gc06-3 - Sundowning& Delirium Sundowning Francisco...

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Unformatted text preview: Sundowning & Delirium Sundowning Francisco Fernandez, M.D., USF Health, Francisco Department of Psychiatry, Tampa, FL Department www.thecjc.org Sundowning: Definition Sundowning: • • Sundowning a group of behaviors occurring in Sundowning some older patients with or without dementia at the time of nightfall or sunset. BEHAVIORS: • • • • • • Confusion Anxiety, agitation, or aggressiveness Anxiety, Psychomotor agitation (pacing, wandering) Disruptive, resistance to redirection Increased verbal activity Increased Overlap with dementia, delirium, and sleep Overlap disturbance. Epidemiology of Sundowning Syndrome Syndrome • • • Not uncommon phenomenon Exact prevalence unknown Exact Reports have ranged between Reports 2.4% and 25% 2.4% • In patients with Alzheimer’s disease In or dementia, the range is widened up to 66% to Risk Factors for Sundowning: Physiologic Factors Physiologic • Circadian abnormalities in elderly and in Circadian patients with Alzheimer’s disease progress concomitantly with their behavioral and cognitive dysfunction. • Sundowning is more common in AzD. Sundowning • Neurofibrillary tangles found in the hypothalamus of Neurofibrillary patients with Alzheimer’s may lead to the behavioral changes of sundowning through mechanical disruption of brain tissue. brain • Pathologic damage to the suprachiasmatic nucleus Pathologic (SCN) is believed to result in disruptive behaviors associated with sundowning. associated Risk Factors for Sundowning: Environmental Factors Environmental • • • • • • Amount of daily light Amount exposure exposure Activities during the Activities day day Noise level Disruptions at night Medications Medical Medical comorbidities comorbidities • Nursing home residents Nursing with sundowning were more likely to more • • • • Recent admission Moved to a new room Staff shift changes Low levels of lighting Low during the day and bright hallway lighting during the night the • Increased naptime during Increased daytime hours and reduced nighttime sleep reduced Etiology of Sundowning Etiology • Dysfunction of the circadian rhythm result in Dysfunction disturbed sleep and agitation disturbed • Deterioration of the SCN seen in patients with Deterioration Alzheimer’s disease is actively investigated to be an important factor in the disruption of the circadian rhythms. circadian • Suprachiasmatic nucleus volume and cell number Suprachiasmatic are found to be decreased in those between the ages of 80 and 100 years. • Melatonin is found to be decreased in the Melatonin cerebrospinal fluid levels of patients with Alzheimer’s disease. Alzheimer’s Mrs. Flabeetz Mrs. Flabeetz • • • 84 yo female, living at the NH for the last 8 years after a stroke; was having problems managing at home Axis III: Type II Diabetes and hypertension Active in her NH, using her walker; also a little more forgetful and repetitive, and this has been getting slowly worse over the last year In the ER… In the ER… • Came into ER after being found on the floor of the NH • Unable to get up and complaining of L hip and abdominal pain • In the ER, very muddled up & disoriented • incontinent of foul smelling urine • Picking at imaginary things, scared, and very frightened Initial work up… Initial work up… • No fracture on X­ray • Normal CBC, lytes and troponins • CT head shows mild atrophy & bilateral lacunar infarcts • Urine collected from foley inserted shows E. coli; started ABX • Admitted to Medicine for further assessment and work up of confusion Alas! It’s been 5 days later, and she’s still not better … TRANSFER TO PSYCHIATRY!!!!!!! What would you do? What would you