- Last edited on June 28, 2020
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| == Prevalence == | == Prevalence == | ||
| - | The community prevalence of delirium is low, between 1 to 2%, but increases with age, rising to 14% in individuals older than 85 years. The prevalence is 10% to 30% in older individuals presenting to emergency departments, where the delirium is a result of a medical illness. Rates are highest in post-surgical (hip surgery), palliative care for advanced cancer (up to 80%), ICU (up to 70%) and dementia populations.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124165/|Brown, T. M., & Boyle, M. F. (2002). Delirium. Bmj, 325(7365), 644-647.]])] | + | * The community prevalence of delirium is low, between 1 to 2%, but increases with age, rising to 14% in individuals older than 85 years. |
| + | * The prevalence is 10% to 30% in older individuals presenting to emergency departments, where the delirium is a result of a medical illness. Rates are highest in post-surgical (hip surgery), palliative care for advanced cancer (up to 80%), ICU (up to 70%) and dementia populations.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124165/|Brown, T. M., & Boyle, M. F. (2002). Delirium. Bmj, 325(7365), 644-647.]])] | ||
| == Risk Factors == | == Risk Factors == | ||
| - | The development delirium can be due to multiple risk factors. Some of these risk factors are modifiable and thus a target in delirium prevention. **Up to 40% of cases of delirium are preventable.**[([[https://www.ncbi.nlm.nih.gov/pubmed/16648149/|Siddiqi, N., House, A. O., & Holmes, J. D. (2006). Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age and ageing, 35(4), 350-364.]])] In elderly patients, [[geri:dementia:home|dementia]] is the most common risk factor (in up to two-thirds of all cases of delirium). | + | * The development delirium can be due to multiple risk factors. Some of these risk factors are modifiable and thus a target in delirium prevention. **Up to 40% of cases of delirium are preventable.**[([[https://www.ncbi.nlm.nih.gov/pubmed/16648149/|Siddiqi, N., House, A. O., & Holmes, J. D. (2006). Occurrence and outcome of delirium in medical in-patients: a systematic literature review. Age and ageing, 35(4), 350-364.]])] |
| + | * In elderly patients, [[geri:dementia:home|dementia]] is the most common risk factor (in up to two-thirds of all cases of delirium). | ||
| <panel type="info" title="Delirium Risk Factors" no-body="true"> | <panel type="info" title="Delirium Risk Factors" no-body="true"> | ||
| - | ^ Modifiable Essentials ^ Modifiable Medical ^ Non-modifiable ^ | + | <mobiletable 1> |
| - | | • Sensory impairment (hearing or vision)\\ • Immobilization (catheters or restraints)\\ • Environment (for example, admission to an intensive care unit)\\ • [[pain-medicine:home|Pain]]\\ • Emotional distress\\ • Sustained sleep deprivation | • Medications (e.g. - [[addictions:sedative-hypnotics|sedative hypnotics]], narcotics, [[meds:toxidromes:anticholinergic-cholinergic|anticholinergic]] drugs, corticosteroids, polypharmacy, **[[addictions:alcohol|alcohol withdrawal]]** or other drugs)\\ • Acute neurological diseases (e.g. - acute stroke [usually right parietal], intracranial hemorrhage, meningitis, [[cl:0-autoimmune-encephalitis|encephalitis]])\\ • Ongoing illness (e.g. - **infection** (UTI), iatrogenic complications, acute illness, anemia, **dehydration** (often giving IV fluids will improve things), poor nutrition, trauma, fractures, HIV)\\ • Metabolic derangement\\ • Surgery | • [[geri:dementia:home|Dementia]] or cognitive impairment\\ • Advancing age (>65 years)\\ • History of delirium, stroke, neurological disease, falls or gait disorder\\ • Multiple comorbidities\\ • Male sex\\ • Chronic renal or hepatic disease | | + | | ^ Items ^ |
| + | ^ Modifiable Essentials | • Sensory impairment (hearing or vision)\\ • Immobilization (catheters or restraints)\\ • Environment (for example, admission to an intensive care unit)\\ • [[pain-medicine:home|Pain]]\\ • Emotional distress\\ • Sustained sleep deprivation | | ||
| + | ^ Modifiable Medical | • Medications (e.g. - [[addictions:sedative-hypnotics:home|sedative hypnotics]], narcotics, [[meds:toxidromes:anticholinergic-cholinergic|anticholinergic]] drugs, corticosteroids, polypharmacy, **[[addictions:alcohol:home|alcohol withdrawal]]** or other drugs)\\ • Acute neurological diseases (e.g. - acute stroke [usually right parietal], intracranial hemorrhage, meningitis, [[cl:0-autoimmune-encephalitis:home|encephalitis]])\\ • Ongoing illness (e.g. - **infection** (UTI), iatrogenic complications, acute illness, anemia, **dehydration** (often giving IV fluids will improve things), poor nutrition, trauma, fractures, HIV)\\ • Metabolic derangement\\ • Surgery | | ||
| + | ^ Non-modifiable | • [[geri:dementia:home|Dementia]] or cognitive impairment\\ • Advancing age (>65 years)\\ • History of delirium, stroke, neurological disease, falls or gait disorder\\ • Multiple comorbidities\\ • Male sex\\ • Chronic renal or hepatic disease | | ||
| + | </mobiletable> | ||
| </panel> | </panel> | ||
| - | ===== Diagnostic Criteria ===== | + | ===== DSM-5 Diagnostic Criteria ===== |
| - | <WRAP group> | + | |
| - | <WRAP half column> | + | |
| == Criterion A == | == Criterion A == | ||
| - | A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). | + | A disturbance in attention (i.e. - reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). |
| == Criterion B == | == Criterion B == | ||
| Line 25: | Line 29: | ||
| == Criterion C == | == Criterion C == | ||
| - | An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception). | + | An additional disturbance in cognition (e.g. - memory deficit, disorientation, language, visuospatial ability, or perception). |
| == Criterion D == | == Criterion D == | ||
| Line 31: | Line 35: | ||
| == Criterion E == | == Criterion E == | ||
| - | There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies. | + | There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. - due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies. |
| - | </WRAP> | + | |
| + | ==== Specifiers ==== | ||
| + | <WRAP group> | ||
| <WRAP half column> | <WRAP half column> | ||
| - | == Specifiers == | ||
| - | <accordion collapsed="false"> | ||
| <panel icon="fa fa-search-plus" size="xs" title="Specifiers"> | <panel icon="fa fa-search-plus" size="xs" title="Specifiers"> | ||
| **Specify if:** | **Specify if:** | ||
| Line 44: | Line 48: | ||
| * **Delirium due to multiple etiologies**: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect). | * **Delirium due to multiple etiologies**: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect). | ||
| </panel> | </panel> | ||
| + | </WRAP> | ||
| + | <WRAP half column> | ||
| <panel icon="fa fa-signal" size="xs" title="Severity Specifier"> | <panel icon="fa fa-signal" size="xs" title="Severity Specifier"> | ||
| **Specify if:** | **Specify if:** | ||
| Line 49: | Line 55: | ||
| * **Persistent**: Lasting weeks or months | * **Persistent**: Lasting weeks or months | ||
| </panel> | </panel> | ||
| + | |||
| <panel icon="fa fa-adjust" size="xs" title="Hyperactive or Hypoactive Specifier"> | <panel icon="fa fa-adjust" size="xs" title="Hyperactive or Hypoactive Specifier"> | ||
| **Specify if:** | **Specify if:** | ||
| Line 55: | Line 62: | ||
| * **Mixed level of activity**: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates. | * **Mixed level of activity**: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates. | ||
| </panel> | </panel> | ||
| - | </accordion> | ||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||
| ==== Hypoactive/Hyperactive/Mixed ==== | ==== Hypoactive/Hyperactive/Mixed ==== | ||
| - | Patients can present with hypoactive delirium, where they appear lethargic, somnolent, and sluggish. This is often not recognized as they do not cause a "disturbance," and may be mistakenly identified as depressed. In hyperactive delirium, patients are often agitated, hallucinating, and have inappropriate behaviour. Some patients can have a mixed delirium where they have a combination of both (fluctuations between agitation and lethargy).[([[https://www.ncbi.nlm.nih.gov/pubmed/16540616|Inouye, S. K. (2006). Delirium in older persons. New England journal of medicine, 354(11), 1157-1165.]])] | + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> |
