Part II: Assessment and Management of Delirium in Older Adults

DELIRIUM
Assessment to determine the Non-pharmacological Select high-risk medications 2 Communication/behavioural • Provide objects familiar to the older person to 5 Baseline and follow up ECG recommended with
cause(s) of delirium: management: contributing to delirium: management reduce disorientation. antipsychotics. For prolongation of QTc intervals Assessment and Treatment for
• Ensure the environment is safe for the patient and to >450 msec or a >25% increase over baseline, Older Adults
• Careful history with collateral information and a 1 Treat underlying Drug Class Examples
• To reduce the patient’s agitation, use behavioural consider cardiology consultation and
complete physical examination. management strategies to identify triggers and to for others. Based on:
predisposing/precipitating causes antipsychotic discontinuation. Canadian Coalition for Seniors’ Mental Health
• Special attention should be paid to those Sedative - • Benzodiazepines modify the person’s environment and/or delivery
• Treat all correctable contributing causes. hypnotics • Barbiturates of care. 6 Benzodiazepines can exacerbate delirium. Their (CCSMH) National Guidelines:
conditions and treatments (including medications) Pharmacological management use should be reserved for older persons with
• Withdraw all drugs (or taper when necessary) • Antihistamines (e.g., diphenhydramine) The Assessment and Treatment of Delirium
that might be contributing to delirium. • Provide for safety using the least restrictive
contributing to delirium whenever possible (or use measures. The use of restraints to control
of the symptoms of delirium: delirium caused by withdrawal from
• Routine investigations should be conducted unless Narcotics • Meperidine is particularly likely to precipitate alcohol/sedative-hypnotics.
lowest possible dose). See “High-Risk Meds” table. delirium, but any opioid can be implicated wandering or prevent falls is not justified. 1 The use of psychotropic medications to treat the
there are specific reasons not to perform them.
• If infection is suspected, start antibiotics promptly. symptoms of delirium should be reserved:
Drugs with • Oxybutynin • Encourage the presence of a family Antipsychotics commonly used in
• Ensure cardiovascular stability, adequate anticholinergic • Tolterodine member/friend (or consider a sitter) to help calm a) for patients in significant distress due to
Investigations usually indicated in effects • Antinauseants (antihistamines, antipsychotics) agitation or psychotic symptoms;
treating the symptoms of delirium:
oxygenation and electrolyte balance. and provide comfort to the patient.
• Promotility agents (e.g., metoclopramide)
persons with delirium: • Ensure hydration; monitor fluid intake and urinary • Tricyclic antidepressants (especially tertiary • Mobilize the patient as appropriate. b) in order to carry out essential investigations or Medication Suggested initial dosage
amine tricyclics agents such as amitriptyline, treatment; and/or
• Complete blood count (CBC) output. imipramine and doxepin) • Consider the need for language interpreters. Haloperidol 0.25 mg - 0.5 mg po od-bid
• Biochemistry – calcium, albumin, magnesium, • Monitor elimination patterns; rule out impaction • Antipsychotics (e.g., low potency neuroleptics c) to prevent older delirious persons from
such as chlorpromazine) • Use clear and simple communication. Avoid
phosphate, creatinine, urea, electrolytes, liver or urinary retention. endangering themselves or others. Risperidone 0.25 mg po od-bid
• Codeine confrontation and use distraction to minimize
function tests (ALT, AST, bilirubin, alkaline • Assess and monitor nutrition and skin integrity. • Cumulative effects of multiple medications
agitation. 2 When using psychotropic medications aim for
phosphatase), glucose with anticholinergic effects Olanzapine 1.25 mg - 2.5 mg po od Production of this pocket card has been made possible
monotherapy, the lowest effective dose and
• Identify and correct sensory deficits (e.g., hearing • Provide the older person and family with ongoing through a financial contribution from the Public Health
• Thyroid function tests (e.g., TSH) tapering as soon as possible. Quetiapine 12.5 mg - 50 mg po od Agency of Canada.
aids, eyeglasses). Histamine-2 • Cimetidine information about delirium.
