal

Attention Impaired, fluctuates Generally normal Minimal impairment but distractible

Orientation Fluctuates in severity, generally impaired May be impaired Selective disorientation

Memory Recent & immediate impaired Recent & remote impaired Selective or patchy impairment,islands of intact memory

Thinking Disorganized, distorted, fragmented, slow oraccelerated incoherent

Difficulty with abstraction,thoughts impoverished, makepoor judgments, words difficult tofind

Intact but with themes ofhopelessness, helplessness or self-deprecation

Perception Distorted; illusions, delusions &hallucinations, difficulty distinguishingbetween reality & misperceptions

Misperceptions often absent Intact; delusions & hallucinationsabsent except in severe cases.


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Obtain Collateral History- tosort it out

Determine baseline functional & cognitive status byseeking out a reliable informant.

Possible questions to ask: Is he/she thinking, behaving & taking care of

themselves differently than they normally do?

Can you give me some examples of how he/shethinking, behaving & taking care of themselvesdifferently than they normally do?

When did this change start?

Was the change gradual or abrupt?

Speak with other involved healthcare professionals

(nursing, PT, OT, etc..)


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Diagnosing & preventing:

To summarize- delirium: is an acute change in cognition and alertness

is one of the most common peri-operativecomplications

makes providing care difficult and is associatedwith bad outcomes

Preventing delirium (pro-active approach)is more effective than managing thealready delirious individual

Preventing it also implies recognizing whois at risk


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Management- assessing risk:

In the surgical setting, always consider the individuals baseline inherent risk for

developing peri-operative delirium the nature of the surgery and post-op complications/events

Proactively assess risk preoperatively withvalidated risk indices


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Determining risk for post-op

delirium:

In the non-cardiac elective surgery setting,

patient risk-factors include (Marcantonio et al., 1994) Age > 70, cognitive impairment, functional dependence,

self reported alcohol abuse, markedly abnormallaboratory values (130>Na>150,3.0>K>6.0, or3.3>glucose>16.7) (1 point assigned for each)

Type of surgery also important (AAA repair- 2 pointsand non-cardiac thoracic surgery-1 point)

Patients with 0, 1, 2 & >2 points had 2 %, 8%,13%, and 50% chance respectively of becoming

delirious


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Risk for Post-op deliriumPatient-centered risk in hip (elective and

emergent) surgery:

Scale originally derived in the medical population(Inouye et al.,1993) has been validated in the hip surgerysetting (Kalisvaart et al.,2005).

Identified risk factors were: cognitive impairment,dehydration, severity of illness (APACHE II score >15), visual impairment (20/70 or worse) 0 points had ~4% (3.8 %) chance of delirium

1-2 points had ~10% (11.1%) chance of delirium 3-4 points had ~ 40% (37.1 %) chance of developing

delirium


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Risk for Post-op deliriumOther risk factors in the non-cardiac surgery

setting:

Multiple studies have looked at risk for developingincident (new) delirium in the non-cardiac ORsetting: Risk factors include: increasing age, cognitive

impairment (****), psychotropic drug use, increasingmedical co-morbidity, dependent functional status,nature of the surgery, visual impairment, depression,residence in assisted-living homes

****Strongest and most consistently found risk factor-Important to do mental status screening before the surgical

procedure

Medical illness should also be treated/ controlled


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Risk for Post-op deliriumPatient-centered risk in cardiac surgery: Risk scale in cardiac surgery (Rudolph et al.,2009), in

patients at least 60 yrs old:

prior history of CVA/ TIA (1 point) Mini Mental Status Exam (MMSE) score (4: 1 point)

Increasing points- increased risk for delirium: 0 points (~10-20 %); 1 point (40-50%); 2 points (60-

70%); 3 or more points (80-90%)


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Surgical risk factors:

The procedure matters:

Highest reported rates in post-hip fracture andemergent surgery (20-70%), bilateral kneereplacements (Williams Russo et al, 1992) & vascularprocedures (25-50%); close to 50% incidence in

AAA repair (Schneider at al., 2002)

Post CABG- earlier studies report higher rates, butrecent studies report 10-30% incidences (Van derMast et al., 1996)

Occurs in minor surgery as well (1-4% in cataractsurgery; 7% in urologic- Summers et al., 1979; Chaudhuri etal, 1994; Milstein et al., 2002; Hamann et al., 2005;)


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Surgical risk factors:Other surgical factors:

blood loss and length of surgery associatedwith risk for delirium (Knill et al., 1991; Hofste et al., 1997;Marcantonio et al., 1998; Bucerius J et al., 2004; Yamagata et al., 2005;

Hamann et al., 2005))

waiting time for hip fracture surgery isassociated with delirium rates (Edlund et al., 1999;Duppils and Wikblad, 2000)

Controversy exists about other surgical factors: Intra-operative BP changes Effect of off-pump by-pass or hypothermic techniques in

cardiac surgery


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Anesthetic risk factors:Anaesthetic and other considerations:

Little evidence to suggest that either general or localanesthetics affect a persons chance of having delirium(Williams Russo et al., 1995), although there may be fewer othercomplications with use of local anesthetics (Rodgers et al., 2000)

Peri-operative pain has been found to correlate with post-

operative delirium (Lynch et al.,1998; Vaurio et al., 2006, Morrison et al.,2003)

Delayed ambulation associated with delirium risk(Kamel etal., 2003)

This continues to be an evolving field of research and newsedating agents (e.g. dexmedetomidine, an alpha2 agonist)may decrease delirium (Maldonado et al., Psychosomatics 2009; 50(3): 206-17


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Post-op factors:Non-operative, post-operative factors:

Surgical patients can also have medical problems,which need to be ruled out- e.g. post-op MI,infections, reactions to drugs, etc..

Pain or lack of pain medications, narcotics

Post-op MIs often do not present with pain

Unfortunately delirium is etiologically non-specific(can accompany virtually any condition)

Urinary retention, constipation


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Possible post-op factors:

Precipitating factors:

Precipitating agent- MULTIFACTORIAL- Can be caused by any of multiple noxious stimuli- non-specific:drugs, ANY medical illness, change of environment,

catheter and restraint use, ICU setting, surgical setting,sleep deprivation, pain, constipation, urinary retention,environmental change, etc..)

In 10-25% of cases there may not be an

underlying offender found (Dubos et al., 1996; Rudberg etal., 1997); this may be even higher in the hipfracture setting (Brauer et al., 2000)


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Possible Causes of delirium

I Watch Deathmnemonic for possible causes of delirium:

I : Infections

W : Withdrawal A: Acute Metabolic T: Toxins, drugs C: CNS pathology

H: Hypoxia

D: Deficiencies E: Endocrine A: Acute Vascular T: Trauma H: Heavy Metals

( American Psychiatric Publishing, Inc., www.appi.org. Adapted from Wise (1986)


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Delirium Prevention Hard facts: we dont know how to decrease the

complications related to delirium (e.g. functional

decline, LTC, death), once it has occurred, andstudies related to managing delirium are scarce

Once delirium occurs, interventions are less

effective & efficient.(Cole, M., Dementia and Geriatric CognitiveDisorders(1999), p. 406- 411; Cole, M. et al, CMAJ ( 2002), p. 753-759; Inouye, S.,Annals of Medicine (2000), p. 257-263, Holroyd-Leduc JM et al, CMAJ (2010); 182(5):465)

Consider preventative measures from thebeginning (especially if at high risk)


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Prevention of Delirium

Systematic reviews suggest multifaceted geriatricassessment programs (largely non-pharmacological)may new delirium or delirium length although

most trials are not RCTs (Cole et al., 1998, Tabet N et al., 2009, Holroyd-Leduc JM et al, 2010)