| + | See also: **[[https://www.bmj.com/content/357/bmj.j2047|Hosker, C., & Ward, D. (2017). Hypoactive delirium. Bmj, 357, j2047.]]** | ||
| + | </alert> | ||
| + | |||
| + | * Patients can present with hypoactive delirium, where they appear lethargic, somnolent, and sluggish. This is often not recognized as they do not cause a "disturbance," and may be mistakenly identified as depressed. | ||
| + | * In hyperactive delirium, patients are often agitated, hallucinating, and have inappropriate behaviour. Some patients can have a mixed delirium where they have a combination of both (fluctuations between agitation and lethargy).[([[https://www.ncbi.nlm.nih.gov/pubmed/16540616|Inouye, S. K. (2006). Delirium in older persons. New England journal of medicine, 354(11), 1157-1165.]])] | ||
| ===== Screening ===== | ===== Screening ===== | ||
| Line 73: | Line 84: | ||
| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||
| + | |||
| <panel title="Delirium Screening Tools" no-body="true" footer="Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8."> | <panel title="Delirium Screening Tools" no-body="true" footer="Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med. 1990; 113:941-8."> | ||
| + | <mobiletable 1> | ||
| ^ Name ^ Rater ^ Description ^ Download ^ | ^ Name ^ Rater ^ Description ^ Download ^ | ||
| ^ Confusion Assessment Method (CAM) | Clinician | The Confusion Assessment Method (CAM) is a standardized evidence-based tool that allows clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings. It has a sensitivity of 94‐100% and specificity of 90‐95%.[([[https://www.ncbi.nlm.nih.gov/pubmed/2240918|Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: the confusion assessment method: a new method for detection of delirium. Annals of internal medicine, 113(12), 941-948.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/20716741|Wong, C. L., Holroyd-Leduc, J., Simel, D. L., & Straus, S. E. (2010). Does this patient have delirium?: value of bedside instruments. Jama, 304(7), 779-786.]])] See the {{ :cl:cam_training_guide.pdf |training guide}} for full instructions. | {{ :cl:cam_short.pdf |Short Version}} \\ {{ :cl:cam_critical_care.pdf |Critical Care Version}} | | ^ Confusion Assessment Method (CAM) | Clinician | The Confusion Assessment Method (CAM) is a standardized evidence-based tool that allows clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings. It has a sensitivity of 94‐100% and specificity of 90‐95%.[([[https://www.ncbi.nlm.nih.gov/pubmed/2240918|Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: the confusion assessment method: a new method for detection of delirium. Annals of internal medicine, 113(12), 941-948.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/20716741|Wong, C. L., Holroyd-Leduc, J., Simel, D. L., & Straus, S. E. (2010). Does this patient have delirium?: value of bedside instruments. Jama, 304(7), 779-786.]])] See the {{ :cl:cam_training_guide.pdf |training guide}} for full instructions. | {{ :cl:cam_short.pdf |Short Version}} \\ {{ :cl:cam_critical_care.pdf |Critical Care Version}} | | ||
| - | </panel> | + | </mobiletable></panel> |
| + | <callout icon="fa fa-lightbulb-o" type="success" title="Mnemonic"> | ||
| + | The mnemonic ''**AIDA**'' can be used to remember the core features of delirium. Remember you need features 1 //AND// 2, plus 3 //OR// 4 for an individual to be positive for delirium on the Confusion Assessment Method (CAM). | ||
| + | - ''**A**'' - **Acute and fluctuating** (a change from baseline, AND a change during the day) | ||
| + | * Is there evidence of an acute change in mental status from the patient’s baseline? | ||
| + | * Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase and decrease in severity? | ||
| + | - ''**I**'' - **Inattention** (difficulty focusing/keeping track, drifting off to sleep, easily distracted) | ||
| + | * Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said? | ||
| + | * Can use [[:cognitive-testing|cognitive tests]] of attention (forward digit span; backward digit span; months of the years backwards; spelling WORLD backwards; serial 7s) | ||
| + | - ''**D**'' - **Disorganized thinking** (incoherent, rambling, irrelevant, illogical, circumstantial, vague) | ||
| + | * Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? | ||
| + | - ''**A**'' - **Altered level of consciousness** (lethargic, vigilant, stuporous, drowsy, agitated) | ||
| + | * Overall, how would you rate the patient’s level of consciousness? (alert [normal], vigilant [hyperalert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [unarousable])? | ||
| + | </callout> | ||
| ===== Approach ===== | ===== Approach ===== | ||
| ==== History ==== | ==== History ==== | ||
| Line 99: | Line 125: | ||
| ==== DIMS-R ==== | ==== DIMS-R ==== | ||
| - | Before even considering pharmacologically managing delirium, always think about what could be //causing// delirium in the first place! First consider the **non-medical issues** that could cause an altered level of consciousness, including: [[pain-medicine:home|pain]], vision deficits, hearing deficits, hunger, constipation, or urinary retention. Then consider the medical etiologies below. In geriatric populations, also consider the [[geri:1-giants|geriatric giants]]. | + | Before even considering pharmacologically managing delirium, always think about what could be //causing// delirium in the first place! First consider the **non-medical issues** that could cause an altered level of consciousness, including: [[pain-medicine:home|pain]], vision deficits, hearing deficits, hunger, constipation (i.e., fecal loading), or urinary retention. Then consider the medical etiologies below. In geriatric populations, also consider the [[geri:1-giants|geriatric giants]]. |
| - | <callout icon="fa fa-lightbulb-o" type="success" title | + | <callout icon="fa fa-lightbulb-o" type="success" title="Mnemonic"> |
| - | ="Mnemonic"> | + | |
| The mnemonic ''**DIMS-R**'' can be used to remember the common causes of delirium and provide a structured approach: | The mnemonic ''**DIMS-R**'' can be used to remember the common causes of delirium and provide a structured approach: | ||
| - | <HTML><br><br></HTML> | + | \\ \\ |
| - | * ''**D**'' - **Drugs**: Is there a drug intoxication, or conversely, a drug withdrawal? Look for sedating medications, anticholinergic medications, and never forget [[addictions:alcohol|alcohol withdrawal]] | + | * ''**D**'' - **Drugs**: Is there a drug intoxication, or conversely, a drug withdrawal? Look for sedating medications, anticholinergic medications, and never forget [[addictions:alcohol:home|alcohol withdrawal]] |
| * ''**I**'' - **Infections**: Is the genitourinary system, chest, skin/soft-issue, or blood infected? If so, consider CXRs or further infectious work up if needed. | * ''**I**'' - **Infections**: Is the genitourinary system, chest, skin/soft-issue, or blood infected? If so, consider CXRs or further infectious work up if needed. | ||
| * ''**M**'' - **Metabolic**: Are there any changes to glucose, electrolytes, extended electrolytes, creatinine, liver enzymes, VBG CO2, TSH, or B12 that would reflect endocrinopathies, renal failure, or liver failure? | * ''**M**'' - **Metabolic**: Are there any changes to glucose, electrolytes, extended electrolytes, creatinine, liver enzymes, VBG CO2, TSH, or B12 that would reflect endocrinopathies, renal failure, or liver failure? | ||
| - | * ''**S**'' - **Structural**: Think about serious intracranial pathologies like stroke, hemorrhage, seizures, or neoplasms. [[neurology:investigations:neuroimaging:home|Neuroimaging]] may be required. | + | * ''**S**'' - **Structural**: Think about serious intracranial pathologies like stroke, hemorrhage, seizures, or neoplasms. Neuroimaging ([[neurology:ct-scan|CT]], [[neurology:mri|MRI]]) may be required. |