blocking agents 3 Antipsychotics are the treatment of choice. For more information visit www.ccsmh.ca
• Blood culture • Assess and manage pain using safest 3 Environmental considerations Haloperidol, when used appropriately, is a
• Oxygen saturation or arterial blood gases interventions. Anticonvulsants • Mysoline This pocket card is intended for information purposes only
• Phenobarbitone • Avoid unnecessary room transfers and have reasonable choice for most patients. and is not intended to be interpreted or used as a standard
• Urine culture • Support normal sleep patterns and avoid the • Phenytoin consistency in staffing. Canadian Coalition for Seniors’ Mental Health of medical practice.
4 Atypical antipsychotics are alternative agents to
• Chest X-ray routine use of sedatives. www.ccsmh.ca © 2010 Canadian Coalition for Seniors’ Mental Health
• Use re-orientation strategies (e.g., clocks, haloperidol, and are preferred for patients who
Monitor the older person’s physiological Antiparkinsonian • Dopamine agonists
• Electrocardiogram (ECG) medications • Levodopa-carbidopa calendars). also have Parkinson’s Disease or Lewy Body Download free copies of the National Guideline on
condition/mental status. Evaluate response to care • Amantadine Dementia. the Assessment and Treatment of Delirium and other
• Provide appropriate lighting to reduce
provided and modify as indicated. • Anticholinergics (e.g., benztropine) evidence-based delirium resources.
misinterpretations and promote sleep.
Part I : Diagnosis, Prevention, Screening, Common Causes Key Messages

Core features of delirium based on Delirium subtypes: Interventions to prevent delirium: Screening instruments: Confusion Assessment Method (CAM): Common 1 Delirium is a common and serious condition encountered
Causes of in older persons. It is a medical emergency that
the DSM-IV criteria are: • Hyperactive: patients with this subtype are 1 Avoid/discontinue inappropriate or unnecessary • The Confusion Assessment Method (CAM) is Screening Tool for Delirium (a summary)
Delirium Examples needs to be identified and managed quickly.
1 Disturbance of consciousness (i.e., reduced clarity restless, agitated, hyperalert, often psychotic medications. recommended as a delirium screening instrument The diagnosis of delirium by CAM requires the
Drug-induced (see “High-Risk Meds” table on reverse) 2 Delirium often has multifactorial etiology with
of awareness of the environment) with reduced (delusions, hallucinations), and can be 2 Use a standardized and staged approach to and diagnostic aid (see CAM table). Other presence of BOTH features A and B predisposing, precipitating and perpetuating factors.
ability to focus, sustain, or shift attention; aggressive. control pain, with judicious analgesic suggested assessment tools that can be used by A Is there evidence of an acute change in Alcohol and drug Alcohol, sedative-hypnotics
health care providers with appropriate training 3 Delirium can often be prevented. Awareness of
• Hypoactive: patients with this subtype appear prescription. Acute onset and mental status from patient baseline? Does withdrawal (see “High-Risk Meds” table on reverse)
2 Change in cognition (such as memory deficit, its potentially modifiable risk factors is key to prevention.
lethargic, drowsy, sluggish, apathetic, quiet, include: fluctuating course the abnormal behaviour:
disorientation, language disturbance) or the 3 Support normal sleep patterns and avoid the • Come and go? Post-operative Cardiac surgery, orthopaedic surgery 4 Delirium is often not recognized or is
development of a perceptual disturbance that is respond slowly to questions, have decreased routine use of sedatives. • To provide information to help inform the • Fluctuate during the day? delirium misdiagnosed as dementia or depression.
spontaneous movement and seem sedated. completion of the CAM: • Increase/decrease in severity?
not better accounted for by a pre-existing, Systematic screening and/or prompt assessment of
4 Regulate bowel/bladder function; avoid Infections Lower respiratory tract infection, urinary suggestive symptoms in populations at risk could
established or evolving dementia; and • Mixed: patients with this subtype present with a Mini-Mental Status Examination (MMSE) B Does the patient:
indwelling catheters. ■
tract infection increase the rate of detection and the timely
mixture of hyperactive and hypoactive Inattention • Have difficulty focusing attention?