Before-after trials of nursing-based detection andprevention programs suggest they may be effective

in cognition and functional outcomes(Lundstrom et al, 1999; Milisen et al., 2001)

In a recent RCT there was a in incidence andduration of delirium in the group randomized to a

multi-factorial intervention program (Lundstrom et al., 2007)


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Prevention of delirium Hospital Elder Life Program targets risk

factors for delirium (Inouye, S. et al, NEJM (1999), p. 669-676):

Cognitive impairment e.g. orient patients

Sleep deprivation e.g. keep environment quiet at night

Immobility- e.g. mobilize

Visual impairment e.g. provide glasses Hearing impairment e.g. provide hearing aids

Dehydration watch for and treat dehydration

Other studies also support the benefit ofnon-pharmacologic approaches (Vidan et al., J AmGeriatr Soc 2009; 57: 2029-36)


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Management of Delirium

First line intervent ions are non-pharmacolgical

Identify and treat the medical cause(s) of thedelirium

Modify the environment & use behaviouralstrategies to address responsive behaviours suchas:

Re-orientate and reassure patient that s/he is safe Talk slowly and calmly, use short simple sentences and

instructions

Distract to a topic s/he likes

Keep patient safe from self harm or harm to others

Educate the patient and family about their delirium


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Assessment & Management of Delirium

Determine and treat the underlyingprecipitant:

Multiple studies suggest that plurality of causation is commonin delirium- often 3 causes found (Francis et al., 1990; Rudberg et al.,1997)

Contributing factors can include:

on-going acute medical conditions- e.g. hepatic or renalfailure, adverse drug reactions, dehydration (Lawlor et al.,2000)

less medically acute, care-related, potentiallymodifiable causes (Francis et al.,1990; Inouye 1999; Brauer et al.,2000):

E.g. urinary retention, constipation, foley catheters, the useof restraints, sensory deprivation, excessive immobility, andenvironmental disturbances


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Assessment & Management of Delirium

Delir ium the medical work-up:

The work up of delirium is largely empiric

American Psychiatric Association PracticeGuidelines, 1999- consensus basedmanagement approach (Am J Psychiatry May 1999; 156(5): 1-20)

Recommend delirious individuals undergo basiclaboratory work-up: lytes, glucose, calcium, albumin,BUN, Creat, AST, ALT, bili, alk phos, Mg, PO4, CBC,EKG, CXR, ABGs (O2 sats), U/A (?Troponin in ORsetting?)

If clinical uncertainty persists consider: Urine C &S,Urine drug screen, VDRL, heavy metal screen, B12 andfolate, ANA, urinary porphyrins, NH4, HIV, blood C & S,serum drug levels, LP, CT/MRI, EEG


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Assessment and Management of Delirium

Determine underlying precipitant:

Use I WATCH DEATH mnemonic

Easy things to check for: Have they moved their bowels? Have they been toileted (is there urinary retention)? Are they on restraints, or other invasive devices

(catheters)? Check their MARS for drugs potentially causing delirium

Drugs: Anticholinergics, psychotropics: TCAs, gravol,

benzodiazepines, even neuroleptics (e.g. Olanzepine),antidepressants, narcotics (never give Demerol)

Case reports suggest diverse drugs can be associatedwith delirium (e.g. quinolones, digoxin)- so considerd/cing what you dont need


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Determine underlyingprecipitant:

Studies suggest CNS causes rarelycause for delirium (Francis J et al., JAMA 1990;263: 1097-1101)

Advanced cancer may an exception(without known CNS mets) where

meningeal involvement has beendescribed in 5-20% of cases (Lawlor etal., 2000; Olofsson et al. 1996; Tuma et al., 2000)


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Modify the environment and behaviouralapproaches: bedside manner matters-

Try to re-orient delirious person

Talk calmly and slowly. Give one step requests to avoidoverwhelming person.