| * ''**R**'' - **Retention**: Is there fecal impaction or urinary retention? If so, consider abdominal X-rays, palpation, DRE, disimpaction. | * ''**R**'' - **Retention**: Is there fecal impaction or urinary retention? If so, consider abdominal X-rays, palpation, DRE, disimpaction. | ||
| </callout> | </callout> | ||
| + | ==== Causes ==== | ||
| + | A non-exhaustive list of potential causes for delirium include: | ||
| + | |||
| + | <panel type="info" title="Common Potential Causes of Delirium" subtitle="Gage L. and Hogan D.B. (2014). 2014 CCSMH Guideline Update: The Assessment and Treatment of Delirium. Toronto: Canadian Coalition for Seniors’ Mental Health" no-body="true" footer=""> | ||
| + | <mobiletable 1> | ||
| + | ^ Course of Delirium ^ Examples ^ Consider if: ^ | ||
| + | ^ Drug-induced | [[addictions:sedative-hypnotics:home|Sedative-hypnotics]], [[meds:toxidromes:anticholinergic-cholinergic|anticholinergics]], [[meds:opioids:home|opioids]], [[meds:mood-stabilizers-anticonvulsants:home|anticonvulsants]], [[meds:dopamine-agonists:home|anti-parkinsonian agents]] | The drug in question has central nervous system effects; a toxic level is documented or there is improvement with dose reduction or discontinuation; and, the time course coincides with the use of the drug. | | ||
| + | ^ Alcohol and drug withdrawal | [[addictions:alcohol:3-withdrawal|Alcohol]], [[addictions:sedative-hypnotics:3-withdrawal|benzodiazepines]] | Recent and long-term use of alcohol or sedative drug; evidence of withdrawal (e.g., autonomic hyperactivity, seizure) or improvement when the same or similar agent given; and, delirium occurs within week of cessation. | | ||
| + | ^ Post-operative delirium | - | Delirium occurs shortly after surgical procedure. | | ||
| + | ^ Infectious | Lower respiratory tract infection, urinary tract infection | Signs of infection present; infection is confirmed by cultures or other indicators; and, the temporal course coincides with the infection. | | ||
| + | ^ Fluid-electrolyte disturbance | Dehydration/hypovolemia ([[cl:hyponatremia|hyponatremia]]) | Clinical evidence of changes in hydration status present (e.g., history of GI losses, signs of hypovolemia/dehydration, signs of volume overload); abnormal laboratory studies (e.g., abnormal electrolytes, high urea/ creatinine ratio); and, temporal course coincides with the abnormality | | ||
| + | ^ Metabolic/endocrine | Uremia, [[cl:hepatic-encephalopathy|hepatic encephalopathy]], hypo/hyperglycemia, [[cl:thyroid-disorders|hypo/hyperthyroidism]], adrenal insufficiency, [[cl:hypercalcemia-hyperparathyroidism|hypercalcemia]] | The metabolic abnormality is known to induce a change in mental status; clinical and laboratory confirmation of the disturbance; and, the temporal course coincides with the disturbance. | | ||
| + | ^ Cardiopulmonary (hypoperfusion and/or hypoxia) | Congestive heart failure/pulmonary edema, shock, respiratory failure | Clinical evidence of a low cardiac output/hypotension or pulmonary compromise; laboratory or radiographic evidence of suspected abnormality (e.g., arterial blood gases); and, the time course coincides with cardiopulmonary disturbance. | | ||
| + | ^ Intracranial | [[geri:stroke|Stroke]], [[cl:tbi|traumatic brain injury]], cerebral edema, subdural hematoma, meningitis, [[neurology:approach-seizures|seizures]] | Clinical evidence of an intracranial process has occurred; laboratory or radiological evidence of the suspected abnormality; and, time course coincides with the disturbance. | | ||
| + | ^ Sensory/Environmental | Visual/hearing impairment, physical restraint use, bladder catheter use, settings (acute care, especially ICU) | There is evidence of a pre-existing dementia and/or significant auditory/visual disturbance; mental status improves with orienting stimuli; and, mental status worsens with recent environmental changes or occurs predominantly at night. | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| ==== Dementia, Depression, or Delirium? ==== | ==== Dementia, Depression, or Delirium? ==== | ||
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[geri:dementia:home|]]**, **[[mood:1-depression:geriatric|]]**, and [[cl:1-delirium|]]</alert> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| - | + | See also: **[[geri:dementia:home|]]**, **[[mood:1-depression:geriatric|]]**, and [[cl:1-delirium|]] | |
| - | In the geriatric population, it is important to differentiate between delirium, dementia, and depression, which can be difficult to distinguish.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124165/|Brown, T. M., & Boyle, M. F. (2002). Delirium. Bmj, 325(7365), 644-647.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535349/|Fong, T. G., Davis, D., Growdon, M. E., Albuquerque, A., & Inouye, S. K. (2015). The interface of delirium and dementia in older persons. The Lancet. Neurology, 14(8), 823.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/table/T1/?report=objectonly|Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature reviews neurology, 5(4), 210.]])] The prevalence of delirium superimposed on dementia ranges anywhere from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. The negative outcomes of these co-occuring conditions include accelerated and long-term cognitive, functional decline, institutionalization, re-hospitalization, and increased mortality.[([[https://www.ncbi.nlm.nih.gov/pubmed/12366629|Fick, D. M., Agostini, J. V., & Inouye, S. K. (2002). Delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society, 50(10), 1723-1732.]])] | + | </alert> |
| - | + | * In the geriatric population, it is important to differentiate between delirium, dementia, and depression, which can be difficult to distinguish.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1124165/|Brown, T. M., & Boyle, M. F. (2002). Delirium. Bmj, 325(7365), 644-647.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535349/|Fong, T. G., Davis, D., Growdon, M. E., Albuquerque, A., & Inouye, S. K. (2015). The interface of delirium and dementia in older persons. The Lancet. Neurology, 14(8), 823.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/table/T1/?report=objectonly|Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature reviews neurology, 5(4), 210.]])] The prevalence of delirium superimposed on dementia ranges anywhere from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. | |
| + | * The negative outcomes of these co-occurring conditions include accelerated and long-term cognitive, functional decline, institutionalization, re-hospitalization, and increased mortality.[([[https://www.ncbi.nlm.nih.gov/pubmed/12366629|Fick, D. M., Agostini, J. V., & Inouye, S. K. (2002). Delirium superimposed on dementia: a systematic review. Journal of the American Geriatrics Society, 50(10), 1723-1732.]])] | ||
| - | <panel type="info" title="A Comparison of Delirium, Dementia, and Depression" footer="Adapted from: Fong, T., et al. Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews Neurology 5.4 (2009): 210." no-body="true"> | + | <panel type="info" title="A Comparison of Delirium, Dementia, and Depression" subtitle="Adapted from: Fong, T., et al. Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews Neurology 5.4 (2009): 210." no-body="true"> |
| + | <mobiletable 1> | ||
| ^ ^ Delirium ^ Dementia ^ Depression ^ | ^ ^ Delirium ^ Dementia ^ Depression ^ | ||
| ^ Cardinal feature | Confusion and Inattention | Memory loss | Sadness, anhedonia | | ^ Cardinal feature | Confusion and Inattention | Memory loss | Sadness, anhedonia | | ||
| Line 134: | Line 177: | ||
| ^ Reversibility | Yes | Rarely | Yes | | ^ Reversibility | Yes | Rarely | Yes | | ||
| ^ EEG Findings | Moderate to severe background slowing | Normal or mild diffuse slowing | Normal (usually) | | ^ EEG Findings | Moderate to severe background slowing | Normal or mild diffuse slowing | Normal (usually) | | ||
| + | </mobiletable> | ||
| </panel> | </panel> | ||
| - | |||
| ===== Pathophysiology ===== | ===== Pathophysiology ===== | ||
| - | <callout type="tip" icon="true">Delirium should be thought of as a symptom, **not** a diagnosis. That is, you must recognize it and treat the //underlying// condition causing the delirium! Also don't forget that delirium is often multifactorial in etiology and therefore requires a multifactorial approach.</callout> | + | <callout type="tip" icon="true"> |