3 The disturbance develops over a short period of Delirium Symptom Interview management of delirious older persons.
characteristics. 5 Promote early detection and management of ■ • Become easily distracted?
time (usually hours to days) and tends to fluctuate • Have difficulty keeping track of what is Fluid-electrolyte Dehydration/hypovolemia
post-operative complications. • To measure the severity of delirium or to monitor disturbance 5 Delirium can often be reversed with proper
during the course of the day. said?
assessment and treatment.
6 Follow a least restraint approach to minimize the its course:
Delirium can occur as a consequence of a general Subsyndromal Delirium (SSD): AND the presence of EITHER feature C or D Metabolic Uremia, hepatic encephalopathy, 6 An interdisciplinary approach is required for the
use of restraints. ■ Delirium Rating Scale R-98 endocrine hypo/hyperglycemia, hypo/hyperthyroidism,
medical condition, substance intoxication, substance C Is the patient’s thinking: effective management of an older delirious person.
withdrawal, due to multiple etiologies, or from other This is a condition in which a person has one or more 7 Encourage mobility. ■ Delirium Index (DI) Disorganized • Disorganized
adrenal insufficiency, hypercalcemia
of the symptoms of delirium but does not meet the full thinking • Incoherent 7 Established effective care of the older person with
causes (e.g., sensory deprivation). It is not always 8 Promote early recognition of dehydration • To help assess alcohol withdrawal delirium: Cardiopulmonary- Congestive heart failure/pulmonary delirium includes:
possible to establish the specific etiology in an older criteria of a DSM-defined delirium. Their outcomes • For example, does the patient have:
hypoperfusion edema, shock, respiratory failure
coupled with efforts to maintain hydration. The Clinical Institute Withdrawal Assessment ■ Rambling speech/irrelevant conversation? • addressing the underlying cause(s);
person. are intermediate between those with delirium and ■
■ Unpredictable switching of subjects?
and/or hypoxia
those without delirium. Research suggests that 9 Provide supplemental oxygen for hypoxia. for Alcohol (CIWA-Ar) ■ Unclear or illogical flow of ideas? • anticipating, planning and taking steps to prevent
patients with subsyndromal delirium require careful Intracranial Stroke, closed head injury, cerebral edema, common complications;
10 Ensure adequate nutritional intake. • To help collect collateral information on baseline subdural hematoma, meningitis, seizures
monitoring. cognitive impairment: D Overall, what is the patient’s level of • assessing and managing behavioural symptoms;
11 Provide reorientation and/or cognitively Altered level of consciousness:
stimulating activities. ■ The Informant Questionnaire on consciousness • Alert (normal) Sensory/ Visual/hearing impairment, physical • alleviating patient distress;
• Vigilant (hyper-alert) environmental restraint use, bladder catheter use, settings
Cognitive Decline in the Elderly (IQCODE) (acute care, especially ICU) • ensuring safety; and
12 Identify the need for sensory aids (e.g., • Lethargic (drowsy but easily roused)
eyeglasses, hearing aids) and ensure their The results from screening tools must be interpreted within a • Stuporous (difficult to rouse) • making every effort to preserve functional abilities
clinical context and do not in themselves result in a • Comatose (unrousable) Vulnerable patients (e.g., those with dementia or severe and mobility.
availability.
diagnosis of delirium. In more complex cases, practitioners underlying illness) may develop delirium with a relatively
Copyright 2003, Sharon K. Inouye, M.D., MPH. Not to be reproduced without permission. Inouye SK et 8 The use of physical restraints should be minimized as
should consider additional measures to evaluate benign insult. Those at low vulnerabilty would require a
al. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann they can increase agitation and precipitate delirium in
neurocognitive status and referral to a specialist. more noxious insult.
Intern Med, 1990; 113: 941-948. CCSMH granted permission to reproduce CAM for this pocket card. those at risk.