delirium evaluation and management - welcome to the …：谵妄评估和管理-欢迎来到…

Delirium in the Elderly,M. Andrew Greganti, MDMarch 19, 2009,Outline of Discussion,Case PresentationDistinguishing characteristics Prevalence Etiology/Pathogenesis/Risk FactorsProdrome Clinical PresentationDiagnosis/Evaluation Prognostic ImplicationsPrevention and Treatment,Case Presentation,86 yo woman presents with confusion post hip fracture surgery. Medical Problems:HypertensionCHF - compensated Sick sinus syndrome S/P pacemakerChronic atrial fibrillationChronic anxiety about health,Case Presentation,Long-term resident of life care community living in an intermediate care facilitySevere anxiety with tendency to obscess over health issues Increasing anxiety level recentlyLess intellectually “sharp” over previous 6 months,Hospital Course,In the ED could not understand that she had broken her hipNo immediate perioperative complications Postop day 2: Confused, agitated, waxing and waning of sensoriumDifficulty recognizing familyMisinterpreted environmental stimuli“Sundowning” requiring a sitter,Hospital Course,Hypoxia secondary to aspirationImproved post antibioticsConfusion and difficulty understanding directions - effective PT impossiblePoor hearing exacerbated confusion.,Hospital Course,After 10 days, cognition improved but not back to baselineDischarged to skilled nursing floor of her life care community with persisting:Confusion DisorientationSevere anxietyPoor recent memory,Post Hospital Course,Fell 2 months post discharge, fracturing R ankleSevere delirium postop marked by episodic yelling outNever returned to baseline: Intermittent confusion Somnolence followed by agitation Repetitive vocalizationsNo response to re-orientation partial response to clonazepam, then olanzapine,Characteristics of Delirium,Disturbance of consciousnessAbnormal attentionAbnormal cognitionOrientation MemoryThought processingExecutive functionPerceptionAcute in onset and fluctuating in coursePrecipitated by acute medical illness, medication, or substance intoxicationHyperactive, hypoactive, and mixed forms,Other Characteristics,Misdiagnosis is frequent unrecognized in up to 70%May develop over hours to days. Abrupt onset more common.The line between dementia and delirium is often unclear.,How common is delirium?,On admission to medical wards, 15 to 20% of older patients meet criteria for delirium.Incidence during medical hospitalization: 5 to 10% - in some studies 30%.Prevalence higher in surgical patients:10 to 15% post general surgery 30% post cardiac surgery50% post hip fractureVery common in terminally ill patients 90%,Etiology,Etiology - Multifactorial in a patient predisposed by underlying dementia:InfectionsToxins, including drugsSubstance withdrawalOrgan failure: heart, liver, kidney, etc.Metabolic derangementsPrimary brain disorders,Pathogenesis,No specific structural brain lesion identified but subcortical and cortical dysfunctionChanges in perfusion pressureDepleted acetylcholine Dopamine excessDopamine, GABA, serotonin, acetylcholine imbalanceCytokine activation,Risk Factors,Dementia: the strongest risk factor 25 to 75% Other predisposing brain diseases: stroke, ParkinsonsAdvanced ageSevere medical illnessMetabolic disturbances: Hyponatremia, dehydrationDrugs: anticholinergics, sedative hypnotics, narcotics,Other Risk Factors,Immobility, low activity levelHearing or vision impairmentNumber of hospital room changesEnvironmental high noise level,Prodrome,Patients may describe and/or manifest:Decreased concentrationIrritability, restlessness, anxiety, depressionHypersensitivity to light and soundPerceptual disturbancesSleep disturbance - daytime somnolence and nocturnal agitation,Clinical Presentation,Disorientation to place, time, situationImpaired consciousnessReduced awarenessReduced or clouded consciousness with or without overt hallucinations,Clinical Presentation,Decreased ability to focus, sustain, or shift attention Decreased selective attentionDistractibilityCognition is made worse by inattention.Speech: Tangential Poorly organizedSlowed, slurred Word finding difficulties: dysnomia, paraphasia, aphasia,Clinical Presentation,Impaired registration, recent/remote memory with associated confabulationPerceptual abnormalities: MicropsiaMacropsia Frank auditory or visual hallucinations, distortion of body imageMay take action in response to hallucinations,Diagnosis,History from family and/or caregiversBedside observationsDiagnostic errors are common in: Hypoactive form The setting of rapid fluctuations of cognition. Those with the patient the entire day (nurses) or less likely to be deceived.Reliable diagnostic instrumentsConfusion Assessment Method (CAM),Confusion Assessment Method,Are these features present?Acute onset and fluctuating courseInattention, distractibilityDisorganized thinking, illogical or unclear ideasAlteration in consciousness,Differential Diagnosis,DementiaAlzheimer dementiaLewy body dementiaDelusional psychosisPsychosis is associated with normal attention, orientation, and sleep/wake cycleSchizophrenia has a more chronic hx with highly systematized delusions.Depression and ManiaMisdiagnosed as depression in as many as 40% of cases,Evaluation,Search for causative medication is especially important up to 40% of cases.Psychotropics, narcotics, anticholinergicsDigoxin, prednisone, furosemide, cimetidine have anticholinergic properties.,Evaluation,CBC, electrolytes, BUN, Cr, glucose, LFTsO2 SaturationUrinalysisTSH, B12Toxin screenCXRCNS imaging LP in febrile patient with meningeal signsCause not identified in 15 to 25%,Prognosis,Delirium is independently associated with:Increased functional disability Increased LOS Admission to long-term careHospital mortality of 22 to 76% - one year mortality of 35 to 40% Highest in the hypoactive subtypeMay persist for months or indefinitely more likely in dementiaTwo factors related to better outcomes:Admission from homeBetter premorbid functioning,Preventive Measures,Supportive overall approach with constant reorientationEffective management of anxietyEffective management of painEarly mobilizationFocus on assuring optimal vision and hearing.Haloperidol and donepezil prophylaxis not effective,Treatment,Recognize and treat the prodromal stageFocus on re-orientation bedside sitterReduce or discontinue psychotropic, anticholinergic, sedative, and narcotic meds.Optimize nutrition. Physical therapy to increase mobility,Treatment,Nonpharmacologic measures:Increase interpersonal contact and environmental support. ? use of around the clock sittersProvide clocks, calendars, soft lighting.Place family pictures in clear view.Reduce noise levels.Maximize visual and auditory acuity.Minimize room changes in the hospital.,Treatment,Use medications only as a last resort:Antipsychotics: haloperidol Atypical antipsychotics: risperidone, aripiprazole, ziprasidone, quetiapine, olanzapineBenzodiazepines - lorazepam,Treatment,Future therapies:Cholinergic drugs: donepezil, rivastigmine, phy