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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