| + | Delirium should be thought of as a symptom, **not** a diagnosis. That is, you must recognize it and treat the //underlying// condition causing the delirium! Also don't forget that delirium is often multifactorial in etiology and therefore requires a multifactorial approach. | ||
| + | </callout> | ||
| + | |||
| + | <alert type="info" icon="fa fa-book fa-lg fa-fw"> | ||
| + | See also: | ||
| + | * **[[https://pubmed.ncbi.nlm.nih.gov/24206937/|Maldonado, J. R. (2013). Neuropathogenesis of delirium: review of current etiologic theories and common pathways. The American Journal of Geriatric Psychiatry, 21(12), 1190-1222.]]** | ||
| + | * **[[https://pubmed.ncbi.nlm.nih.gov/29278283/|Maldonado, J. R. (2018). Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. International journal of geriatric psychiatry, 33(11), 1428-1457.]]** | ||
| + | </alert> | ||
| - | One of the prevailing theories of the pathogenesis of delirium is acetylcholine deficiency.[([[https://www.ncbi.nlm.nih.gov/pubmed/24206937|Maldonado, J. R. (2013). Neuropathogenesis of delirium: review of current etiologic theories and common pathways. The American Journal of Geriatric Psychiatry, 21(12), 1190-1222.]])] | + | * One of the prevailing theories of the pathogenesis of delirium is acetylcholine deficiency.[([[https://www.ncbi.nlm.nih.gov/pubmed/24206937|Maldonado, J. R. (2013). Neuropathogenesis of delirium: review of current etiologic theories and common pathways. The American Journal of Geriatric Psychiatry, 21(12), 1190-1222.]])] |
| - | Acetylcholine plays an extensive role in attention and consciousness, and deficiencies are thought to result in the core symptoms of both hypoactive and hyperactive delirium. These symptoms include inattention, disorganized thinking, and hallucinations.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917793/|Hshieh, T. T., Fong, T. G., Marcantonio, E. R., & Inouye, S. K. (2008). Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 63(7), 764-772.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225129/|Ali, S., Patel, M., Jabeen, S., Bailey, R. K., Patel, T., Shahid, M., ... & Arain, A. (2011). Insight into delirium. Innovations in clinical neuroscience, 8(10), 25.]])] Dopaminergic excess, inflammation (via interleukin-1, interleukin-2, interleukin-6, TNF-α, interferon), chronic stress (resulting in hypercortisolism), and diurnal changes are also thought to be factors that lead to the development of delirium.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917793/|Hshieh, T. T., Fong, T. G., Marcantonio, E. R., & Inouye, S. K. (2008). Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 63(7), 764-772.]])] | + | * Acetylcholine plays an extensive role in attention and consciousness, and deficiencies are thought to result in the core symptoms of both hypoactive and hyperactive delirium. These symptoms include inattention, disorganized thinking, and hallucinations.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917793/|Hshieh, T. T., Fong, T. G., Marcantonio, E. R., & Inouye, S. K. (2008). Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 63(7), 764-772.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3225129/|Ali, S., Patel, M., Jabeen, S., Bailey, R. K., Patel, T., Shahid, M., ... & Arain, A. (2011). Insight into delirium. Innovations in clinical neuroscience, 8(10), 25.]])] Dopaminergic excess, inflammation (via interleukin-1, interleukin-2, interleukin-6, TNF-α, interferon), chronic stress (resulting in hypercortisolism), and diurnal changes are also thought to be factors that lead to the development of delirium.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2917793/|Hshieh, T. T., Fong, T. G., Marcantonio, E. R., & Inouye, S. K. (2008). Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 63(7), 764-772.]])] |
| ===== Investigations ===== | ===== Investigations ===== | ||
| == Baseline == | == Baseline == | ||
| - | Routine investigations include: CBC, electrolytes, BUN/Cr, Ca, Mg, phosphate, LFTs, glucose, TSH, oxygen saturation or ABGs, urinalysis, CXR, and ECG. | + | * Routine investigations include: |
| - | + | * Bloodwork | |
| - | == Neuroimaging == | + | * CBC, electrolytes, BUN/Cr, electrolytes (Na, Cl), extended electrolytes (Ca, Mg, phosphate), CK |
| - | Neuroimaging generally has low yield in detecting delirium. Only consider this if there are new focal neurologic signs, a history of head trauma (suggesting a subdural hemorrhage), infections (encephalitis), or if there is no identifiable cause or improvement. | + | * LFTs, lipase, albumin, troponin |
| - | + | * Random glucose, B12 | |
| - | == EEG == | + | * TSH, free T3, free T4 ([[cl:0-autoimmune-encephalitis:hashimotos|Hashimoto's]]) |
| - | In some settings, EEGs may be used to identify delirium. EEG features such as posterior dominant rhythm and visual analysis of EEG features have approximately 80% accuracy in differentiating delirious from non‐delirious patients[([[https://www.ncbi.nlm.nih.gov/pubmed/3285901|Trzepacz, P. T., Brenner, R. P., Coffman, G., & van Thiel, D. H. (1988). Delirium in liver transplantation candidates: discriminant analysis of multiple test variables. Biological psychiatry, 24(1), 3-14.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/17519320|Thomas, C., Hestermann, U., Walther, S., Pfueller, U., Hack, M., Oster, P., ... & Weisbrod, M. (2008). Prolonged activation EEG differentiates dementia with and without delirium in frail elderly patients. Journal of Neurology, Neurosurgery & Psychiatry, 79(2), 119-125.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/25166725|Van Der Kooi, A. W., Zaal, I. J., Klijn, F. A., Koek, H. L., Meijer, R. C., Leijten, F. S., & Slooter, A. J. (2015). Delirium detection using EEG. Chest, 147(1), 94-101.]])] EEGs may also be useful in identifying occult seizures and differentiate delirium from psychiatric disorders. | + | * Oxygen saturation or ABGs |
| + | * Imaging | ||
| + | * Chest X-Ray (CXR) (pneumonia) | ||
| + | * Abdominal X-Ray (fecal loading or constipation, especially in patients with dementia or confusion who cannot report this accurately) | ||
| + | * CT Head (acute stroke or intracranial abnormality) | ||
| + | * ECG | ||
| + | * Infectious etiology work up includes HIV, [[cl:neurosyphilis|syphilis]] (EIA), lactate | ||
| + | * Inflammatory work up, including CRP, [[cl:systemic-lupus-erythematosus|lupus]] (ANA , ESR, CRP) | ||
| + | * Urinalysis (cultures), [[meds:urine-drug-screen|urine drug screen]], urine/serum toxicology screen | ||
| + | ==== Neuroimaging ==== | ||
| + | * Neuroimaging generally has low yield in detecting delirium. Only consider this if there are new focal neurologic signs, a history of head trauma (suggesting a subdural hemorrhage), infections (encephalitis), or if there is no identifiable cause or improvement. | ||
| + | ==== EEG ==== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See main article: **[[neurology:eeg|]]** | ||
| + | </alert> | ||
| + | * EEGs may also be useful in identifying occult seizures and differentiate delirium from psychiatric disorders. | ||
| + | * Certain features on EEG have close to 80% accuracy in differentiating delirious from non‐delirious patients, including:[([[https://www.ncbi.nlm.nih.gov/pubmed/3285901|Trzepacz, P. T., Brenner, R. P., Coffman, G., & van Thiel, D. H. (1988). Delirium in liver transplantation candidates: discriminant analysis of multiple test variables. Biological psychiatry, 24(1), 3-14.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/17519320|Thomas, C., Hestermann, U., Walther, S., Pfueller, U., Hack, M., Oster, P., ... & Weisbrod, M. (2008). Prolonged activation EEG differentiates dementia with and without delirium in frail elderly patients. Journal of Neurology, Neurosurgery & Psychiatry, 79(2), 119-125.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/25166725|Van Der Kooi, A. W., Zaal, I. J., Klijn, F. A., Koek, H. L., Meijer, R. C., Leijten, F. S., & Slooter, A. J. (2015). Delirium detection using EEG. Chest, 147(1), 94-101.]])][([[https://pubmed.ncbi.nlm.nih.gov/10837097/|Jacobson, S., & Jerrier, H. E. E. G. (2000, April). EEG in delirium. In Seminars in clinical neuropsychiatry (Vol. 5, No. 2, pp. 86-92).]])] | ||