do? Is this Delirium? Dementia?? Or something else??? Would you transfer to Psychiatry Service? Delirium • • Most common psychiatric disorder in the medically ill Point prevalence - 20% of all admissions • 30% new onset among medical inpatients • 50% medical and surgical patients > 60 yo • 89% of patients with known dementia • • • Higher prevalence with increasing age, CNS disease, Higher CABG, and THR CABG, NOT a benign condition - sign of impending death in NOT 25% cases 25% Etiology - multifactorial Rothschild et al, Arch Int Med 2000; Burns et al, JNNP 2004 Diagnostic Criteria: DSM-IV Diagnostic • Disturbance of consciousness (reduced Disturbance clarity of awareness of environment) • Reduced ability to focus, sustain or shift Reduced attention attention • A change in cognition (memory, change disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted by dementia by Diagnostic Criteria: DSM-IV Diagnostic • • The disturbance develops over a short The period of time (usually hours to days) All abnormalities tend to fluctuate during All the course of the day the Diagnostic Criteria: DSM-IV Diagnostic • There is evidence from the medical history, There physical examination, or laboratory findings of: 1. A general medical condition etiologically related 1. • Sepsis, seizures, tumor, hypercalcemia, hypoglycemia 1. Substance induced intoxication or withdrawal 2. More than one etiology More 3. NOS 3. “Motoric” Subtypes Various levels of psychomotor activity Various are associated with delirium: are 1. 2. 3. Hypoactive Hyperactive Mixed Characteristics Hypoactive Characteristics Hyperactive Age MMSE Digit span 54.3 (18.7) 13.6 (7.4) 13.6 4.1 (2.4) 5.7 (2.4) 59.4 (17.8) 13.2 (7.3) 13.2 4.6 (2.2) 5.6 (2.3) 5.4 (2.3) 3% 0% 3% 0% 0% 21% 2.4 (2.0) *** 67% *** 26% *** 50% *** 20%*** 20%*** 72% *** Clouding of Clouding Consciousness Consciousness Somnolence Hallucinations Illusions Delusions Paranoia Agitation Adapted from Ross et al., Int Psychoger 1991 “Motoric” Subtypes • • Subtyping not fully accepted by all Subtyping disciplines disciplines Subtyping may have implications for Subtyping treatment treatment Epidemiology & Risk Factors Epidemiology • Depending on the cohort, the Depending prevalence of delirium ranges from 8% to 80% to • Post-surgical rates > general medical Post-surgical patients patients • Advancing age increases the risk (> 60 Advancing yoa) yoa) • 15-20% of patients on a medical 15-20% surgical ward have an undetected delirious process delirious Burns et al, JNNP 2004; Kales et al, JNNP 2002; vanZyl & Davidson, Can J Psych 2003 Epidemiology and Risk Factors Factors • The Commonwealth-Harvard Study The (Levekoff et al., Int Psychoger, 1991) 1991) • • Patients 65 yoa or older Admissions to Beth Israel Hospital from Admissions Hebrew Rehabilitation Center (n=114) and East Boston CHC (n=211) East • CHC 24.2% were delirious CHC • HRC 64.9% were delirious HRC Epidemiology and Risk Factors Factors • CNS abnormality CNS • Dementia, coexisting structural brain disease, Dementia, and HIV-1 infection increase the risk and • Drug dependency • Alcohol, sedative hypnotics, stimulants, steroid Alcohol, (rapid taper) increase the risk (rapid • Low serum albumin Low • Malnutrition, chronic disease, aging, nephrotic Malnutrition, syndrome, hepatic insufficiency Why is Delirium important? Why Delirium has a poor prognosis • • • • • ⇑ ⇑ ⇑ ⇑ ⇑ LOS (>7d more) LOS risk dementia dx (55%/2y) risk ADL decline ADL institutionalization institutionalization mortality (2.1x/12 mos) mortality McCusker et al, JAGS 2003; McCusker et al, Arch Int Med 2002; Rahkonen et al, JNNP; Inouye et al, JGIM 1998 Delirium Risk : A Predictive model model • Independent risk factors on Independent admission in a prospective cohort of elderly medical inpts cohort 1. Vision < 20/70 Vision 2. Severe illness (APACHE > 16) 2. 