Provide glasses and hearing aids

Place familiar objects in room

Too much/too little sensory stimulation?

Modify your approach. Try to do task later when patient not

resistive.

Encourage family to spend time with delirious individual(unless this worsens things)


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Non-pharmacologic management

Keeping patients safe- preventcomplications:

Are they eating/ drinking/ aspirating?

Consider hydration with IVFs, prevent renal compromise/failure & electrolyte imbalance, watch for aspirationpneumonia (?SLP consult?)

Are they mobilizing- will prevent deconditioning & pressureulcers and will help with lung status

Consult PT prn If not contraindicated, mobilize and get up in chair TID

Are they restrained? Do they have unnecessary foleycatheters? (both can aggravate their delirium)

Consider discontinuing. Follow Restraint policy if restrained.

Are they a fall risk? Use fall prevention strategies & monitor for falls


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Non-pharmacologic management

Non-pharmacologic approaches canduration of, or complications of delirium:

A RCT done in the ICU showed early mobilizationdecreased the duration of delirium (Schweickert et al.,Lancet 2009; 373: 1874-82)

Multifaceted intervention studies suggest that

complications can be prevented: e.g. fewer days of delirium, less delirium, and fewer

falls, in both delirious and non-delirious individuals,lower post-op LOS (Lundstrom M, et al. Aging-Clinical &Experimental Research, 2007; 19 (3): 178-86)


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Other management approaches (drugs):

Pharmacological treatments - Not alwaysrequired:

No evidence that medications alter complications relatedto delirium

No RCTs demonstrate the benefit of psychotropics innon-alcohol withdrawl delirium (Crit Care Med 2010; 38: 428-37)

Benzodiazepines can cause paradoxical agitation Other psychotropics can contribute to delirium and can

have other significant side effects.

Constant observation more effective than restraints, or

sedation to keep patient safe.


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Pharmacological Interventions:

Avoid psychotropic medications when possible

If agitation occurs: Speak with allied healthcare professionals to identify

(and avoid if possible) triggers Modify environment and/or care approach. Flex care

In absence of psychotic symptoms or causingdistress, or harmful behaviours, treatment ofdelirium with psychotropic medication is notrecommended.

Psychotropic medication to control wanderingis NOT recommended.


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When to use drugs? Reserve psychotropic medications for

older persons w ith delirium w ho aredistressed due to agitation orpsychotic symptoms in order:

To carry out essentialinvestigations or treatment.

To prevent delirious older personfrom endangering themselves or

others.CCSMH National Guidelines for Seniors Mental Health:The Assessment and Treatment of Delirium (2006), p.16)


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When psychotrophic medication used:

Aim for monotherapy, lowest effective dose andtaper as soon as possible

Monitor for any side effects- (CCSMH National Guidelines forSeniors Mental Health: The Assessment and Treatment of Delirium (2006),

p.16)

e.g. arm/leg tone, neuroleptic malignant syndrome,postural BPs drops (seroquel) and QTc interval

Use medication with low side-effect profile.

Titrate with very small increments

Trial for short periods, re-evaluate need for drugsregularly



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Pharmacological Interventions: Few studies to determine optimal doses of anti-psychotics in

treatment of delirium.

Anti-psychotics drug of choice in treatment of delirium (Ozbolt et al.,2008).

No RCTs to show us that psychotropics improve outcomes fordelirium

Haloperidol (typical antipsychotic) suggested as anti-psychotic ofchoice and continues to be first line agent for treatment ofsymptoms of delirium.