| + | * Slowing or dropout of the posterior dominant rhythm | ||
| + | * Reduced alpha wave frequency[([[https://pubmed.ncbi.nlm.nih.gov/7964803/|Binnie, C. D., & Prior, P. F. (1994). Electroencephalography. Journal of Neurology, Neurosurgery & Psychiatry, 57(11), 1308-1319.]])] | ||
| + | * Generalized theta or delta slow-wave activity | ||
| + | * Poor organization of the background rhythm and and diffuse slowing | ||
| + | * Loss of reactivity of the EEG to eye opening and closing | ||
| ===== Prevention and Treatment ===== | ===== Prevention and Treatment ===== | ||
| - | ==== Non-pharmacological ==== | + | <callout> |
| + | //"An exclusively reductionist, biomedical approach to this condition will not likely work"// | ||
| + | \\ | ||
| + | -- National Guidelines for Seniors’ Mental Health: The Assessment and Treatment of Delirium (2006)[([[https://ccsmh.ca/projects/delirium/|Canadian Coalition for Seniors' Mental Health (CCSMH)]])] | ||
| + | </callout> | ||
| + | |||
| + | ==== Non-Pharmacological ==== | ||
| In non-ICU setting patients, always start with non-pharmacological interventions first, both in the prevention and management of delirium.[([[https://www.ncbi.nlm.nih.gov/pubmed/10053175|Inouye, S. K., Bogardus Jr, S. T., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., & Cooney Jr, L. M. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England journal of medicine, 340(9), 669-676.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842841/|Holroyd-Leduc, J. M., Khandwala, F., & Sink, K. M. (2010). How can delirium best be prevented and managed in older patients in hospital?. Cmaj, 182(5), 465-470.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/22589080|Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., & Fuentes, P. (2012). Preventing delirium in an acute hospital using a non-pharmacological intervention. Age and ageing, 41(5), 629-634.]])] Multiple risk factors should be mitigated as suggested by the table below: | In non-ICU setting patients, always start with non-pharmacological interventions first, both in the prevention and management of delirium.[([[https://www.ncbi.nlm.nih.gov/pubmed/10053175|Inouye, S. K., Bogardus Jr, S. T., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., & Cooney Jr, L. M. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England journal of medicine, 340(9), 669-676.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2842841/|Holroyd-Leduc, J. M., Khandwala, F., & Sink, K. M. (2010). How can delirium best be prevented and managed in older patients in hospital?. Cmaj, 182(5), 465-470.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/22589080|Martinez, F. T., Tobar, C., Beddings, C. I., Vallejo, G., & Fuentes, P. (2012). Preventing delirium in an acute hospital using a non-pharmacological intervention. Age and ageing, 41(5), 629-634.]])] Multiple risk factors should be mitigated as suggested by the table below: | ||
| - | <panel type="info" title="Non-pharmacological Delirium Prevention" no-body="true" footer="Adapted from: Inouye, Sharon K., et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New England journal of medicine 340.9 (1999): 669-676."> | + | <panel type="info" title="Non-pharmacological Delirium Prevention" no-body="true" subtitle="Adapted from: Inouye, Sharon K., et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New England journal of medicine 340.9 (1999): 669-676."> |
| ^ Risk Factor ^ Intervention ^ | ^ Risk Factor ^ Intervention ^ | ||
| ^ Cognitive impairment | Orient the patient by having a clock, watch, or calendar. Have a board with team member names, a schedule, ongoing communication to reorient them (e.g. - remind the patient where they are, get a sitter, asking family members to stay, asking family to bring items that can keep patient occupied). Do therapeutic activities including: cognitively stimulating activities TID (e.g. - current events, word games, structured reminiscence [get them to recall events in the past]). | | ^ Cognitive impairment | Orient the patient by having a clock, watch, or calendar. Have a board with team member names, a schedule, ongoing communication to reorient them (e.g. - remind the patient where they are, get a sitter, asking family members to stay, asking family to bring items that can keep patient occupied). Do therapeutic activities including: cognitively stimulating activities TID (e.g. - current events, word games, structured reminiscence [get them to recall events in the past]). | | ||
| Line 170: | Line 248: | ||
| ==== Medication Review ==== | ==== Medication Review ==== | ||
| - | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See also: **[[geri:1-giants#beer-s-list|Geriatric Giants: Beer's List]]** and **[[geri:1-giants#beer-s-list|Geriatric Giants: STOPP/START Criteria]]**</alert> | + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> |
| + | See also: **[[geri:1-giants#beer-s-list|Geriatric Giants: Beer's List]]** and **[[geri:1-giants#beer-s-list|Geriatric Giants: STOPP/START Criteria]]** | ||
| + | </alert> | ||
| - | Medications that might be contributing delirium should be withdrawn whenever possible. Psychoactive medications, including those with anticholinergic effects, and/or drugs recently initiated or with a dosage change are more likely to be precipitants of delirium. If the medication cannot be withdrawn, the //lowest// possible dose should be used, or substituted with a similar but lower risk medication.[([[https://ccsmh.ca/national-guidelines-for-seniors-mental-health-project/|2014 CCSMH Guideline Update - Canadian Coalition for Seniors Mental Health]])] | + | * Medications that might be contributing delirium should be withdrawn whenever possible. Psychoactive medications, including those with anticholinergic effects, and/or drugs recently initiated or with a dosage change are more likely to be precipitants of delirium. |
| + | * If the medication cannot be withdrawn, the //lowest// possible dose should be used, or substituted with a similar but lower risk medication.[([[https://ccsmh.ca/national-guidelines-for-seniors-mental-health-project/|2014 CCSMH Guideline Update - Canadian Coalition for Seniors Mental Health]])] | ||
| + | |||
| + | <panel type="info" title="Selection of High Risk Medications That May Contribute to Delirium" subtitle="Gage L. and Hogan D.B. (2014). 2014 CCSMH Guideline Update: The Assessment and Treatment of Delirium. Toronto: Canadian Coalition for Seniors’ Mental Health" no-body="true" footer=""> | ||
| + | ^ Sedative-hypnotics | • [[meds:benzos:home|Benzodiazepines]]\\ • Barbituates\\ • Antihistamines (e.g. - [[meds:anticholinergic:diphenhydramine|diphenhydramine]]) | | ||
| + | ^ Narcotics | • Meperidine appears to be particularly likely to precipitate delirium | | ||
| + | ^ Drugs with anticholinergic effects | • Oyybutynin\\ • Tolteridine\\ • Anti-nauseants (antihistamines, antipsychotics)\\ • Promotility agents\\ • Tricyclic antidepressants (especially tertiary amine tricyclic agents such as amitriptyline, imipramine and doxepin)\\ • [[meds:antipsychotics:home|Antipsychotics]] (e.g. - low potency neuroleptics such as chlorpramazine)\\ • Cumulative effect of multiple medications with [[meds:toxidromes:anticholinergic-cholinergic|anticholinergic effects]] | | ||
| + | ^ Histamine-2 Blocking agents | • Cimetidine | | ||
| + | ^ Antiparkinsonian medications | • [[meds:dopamine-agonists:home|Dopamine agonists]]\\ • [[meds:dopamine-agonists:carbidopa-levodopa|Levodopa-carbidopa]]\\ • [[meds:dopamine-agonists:amantadine|Amantadine]]\\ • [[meds:toxidromes:anticholinergic-cholinergic|Anticholinergics]]\\ • [[meds:anticholinergic:benztropine|Benztropine]] | | ||
| + | ^ Anticonvulsants | • Mysoline\\ • Phenobarbitone\\ • [[meds:mood-stabilizers-anticonvulsants:phenytoin|Phenytoin]] | | ||
| + | </panel> | ||
| ==== Pharmacological ==== | ==== Pharmacological ==== | ||
| Line 178: | Line 268: | ||