3. MMSE <24 Inouye et al, Ann Int Med 1993 Diagnosis Diagnosis • Rapid recognition of either prodromal or Rapid fully developed clinical features fully • “A,B,C’s” of Neuropsychiatry (Affect, Behavior A,B,C’s” and Cognition) and • Prodromal features • Restlessness, anxiety, irritability, sleeplessness, Restlessness, hypervigilance, distractibility, fatigue, disinterest, hypersomnolence, inattentiveness, depressed, disillusionment disillusionment Diagnosing Delirium Diagnosing Delirium Sx Interview 1. Orientation 1. 2. Sleep disturbance 2. 3. Perceptual disturbance 3. 4. Speech disturbance 5. Disturbance of consciousness 5. 6. Psychomotor activity 6. 7. Affect & behavior 7. Albert et al, J Ger Psych Neurol 1992 Diagnosis: MSE Diagnosis: • Mental status examination Mental • Cognitive history chart review Cognitive • What changes (consciousness, restlessness, What anxiety, moodiness) anxiety, • When did changes occur (starting/stopping When drug, fever, hypotension, deteriorating renal function, rhythm changes) function, • MMSE, focused NBE Diagnosis Testing - Standard Diagnosis MMSE & CDT -Not designed for delirium -Useful at separating “normal” from “abnormal” -Not specific for distinguishing delirium from dementia -May be useful as change from baseline -Overkill add TMT-A, TMT-B Diagnostic Testing: Tools Diagnostic Sensitivity Sensitivity • • • • • CAM* .46-.92 Delirium Rating Scale .82-.94 Delirium .82-.94 Clock draw+ .87 MMSE (24 cutoff) .52-.87 Digit span test .34 Specificity .90.92 .82-.94 .93 .76-.82 .90 *validated for delirium & capable of distinguishing *validated delirium from dementia delirium +validated for delirium, correlated with deterioration of +validated dominant frequencies on EEG dominant 1. [Acute Onset] Is there evidence of an acute change in mental status from the patient's baseline? [Acute 2A. [Inattention] Did the patient have difficulty focusing attention, for example, being easily 2A. [Inattention] distractible, or having difficulty keeping track of what was being said? distractible, 2B. (If present or abnormal) Did this behavior fluctuate during the interview, that is, tend to come 2B. (If and go or increase and decrease in severity? and 3. [Disorganized thinking] Was the patient's thinking disorganized or incoherent, such as rambling 3. [Disorganized or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? subject 4. [Altered level of consciousness] Overall, how would you rate this patient's level of 4. [Altered consciousness? (Alert [normal]; Vigilant [hyperalert, overly sensitive to environmental stimuli, startled very easily], Lethargic [drowsy, easily aroused]; Stupor [difficult to arouse]; Coma; [unarousable]; Uncertain) [unarousable]; 5. [Disorientation] Was the patient disoriented at any time during the interview, such as thinking 5. [Disorientation] that he or she was somewhere other than the hospital, using the wrong bed, or misjudging the time of day? time 6. [Memory impairment] Did the patient demonstrate any memory problems during the interview, 6. [Memory such as inability to remember events in the hospital or difficulty remembering instructions? such 7. [Perceptual disturbances] Did the patient have any evidence of perceptual disturbances, for 7. [Perceptual example, hallucinations, illusions or misinterpretations (such as thinking something was moving when it was not)? when 8A. [Psychomotor agitation] At any time during the interview did the patient have an unusually 8A. [Psychomotor increased level of motor activity such as restlessness, picking at bedclothes, tapping fingers or making frequent sudden changes of position? making 8B. [Psychomotor