Delirium in the Elderly: Recognition, Prevalence, Risk Factors, and Management, Slides of Geriatrics

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Delirium in the Elderly

Case Study

• Mrs. M. is a 70 year old woman with a history of thalamic CVA, bipolar illness, chronic pain, and osteoarthritis. She takes tylenol with codeine, valproate, lithium, conjugated estrogens with progesterone, and aspirin. Two months ago, her daughter died unexpectedly, and she has been more depressed. One week ago, she became agitated and uncooperative. She was seen in the ER, where labs and CXR were normal. A consulting psychiatrist recommended clonezapam.

Presentation of MI in the Elderly

AGE # CP SOB Neuro

65 387 19% 20% 33%

74 87 59% 22% 16%

76 777 66% 42% 30%

62 110 22% 35% 18%

Pathy 1967 Tinker 1981 Bayer 1986 Aronow 1987

Atypical Presentations

“Well Elderly” “Frail elderly”

% with atyp. present 25% 59%

Type of Presentation

Delirium 32% 61%

Falls 37% 9%

Immobility 5% 6%

Functional decline 26% 19%

Other 0 5%

Jarrett et al. Arch Int Med 1995

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

Prevalence

• Schor 1992 Medical & surgical >65 N=
  • 11% Prevalence, 31% incidence
• Johnson 1990 Medical >70 N=
  • 16% prevalence, 5% incidence
• Francis 1990 Medical >70 N=
  • 16% prevalence, 8% incidence
• Gufstafson 1988 Femoral neck Fx >65 N=
  • 33% prevalence before surgery, 42% incidence after

srugery

Delirium Risk Factors

• Age
• Cognitive impairment
  • 25% delirious are demented
  • 40% demented in hospital delirious
• 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:
    • Azotemia
    • Hypo- or hyperglycemia
    • Hypo- or hypernatrmiea
  • Depression
  • Alcoholism
  • Pain

Delirium Risk Model

0

2

4

6

8

10

12

High Low

Low

High

Low Intermediate High

Baseline Risk Group

Precipitating Factor Group

Incidence of delirium per day

Inouye JAMA 1996

Patient Factors + Extrinsic Factors

Clinical Prediction Rule for Post-surgical

Delirium

• Total Points Risk of Delirium (incidence, validation cohort)
• 0 2
• 1 or 2 11
• 3 or more 50
  • Marcantonio et al. JAMA 1994 134-

Outcomes

• Death: 8% vs. 1%, 90 day mortality 11% vs. 3%

• Lengthened hospital stay: 12 days vs. 7 days

• Increased nursing home placement: 16% vs. 3%

• Functional decline

• Iatrogenesis

Francis J et al. JAMA 1990;263:1097. Levkoff SE et al. Arch Intern Med 1992;152: Pompei et al. JAGS 1994; 42: 809

Differential Diagnosis

• CNS pathology

• Dementia, particularly frontal lobe

• Other Psychiatric disorders

• Psychosis
• Depression: 41% misdiagnosed as depression Farrell Arch Intern Med 1995
• Bipolar disorder

• Aconvulsive status epilepticus

• Akathisia

• Overall, 32-67% missed or misdiagnosed

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

Diagnostic Tools

» Sensitivity Specificity

• CAM* .46-.92 .90.

• Delirium Rating Scale* .82-.94 .82-.

• Clock draw .87.

• MMSE (23/24 cutoff) .52-.87 .76-.

• Digit span test .34.

• *validated for delirium & capable of distinguishing delirium from dementia

Diagnosis

MMSE & Clock draw

-Not designed for delirium

-Useful at separating “normal” from

“abnormal”

-Not specific for distinguishing delirium

from dementia

-May be useful as change from baseline