| Pharmacologic management should only be used if the symptoms of delirium threaten the patient's own safety, the safety of others, or would result in the interruption of essential therapy. Always start low and go slow, even if other healthcare providers might insist on higher doses earlier. (Remember that no drug is currently approved by any regulatory agency for the treatment of hospital-associated delirium). | Pharmacologic management should only be used if the symptoms of delirium threaten the patient's own safety, the safety of others, or would result in the interruption of essential therapy. Always start low and go slow, even if other healthcare providers might insist on higher doses earlier. (Remember that no drug is currently approved by any regulatory agency for the treatment of hospital-associated delirium). | ||
| </callout> | </callout> | ||
| - | <callout icon="true" type="warning">Don't forget to order a baseline ECG for a [[meds:qtc|QTc]], especially if you are starting out with haloperidol.</callout> | ||
| - | Most studies have shown that haloperidol (at doses < 3.5 mg daily), risperidone, and olanzapine were all equally effective in managing delirium. There is no evidence that prophylactic or preventative pharmacologic treatment works.[([[https://jamanetwork.com/journals/jama/article-abstract/2673149?redirect=true|van den Boogaard, M., Slooter, A. J., Brüggemann, R. J., Schoonhoven, L., Beishuizen, A., Vermeijden, J. W., ... & Van der Voort, P. H. (2018). Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium: The REDUCE Randomized Clinical Trial. JAMA, 319(7), 680-690.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/31476766|Oh, E. S., Needham, D. M., Nikooie, R., Wilson, L. M., Zhang, A., Robinson, K. A., & Neufeld, K. J. (2019). Antipsychotics for Preventing Delirium in Hospitalized Adults. Annals of internal medicine, 171(7), 474-484.]])] There is some emerging evidence that [[meds:melatonin-agonist:melatonin|melatonin]] and melatonin agonists may be effective in the prevention and management of delirium.[([[https://www.ncbi.nlm.nih.gov/pubmed/20845391|Al‐Aama, T., Brymer, C., Gutmanis, I., Woolmore‐Goodwin, S. M., Esbaugh, J., & Dasgupta, M. (2011). Melatonin decreases delirium in elderly patients: a randomized, placebo‐controlled trial. International journal of geriatric psychiatry, 26(7), 687-694.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/24554232|Hatta, K., Kishi, Y., Wada, K., Takeuchi, T., Odawara, T., Usui, C., & Nakamura, H. (2014). Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA psychiatry, 71(4), 397-403.]])] | + | <callout icon="true" type="warning"> |
| + | Don't forget to order a baseline ECG for a [[meds:qtc|QTc]], especially if you are starting out with [[meds:antipsychotics:first-gen-typical:1-haloperidol|haloperidol]]. | ||
| + | </callout> | ||
| + | * Antipsychotic medications should not be used as standard treatment for delirium, and should only be considered for patients with delirium experiencing severe agitation or distress.[([[https://www.cmaj.ca/content/195/31/E1038|Reppas-Rindlisbacher, C., Wiesenfeld, L., & Stall, N. M. (2023). Antipsychotic medications for older adults with delirium admitted to hospital. CMAJ, 195(31), E1038-E1039.]])] | ||
| + | * Most studies have shown that haloperidol (at doses < 3.5 mg daily), risperidone, and olanzapine are all equally effective in managing delirium. | ||
| + | * There is no evidence that prophylactic or preventative pharmacologic treatment works.[([[https://jamanetwork.com/journals/jama/article-abstract/2673149?redirect=true|van den Boogaard, M., Slooter, A. J., Brüggemann, R. J., Schoonhoven, L., Beishuizen, A., Vermeijden, J. W., ... & Van der Voort, P. H. (2018). Effect of Haloperidol on Survival Among Critically Ill Adults With a High Risk of Delirium: The REDUCE Randomized Clinical Trial. JAMA, 319(7), 680-690.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/31476766|Oh, E. S., Needham, D. M., Nikooie, R., Wilson, L. M., Zhang, A., Robinson, K. A., & Neufeld, K. J. (2019). Antipsychotics for Preventing Delirium in Hospitalized Adults. Annals of internal medicine, 171(7), 474-484.]])] | ||
| + | * The adverse effects of antipsychotic medications include sedation, hypotension, falls, [[geri:parkinsons|parkinsonism]], [[meds:qtc|QT interval prolongation]] and aspiration pneumonia.[([[https://www.cmaj.ca/content/195/31/E1038|Reppas-Rindlisbacher, C., Wiesenfeld, L., & Stall, N. M. (2023). Antipsychotic medications for older adults with delirium admitted to hospital. CMAJ, 195(31), E1038-E1039.]])] | ||
| + | * If there are [[meds:qtc|QTc prolongation]] concerns, then lower-risk antipsychotics such as aripiprazole can also be used.[([[https://pubmed.ncbi.nlm.nih.gov/25514894/|Kirino, E. (2015). Use of aripiprazole for delirium in the elderly: a short review. Psychogeriatrics, 15(1), 75-84.]])] | ||
| + | * Antipsychotics if prescribed, should be at the lowest effective dose for the shortest possible duration and be reevaluated at or shortly after discharge.[([[https://www.cmaj.ca/content/195/31/E1038|Reppas-Rindlisbacher, C., Wiesenfeld, L., & Stall, N. M. (2023). Antipsychotic medications for older adults with delirium admitted to hospital. CMAJ, 195(31), E1038-E1039.]])] | ||
| + | * There is some emerging evidence that [[meds:melatonin-agonist:melatonin|melatonin]] and melatonin agonists may be effective in the prevention and management of delirium.[([[https://www.ncbi.nlm.nih.gov/pubmed/20845391|Al‐Aama, T., Brymer, C., Gutmanis, I., Woolmore‐Goodwin, S. M., Esbaugh, J., & Dasgupta, M. (2011). Melatonin decreases delirium in elderly patients: a randomized, placebo‐controlled trial. International journal of geriatric psychiatry, 26(7), 687-694.]])][([[https://www.ncbi.nlm.nih.gov/pubmed/24554232|Hatta, K., Kishi, Y., Wada, K., Takeuchi, T., Odawara, T., Usui, C., & Nakamura, H. (2014). Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA psychiatry, 71(4), 397-403.]])] | ||
| <panel type="info" title="Pharmacological Management of Delirium" no-body="true"> | <panel type="info" title="Pharmacological Management of Delirium" no-body="true"> | ||
| - | ^ Medication ^ Use ^ Recommended Dosing ^ Side Effects ^ Clinical Pearls ^ | + | <mobiletable 1> |
| - | ^ [[meds:antipsychotics:first-gen-typical:1-haloperidol|Haloperidol]] | First-line | 0.5‐1 mg PO/IM bid and q4h PRN | [[meds:antipsychotics:eps]] at higher doses (> 3mg), [[meds:qtc|QTc prolongation]], and [[meds:antipsychotics:nms-neuroleptic-malignant-syndrome|neuroleptic malignant syndrome]], somnolence, falls. | Both typical and atypical antipsychotics increase the risk of death and cerebrovascular events, compared with placebo in elderly patients (> 65 years) //with// dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/16319382|Wang, P. S., Schneeweiss, S., Avorn, J., Fischer, M. A., Mogun, H., Solomon, D. H., & Brookhart, M. A. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22), 2335-2341.]])] In the elderly with Parkinson's disease or Lewy Body Dementia, atypical antipsychotics are preferred. | | + | ^ Medication ^ Use ^ Recommended Dosing ^ Side Effects ^ Clinical Pearls ^ |
| - | ^ [[meds:antipsychotics:second-gen-atypical:1-risperidone|Risperidone]] | First-line | 0.5 mg BID | [[meds:antipsychotics:eps]] (less likely than typicals like haloperidol, but still a risk, especially at higher doses), [[meds:qtc|QTc prolongation]], [[meds:antipsychotics:nms-neuroleptic-malignant-syndrome|neuroleptic malignant syndrome]], somnolence, falls. | Both typical and atypical antipsychotics increase the risk of death and cerebrovascular events, compared with placebo in elderly patients (> 65 years) //with// dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/16319382|Wang, P. S., Schneeweiss, S., Avorn, J., Fischer, M. A., Mogun, H., Solomon, D. H., & Brookhart, M. A. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22), 2335-2341.]])] In the elderly with Parkinson's disease or Lewy Body Dementia, atypical antipsychotics are preferred. | | + | ^ [[meds:antipsychotics:first-gen-typical:1-haloperidol|Haloperidol]] | First-line | 0.5‐1 mg PO/IM bid and q4h PRN | [[meds:antipsychotics:eps]] at higher doses (> 3mg), [[meds:qtc|QTc prolongation]], and [[meds:antipsychotics:nms-neuroleptic-malignant-syndrome|neuroleptic malignant syndrome]], somnolence, falls. | Both typical and atypical antipsychotics increase the risk of death and cerebrovascular events, compared with placebo in elderly patients (> 65 years) //with// dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/16319382|Wang, P. S., Schneeweiss, S., Avorn, J., Fischer, M. A., Mogun, H., Solomon, D. H., & Brookhart, M. A. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22), 2335-2341.]])] In the elderly with Parkinson's disease or Lewy Body Dementia, atypical antipsychotics are preferred. | |