retardation]. At any time during the interview did the patient have an unusually 8B. [Psychomotor decreased level of motor activity such as sluggishness, staring into space, staying in one position for a long time or moving very slowly? position 9. [Altered sleep-wake cycle]. Did the patient have evidence of disturbance of the sleep-wake 9. [Altered cycle, such as excessive daytime sleepiness with insomnia at night? cycle, Dx Delirium with CAM http://www.hartfordign.org/publications/trythis/issue13.pdf http://www.hartfordign.org/publications/trythis/issue13.pdf 1. Acute onset, fluctuating course AND 2. Inattention 2. AND EITHER 3. Disorganized thinking 3. OR 4. Altered level of consciousness 4. *sensitivity 94 - 100%; specificity 90 - 95% Inouye et al, Ann Int Med 1990 Diagnostic Testing: EEG Diagnostic • Diffuse slowing • Most helpful to get a baseline • Patients with AzD may have abnormally slowed Patients EEG EEG • Worsens from baseline with delirium • Patients with minimal slowing may have test Patients read as “normal” read • Alpha (13 cps) may slow down (9 cps) and still be in Alpha normal range normal • Comparison with baseline • Comparison with repeat EEG post delirium What Causes Delirium? What The Importance of DDx Differential Diagnosis: Urgent Differential • When in doubt, throw out the When • • • • • • • • • Wernicke’s Withdrawal Hypoxia Hypoglycemia Hyper- hypotension Infection Intracranial bleed Meningitis Poisoning • Failure to make these diagnoses may lead to permanent Failure CNS damage CNS I WATCH DEATH I WATCH DEATH • I Infection: Most Infection common are pneumonias & UTI in elderly, but sepsis, cellulitis, SBE and meningitis can also occur occur I WATCH DEATH I WATCH DEATH • I Infection • W Withdrawal: Withdrawal: benzodiazapines, ETOH, opiates ETOH, I WATCH DEATH I WATCH DEATH • I Infection • W Withdrawal A Acute metabolic: Acute • electrolytes, renal failure, acid-base disorders, abnormal glycemic control, pancreatitis pancreatitis I WATCH DEATH I WATCH DEATH • I Infection • W Withdrawal A Acute metabolic T Trauma: head injury Trauma • • (SDH, SAH), pain, vertebral or hip fracture, concealed bleed, urinary retention, fecal impaction impaction I WATCH DEATH I WATCH DEATH • I Infection • W Withdrawal A Acute metabolic T Trauma C CNS pathology: CNS • • • tumor, dementia, encephalitis, meningitis, abscess abscess I WATCH DEATH I WATCH DEATH • I Infection • W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia from • • • • COPD exacerbation, CHF CHF I WATCH DEATH I WATCH DEATH • I Infection • • • • • • W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia D Deficiencies: BDeficiencies B12, folate, protein, 12, calories, water calories, I WATCH DEATH I WATCH DEATH • I Infection • • • • • • W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia • D Deficiencies E Endocrine Endocrine thyroid, cortisol, cancer thyroid, I WATCH DEATH I WATCH DEATH • I Infection • • • • • • W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia • • D Deficiencies E Endocrine A Acute vascular/MI : stroke, vascular/MI myocardial infarction myocardial I WATCH DEATH I WATCH DEATH • I Infection • • • • • • W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia • • • D Deficiencies E Endocrine A Acute vascular/MI T Toxins-drugs Really anything, but antiReally cholinergics, long acting cholinergics, benzodiazepines, narcotics (meperidine) and other psychotropics are common bad actors, OTC, OPM bad I WATCH DEATH I WATCH DEATH • I Infection • • • • • • W Withdrawal A Acute metabolic T Trauma C CNS pathology H Hypoxia • • • • D Deficiencies E Endocrine A Acute vascular/MI T Toxins-drugs: H Heavy metals (lead, metals mercury, platinum) mercury, Dementia and Delirium Dementia • • Dementia