Starting dose of Haldol: 0.25-0.5 mg PRN, increase gradually asneeded

Use of benztropine and related medications should be avoided indelirium due to anti-cholinergic effects, and should not be started asprophylaxis with haloperidol. (CCSMH National Guidelines for Seniors MentalHealth:The Assessment and Treatment of Delirium(2006), p.42)


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Pharmacological Interventions-

Neuroleptics:

A recent RCT suggested that haldolprophylaxismay delirium duration and length of hospital stay in individualswithout delirium pre-operatively, prior to hip surgery, if theyare at increased risk for delirium (Kalisvaart et al., 2005)

Given the possible toxicity of neuroleptic use, caution should beexerted, and these results should be verified beforeprophylactic use becomes recommended

The effect on long or short term functional outcomes is

unknown


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Atypical anti-psychotics: reasonable alternative agents for older persons

with delirium due to fewer EPS side effect(consider especially for individuals sensitive to

dopamine- e.g. Parkinsons disease, Lewybody dementia).

Slight increase risk of stroke and all-causemortality with atypical anti-psychotics in

persons with dementia.(CCSMH National Guidelines for Seniors Mental Health: The Assessment and

Treatment of Delirium (2006), p.43)


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Atypical anti-psychotics (contd)

Clozapine for delirium not recommended because ofpossible serious hematologic side effects.

Studies limited risperidone- most evidence amongatypicals in treating symptoms of delirium in adultpopulation

Risperidone produces less sedation and negligible anti-cholinergic effects

Quetiapine has fewer parkinsonian side effects but cancause drowsiness and postural BP drops

(CCSMH National Guidelines for Seniors MentalHealth: The Assessment andTreatment of Delirium(2006), p.43)


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Olanzapine can produce over-sedation and gaitdisturbances, and may have anti-cholinergic side effects,especially at higher doses (Breitbart et al., 2002)

Concerns about weight gain, glucose dysregulation andhypercholesterolemia likely less with short duration oftreatment; however, use with caution in persons withdiabetes mellitus as there is risk of hyperglycemia

(CCSMH National Guidelines for Seniors Mental Health: TheAssessment and Treatment of Delirium (2006), p.43)


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Suggested initial dosing ranges (start low &go slow approach): Quetiapine:

Start at 6.25-12.5 mg OD-BID, for a few days ifperson is very frail and elderly

Monitor postural BP & P, and if stable, increase slowly

Risperidone 0.25 mg daily to bid

Olanzapine 1.25-2.5 mg daily


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Cholinesterase Inhibitors Increasing interest in use for treatment of

symptoms of delirium.

Case reports support use of rivastigmine in

lithium toxicity induced delirium and inprolonged delirium.

Promising, but more research needed to guide

clinical practice.(CCSMH National Guidelines for Seniors Mental Health: The Assessment and

Treatment of Delirium (2006),p.44)


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Pharmacological Management (contd)

Management of Alcohol Withdrawal Delirium (AWD):

Rule out other concurrent physical causes for delirium(CCSMH National Guidelines for Seniors Mental Health: TheAssessment and Treatment of Delirium (2006),p. 45)

Benzodiazepines as monotherapy are reserved for olderpersons with delirium caused by withdrawl from alcohol/sedative-hypnotics

Shorter acting benzodiazepines (i.e., lorazepam) agentsof choice in the elderly.

Anti-psychotics may be added if psychosis cannot beadequately controlled with benzodiazepines alone.

Taper Benzodiazepines following AWD rather than

abruptly stopping Give Thiamine(CCSMH National Guidelines for Seniors Mental Health: The Assessment and

Treatment of Delirium (2006),p. 17)

Delirium Conclusions:


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Delirium - Conclusions:

Delirium occurs in all specialties and healthcare sectors Surgical patients are often older with multiple medical

conditions

Delirium is one of the most common post-operativecomplications encountered

Risk/causes of post-op delirium can involve patient,operative, and post-op factors

Must obtain collateral history to obtain baseline mentalstatus, and use an interdisciplinary approach todiagnose and care for a delirious person