| - | ^ [[meds:antipsychotics:second-gen-atypical:3-olanzapine|Olanzapine]] | First-line | 2.5‐5 mg PO daily | Same as risperidone | Both typical and atypical antipsychotics increase the risk of death and cerebrovascular events, compared with placebo in elderly patients (> 65 years) //with// dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/16319382|Wang, P. S., Schneeweiss, S., Avorn, J., Fischer, M. A., Mogun, H., Solomon, D. H., & Brookhart, M. A. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22), 2335-2341.]])] In the elderly with Parkinson's disease or Lewy Body Dementia, atypical antipsychotics are preferred. | | + | ^ [[meds:antipsychotics:second-gen-atypical:1-risperidone|Risperidone]] | First-line | 0.5 mg BID | [[meds:antipsychotics:eps]] (less likely than typicals like haloperidol, but still a risk, especially at higher doses), [[meds:qtc|QTc prolongation]], [[meds:antipsychotics:nms-neuroleptic-malignant-syndrome|neuroleptic malignant syndrome]], somnolence, falls. | Both typical and atypical antipsychotics increase the risk of death and cerebrovascular events, compared with placebo in elderly patients (> 65 years) //with// dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/16319382|Wang, P. S., Schneeweiss, S., Avorn, J., Fischer, M. A., Mogun, H., Solomon, D. H., & Brookhart, M. A. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22), 2335-2341.]])] In the elderly with Parkinson's disease or Lewy Body Dementia, atypical antipsychotics are preferred. | |
| - | ^ [[meds:antipsychotics:second-gen-atypical:6-quetiapine|Quetiapine]] | First-line | 25 mg BID | Same as risperidone | Both typical and atypical antipsychotics increase the risk of death and cerebrovascular events, compared with placebo in elderly patients (> 65 years) //with// dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/16319382|Wang, P. S., Schneeweiss, S., Avorn, J., Fischer, M. A., Mogun, H., Solomon, D. H., & Brookhart, M. A. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22), 2335-2341.]])] In the elderly with Parkinson's disease or Lewy Body Dementia, atypical antipsychotics are preferred. | | + | ^ [[meds:antipsychotics:second-gen-atypical:3-olanzapine|Olanzapine]] | First-line | 2.5‐5 mg PO daily | Same as risperidone | Both typical and atypical antipsychotics increase the risk of death and cerebrovascular events, compared with placebo in elderly patients (> 65 years) //with// dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/16319382|Wang, P. S., Schneeweiss, S., Avorn, J., Fischer, M. A., Mogun, H., Solomon, D. H., & Brookhart, M. A. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22), 2335-2341.]])] In the elderly with Parkinson's disease or Lewy Body Dementia, atypical antipsychotics are preferred. | |
| - | ^ [[meds:benzos:4-lorazepam|Lorazepam]] | Second-line | 0.5‐1 mg PO q4h PRN | [[meds:paradoxical-reactions|Paradoxical reactions]], respiratory depression, sedation/somnolence, falls. | This may worsen or prolong delirium! Really should only be used for patients with alcohol withdrawal, or patients with antipsychotic sensitivity (i.e. - [[geri:parkinsons|]] or [[geri:dementia:lewy-body|]]) | | + | ^ [[meds:antipsychotics:second-gen-atypical:6-quetiapine|Quetiapine]] | First-line | 25 mg BID | Same as risperidone | Both typical and atypical antipsychotics increase the risk of death and cerebrovascular events, compared with placebo in elderly patients (> 65 years) //with// dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/16319382|Wang, P. S., Schneeweiss, S., Avorn, J., Fischer, M. A., Mogun, H., Solomon, D. H., & Brookhart, M. A. (2005). Risk of death in elderly users of conventional vs. atypical antipsychotic medications. New England Journal of Medicine, 353(22), 2335-2341.]])] In the elderly with Parkinson's disease or Lewy Body Dementia, atypical antipsychotics are preferred. | |
| + | ^ [[meds:benzos:4-lorazepam|Lorazepam]] | Second-line | 0.5‐1 mg PO q4h PRN | [[meds:paradoxical-reactions|Paradoxical reactions]], respiratory depression, sedation/somnolence, falls. | Lorazepam may worsen or prolong delirium! Although a recent network meta-analysis suggested the use lorazepam in delirium, this result cannot be generalized to routine clinical practice because the result was derived from only one study.[([[https://pubmed.ncbi.nlm.nih.gov/30810723/|Wu, Y. C., Tseng, P. T., Tu, Y. K., Hsu, C. Y., Liang, C. S., Yeh, T. C., ... & Carvalho, A. F. (2019). Association of delirium response and safety of pharmacological interventions for the management and prevention of delirium: a network meta-analysis. JAMA psychiatry, 76(5), 526-535.]])][([[https://pubmed.ncbi.nlm.nih.gov/31268505/|Neerland, B. E., Neufeld, K. J., & Slooter, A. J. (2019). Pharmacological management of delirium. JAMA psychiatry, 76(9), 983-983.]])]\\ Lorazepam should only be used for patients with alcohol withdrawal, or patients with antipsychotic sensitivity (i.e. - [[geri:parkinsons|Parkinson's]] or [[geri:dementia:lewy-body|Lewy Body]]) | | ||
| + | </mobiletable> | ||
| </panel> | </panel> | ||
| Line 196: | Line 296: | ||
| ==== Specialist Involvement ==== | ==== Specialist Involvement ==== | ||
| - | Proactive involvement with a specialist geriatrics consultation team may also play a role in reducing delirium in acute hospital settings.[([[https://www.ncbi.nlm.nih.gov/pubmed/11380742|Marcantonio, E. R., Flacker, J. N., Wright, J. R., & Resnick, N. M. (1999, September). Reducing delirium after hip fracture: A randomized trial. In Journal of the American Geriatrics Society (Vol. 47, No. 9, pp. S3-S3). 530 WALNUT ST, PHILADELPHIA, PA 19106-3621 USA: LIPPINCOTT WILLIAMS & WILKINS.]])] | + | * Proactive involvement with a specialist geriatrics consultation team may also play a role in reducing delirium in acute hospital settings.[([[https://www.ncbi.nlm.nih.gov/pubmed/11380742|Marcantonio, E. R., Flacker, J. N., Wright, J. R., & Resnick, N. M. (1999, September). Reducing delirium after hip fracture: A randomized trial. In Journal of the American Geriatrics Society (Vol. 47, No. 9, pp. S3-S3). 530 WALNUT ST, PHILADELPHIA, PA 19106-3621 USA: LIPPINCOTT WILLIAMS & WILKINS.]])] |
| + | |||
| + | ===== Delirium Myths ===== | ||
| + | <panel type="info" title="Delirium Myths" subtitle="Adapted from: Oldham, Mark A., et al. Responding to ten common delirium misconceptions with best evidence: an educational review for clinicians. The Journal of neuropsychiatry and clinical neurosciences 30.1 (2018): 51-57." no-body="true" footer=""> | ||
| + | <mobiletable 1> | ||
| + | ^ Misconception/Myth ^ Best Evidence ^ | ||
| + | ^ This patient is oriented to person, place, and time. They’re not delirious. | Delirium evaluation minimally requires assessing attention, orientation, memory, and the thought process, ideally at least once per nursing shift, to capture daily fluctuations in mental status.[([[https://pubmed.ncbi.nlm.nih.gov/28876970/|Oldham, M. A., Flanagan, N. M., Khan, A., Boukrina, O., & Marcantonio, E. R. (2018). Responding to ten common delirium misconceptions with best evidence: an educational review for clinicians. The Journal of neuropsychiatry and clinical neurosciences, 30(1), 51-57.]])] | | ||
| + | ^ Delirium always resolves. | Especially in cognitively vulnerable patients, delirium may persist for days or even months after the proximal “causes” have been addressed. | | ||
| + | ^ We should expect frail, older patients to get confused at times, especially after receiving pain medication. | Confusion in frail, older patients always requires further assessment. | | ||
| + | ^ The goal of a delirium work-up is to find the main cause of delirium. | Delirium etiology is typically multifactorial. | | ||
| + | ^ New-onset psychotic symptoms in late life likely represents primary mental illness. | New delusions or hallucinations, particularly nonauditory, in middle age or later deserve evaluation for delirium or another medical cause. | | ||
| + | ^ Delirium in patients with dementia is less important because these patients are already confused at baseline. | Patients with dementia deserve even closer monitoring for delirium because of their elevated delirium risk and because delirium superimposed on dementia indicates marked vulnerability. | | ||
| + | ^ Delirium treatment should include psychotropic medication. | The role of psychotropic medications in delirium remains unclear. They are best used judiciously, if at all, for specific behaviors or symptoms rather than delirium itself. | | ||
| + | ^ The patient is delirious due to a psychiatric cause. | Delirium always has a physiological cause. | | ||
| + | ^ It’s often best to let quiet patients rest. | Hypoactive delirium is common and often under-recognized. | | ||
| + | ^ Patients become delirious just from being in the intensive care unit. | Delirium in the intensive care unit, as with delirium occurring in any setting, is caused by physiological and pharmacological insults. | | ||
| + | </mobiletable> | ||
| + | </panel> | ||
| ===== Follow Up ===== | ===== Follow Up ===== | ||
| - | Delirium may serve as a marker for future cognitive decline and risk for future development of dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/10990515|Rahkonen, T., Luukkainen-Markkula, R., Paanila, S., Sivenius, J., & Sulkava, R. (2000). Delirium episode as a sign of undetected dementia among community dwelling elderly subjects: a 2 year follow up study. Journal of Neurology, Neurosurgery & Psychiatry, 69(4), 519-521.]])] Incomplete recovery from delirium (even after discharge from hospital) can be common, and patients may need weeks or months to gradually recover.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1079829/|Andrew, M. K., Freter, S. H., & Rockwood, K. (2005). Incomplete functional recovery after delirium in elderly people: a prospective cohort study. BMC geriatrics, 5(1), 5.]])] Some patients may have vivid recollections of their hospitaliation after an episode of delirium, and in some cases may develop [[trauma-and-stressors:ptsd|posttraumatic stress disorder]].[([[https://www.ncbi.nlm.nih.gov/pubmed/17727586|Roberts, B. L., Rickard, C. M., Rajbhandari, D., & Reynolds, P. (2007). Factual memories of ICU: recall at two years post‐discharge and comparison with delirium status during ICU admission–a multicentre cohort study. Journal of Clinical Nursing, 16(9), 1669-1677.]])] Thus close post-discharge follow up and monitoring should be done for high-risk patients. | + | * Delirium may serve as a marker for future cognitive decline and risk for future development of dementia.[([[https://www.ncbi.nlm.nih.gov/pubmed/10990515|Rahkonen, T., Luukkainen-Markkula, R., Paanila, S., Sivenius, J., & Sulkava, R. (2000). Delirium episode as a sign of undetected dementia among community dwelling elderly subjects: a 2 year follow up study. Journal of Neurology, Neurosurgery & Psychiatry, 69(4), 519-521.]])] Incomplete recovery from delirium (even after discharge from hospital) can be common, and patients may need weeks or months to gradually recover.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1079829/|Andrew, M. K., Freter, S. H., & Rockwood, K. (2005). Incomplete functional recovery after delirium in elderly people: a prospective cohort study. BMC geriatrics, 5(1), 5.]])] Some patients may have vivid recollections of their hospitaliation after an episode of delirium, and in some cases may develop [[trauma-and-stressors:ptsd|posttraumatic stress disorder]].[([[https://www.ncbi.nlm.nih.gov/pubmed/17727586|Roberts, B. L., Rickard, C. M., Rajbhandari, D., & Reynolds, P. (2007). Factual memories of ICU: recall at two years post‐discharge and comparison with delirium status during ICU admission–a multicentre cohort study. Journal of Clinical Nursing, 16(9), 1669-1677.]])] Thus close post-discharge follow up and monitoring should be done for high-risk patients. |
| + | |||
| + | ===== Guidelines ===== | ||
| + | <alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success"> | ||
| + | See also: **[[teaching:clinical-practice-guidelines-cpg|]]** | ||
| + | </alert> | ||
| + | |||
| + | {{page>teaching:clinical-practice-guidelines-cpg#delirium&nouser&noheader&nodate&nofooter}} | ||
| ===== Resources ===== | ===== Resources ===== | ||
| Line 205: | Line 329: | ||
| <WRAP half column> | <WRAP half column> | ||
| == For Providers == | == For Providers == | ||
| - | * [[https://ccsmh.ca/national-guidelines-for-seniors-mental-health-project/|2014 CCSMH Guideline Update - Canadian Coalition for Seniors Mental Health]] | + | * [[https://www.cmaj.ca/content/195/31/E1038|Reppas-Rindlisbacher, C., Wiesenfeld, L., & Stall, N. M. (2023). Antipsychotic medications for older adults with delirium admitted to hospital. CMAJ, 195(31).]] |
| + | * **[[https://www.nature.com/articles/s41572-020-00223-4|Wilson, J.E. et al. Delirium. Nature Reviews Disease Primers 6, 90 (2020).]]** | ||
| * [[https://www.bcmj.org/articles/clarifying-confusion-about-confusion-current-practices-managing-geriatric-delirium|Chan, P. K. (2011). Clarifying the confusion about confusion: current practices in managing geriatric delirium. BCMJ, 53(8), 409-15.]] | * [[https://www.bcmj.org/articles/clarifying-confusion-about-confusion-current-practices-managing-geriatric-delirium|Chan, P. K. (2011). Clarifying the confusion about confusion: current practices in managing geriatric delirium. BCMJ, 53(8), 409-15.]] | ||
| - | * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/|Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature reviews neurology, 5(4), 210.]] | + | * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3065676/|Fong, T. G. et al. (2009). Delirium in elderly adults: diagnosis, prevention and treatment. Nature reviews neurology, 5(4), 210.]] |
| - | * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535349/|Fong, T. G., Davis, D., Growdon, M. E., Albuquerque, A., & Inouye, S. K. (2015). The interface of delirium and dementia in older persons. The Lancet. Neurology, 14(8), 823.]] | + | * [[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535349/|Fong, T. G. et al. (2015). The interface of delirium and dementia in older persons. The Lancet. Neurology, 14(8), 823.]] |
| - | * [[https://www.ncbi.nlm.nih.gov/pubmed/23989095|Peitz, G. J., Balas, M. C., Olsen, K. M., Pun, B. T., & Ely, E. W. (2013). Top 10 myths regarding sedation and delirium in the ICU. Critical care medicine, 41(9), S46-S56.]] | + | * [[https://www.ncbi.nlm.nih.gov/pubmed/23989095|Peitz, G. J. et al. (2013). Top 10 myths regarding sedation and delirium in the ICU. Critical care medicine, 41(9), S46-S56.]] |
| - | * [[http://www.bcmj.org/articles/delirium-older-adults-diagnosis-prevention-and-treatment|Wan, M., & Chase, J. M. (2017). Delirium in older adults: Diagnosis, prevention, and treatment. British Columbia Medical Journal, 59(3), 165-170.]] | + | * [[http://www.bcmj.org/articles/delirium-older-adults-diagnosis-prevention-and-treatment|Wan, M. et al. (2017). Delirium in older adults: Diagnosis, prevention, and treatment. British Columbia Medical Journal, 59(3), 165-170.]] |
| * [[https://www.pogoe.org/ask/antipsychotics|POGOe: What is the best choice of antipsychotic medications for delirium in the hospitalized elderly patient?]] | * [[https://www.pogoe.org/ask/antipsychotics|POGOe: What is the best choice of antipsychotic medications for delirium in the hospitalized elderly patient?]] | ||
| + | * [[https://help.agscocare.org/|AGS CoCare: HELP (Hospital Elder Life Program)]] | ||
| </WRAP> | </WRAP> | ||
| <WRAP half column> | <WRAP half column> | ||
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| </WRAP> | </WRAP> | ||
| </WRAP> | </WRAP> | ||
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