Management requires a systematic approach since

anything can contribute to delirium

l l


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Delirium - Conclusions: Preventive and non-pharmacologic interventions are

first line before pharmacological therapies

Little evidence presently that psychotropics improve

outcomes Psychotropics have well known side effects

Use psychotropics only when needed

Neuroleptics (haldol or Risperidone) in low doses for

aggression or psychosis; Quetiapine reasonable option Monitor tone & for NMS, postural hypotension, QTc interval

Start with low dose, increase slowly, constantly review needfor psychotropics and wean asap when delirium resolves

Benzodiazepines only indicated in specific cases-alcohol or benzodiazepine withdrawl


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Case 1

A 78 year old man is admitted for

elective AAA repair PMH: MI (3 years ago), DM II, OA

Meds: Glyburide, ASA, metoprolol,

tylenol #3 (typically takes 2 beforebed)

What is important to do/ask toassess his risk for post-op delirium?

C 2


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Case 2

A 67 year old man is admitted for electiveright knee replacement (arthorplasty)

PMH: AAA repair (with post-op delirium),CAD, MI (3 years ago), heavy EtOH usewith withdrawl, GERD, HTN

Possible h/o depression/ anxiety- startedon Nortryptiline 6 months ago (on 75 mgOD)

Although was independent in ADLs, wiferelays 6 month h/o memory decline (oncehe mistook his grand-dtr for his m-i-l)

C 2


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Case 2

Now 8 days post-op, and very

confused, hallucinating, requiringrestraints because of safety concerns(fear of falling)

When we saw him, he was restrainedand thought he was in a gay bar,and his speech was illogical and

nonsensical What would you do next?

C 2


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Case 2

MARS review- receiving lorazepam up to 6times per day (EtOH withdrawl initial

indication), on baclofen, tylenol 650 mgqid, nortryptiline 75 mg OD, norvasc,metoprolol

No BM in 8 days

Recent urinary retention

Recent labs otherwise WNL

What would you do now?

C 3


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Case 3-

Mrs. P- 76 year old woman on the Plasticsservice (s/p excision of facial SCC, seen 5

days post-op)- RFR- weakness, confusion,falls

Intermittent confusion throughout hospital

stay- e.g. called husband telling him I have to go to

the hospital

e.g. at times thought her husband was her

father C/O severe pain

C 3


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Case 3-

Collateral history-

declining STM for one and half years,worse in last 3-4 months (e.g.forgetting what she ate in the AM orwhere she went the day before)

declining ability to do certain IADLs(e.g. meal preparation) largely becauseof back pain

Case 3


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Case 3-

PMH: HTN, DM, CRF, severe DDD, h/oright parotid lymphoma (radiated 1999),

prior DVT x 2 Present drugs: tylenol PRN, percocet PRN

(not received in days), bromazepam 6 mg

QHS, ranitidine 150 mg OD, amlodipine7.5 mg, thyroxine 0.1 mg, detrol 1 mgBID, dyazide, multivits, glyburide,

amitryptiline 100 mg OD, metoprolol 75mg BID, coumadin

Case 3


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Case 3-

O/E- pleasant, alert and cooperative, notdepressed

Fatigued- with only partial co-operationwith cognitive testing- 7/10 on orientation,1/3 on 5 min recall, -1 on WORLD

backwards (attention), preseverative,problems misplacing hands on clock

Neuro- non-focal except for cognitiveproblems

Qs: What does she have? Would this have been expected?What next?

Selected References:


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Selected References: American Psychiatric Association, Diagnostic and statistical manual of

mental disorders, 4th ed. Washington, DC, 1994. American Psychiatric Association. (1999). The American Journal of

Psychiatry, (Supplement), 156(5).

American Psychiatric Publishing, Inc., www.appi.org. Adapted from Wise(1986)

Brauer C, Morrison RS, Silberzweig SB et al. The cause of delirium inpatients with hip fracture. Arch Intern Med. 2000; 160: 1856-60.

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Oct 6 - Postop Delirium in the Older Person (Brymer)