is a risk factor for delirium Diagnosis of delirium in context of Diagnosis dementia is often missed dementia • Of 2000 consecutive admissions: • 9.1% of patients had diagnosis of dementia • 41.4% of these demented patients had delirious 41.4% process on admission process Erkinjuntii et al., Arch Int Med, 1986 Erkinjuntii 1986 Delirium versus Dementia? Delirium versus Dementia? DELIRIUM • Acute • Inattention • AbN LOC • Fluctuations/minutes • Reversible • Hallucinations common DEMENTIA • Gradual • Memory disturbance • N LOC • None/days • Irreversible • Hallucinations common only in advanced disease It is common for Delirium to be superimposed on Dementia! So What? Who Cares? So What? Who Cares? Delirium is unimportant! 3 criteria: criteria: Common, Morbidity & Costly! Common •On admit? 15­20% •Death ~20­35% •LOS doubles •In hospital? 7­31% •Cognitive drop in 40% • ++ hospital $ •Ortho ­ 25­65% •ICU: 90% •Premature institutionalization •Caregiver burden What can trigger Delirium? What ANYTHING!!! Patient Predisposing Factors Patient • Age • ↓ Physical fn/ immobility Physical • Dementia Dementia • ↓ Hearing Hearing • Male Male • ↓ Vision • Dehydration Dehydration • Severity of illness Severity • Malnutrition • Comorbid psych dx (Depression; (Depression; EtOH abuse) EtOH Elie et al, JGIM 1998; Burns et al, JNNP 2004 Environmental Predisposing Factors Factors • # of room changes • Bladder catheter • Absent clock/watch • ICU or LTC • Absent reading glasses • Restraints • Absence of family McCusker et al, JAGS 2001 Delirium Precipitants Delirium Prospective study incidence of delirium 229 elderly medical inpatients 229 • • • • • • • • Fluid/ electrolyte dysfunction (40%) Infection (40%) Drugs (30%) Metabolic/Endo (26%) Sensory/ Environmental (24%) ⇓ perfusion/⇓ Ο2 (14%) perfusion/ Neurological EtOH/Drug Withdrawal **No clear precipitant in 15 – 25% Francis et al, JAMA 1990 Delirium Workup Delirium Workup History: History: time course of mental status changes time association with other events (i.e.. meds, illness) Pre-existing impairments of cognition or sensory Pre-existing modalities modalities Physical Exam Physical Exam • Vitals: normal range of BP, HR, pO2, Temp • Good physical exam: particular emphasis on Cardiac, pulmonary and neurological systems Cardiac, • Hydration status (dry axilla = dehyd!) • Also rule out Also • • • fecal impaction fecal urinary retention (bladder U/S, in-and-out catheter) Infected decubitis ulcer Treatment and Management Treatment • Identify and “correct Identify the correctibles” the • Multiple causes in Multiple elderly elderly • Careful monitoring • Place patient near Place nursing station (1:1) nursing • VS, I & O, O2 • Reduce psychiatric Reduce symptomatology symptomatology • Agitation • Psychosis • Discontinue nonessential medication • Drug toxicity and Drug drug induced delirium is most common • See Medical Letter See Drugs that cause psychiatric symptoms psychiatric •(Larsen et al., J Gerontol, 1985) (Larsen 1985) Treatment and Management Treatment • ENVIRONMENTAL • Restraints often indicated: posies, vests, mitts, helmets, geri-chairs, locked leathers mitts, • Provide cognitive structure, emotional Provide support to patient and loved ones support • Make sure behavioral monitoring is Make adequate and if empathy exists adequate • Soft light, clock, familiar objects from home Nonspecific Treatment of Delirium, Mild Agitation, Lability, and Psychosis Mild A Case for Psychopharmacology Pharmacology Of Atypical Antipsychotics Clozapine Risperidone M1 5HT2A 5HT2A D2 α1 H1 5HT2C H1 α1 5HT2C 5HT2A α1 D2 H1 5-HT1A Olanzapine M1 D2 Ziprasidone 5-HT1D 5HT2A Quetiapine 5HT2C M1 D2 5D2 HT2A α1 H1 H1 5HT2C Zorn SH et al. Interactive Monoaminergic Brain Disorders. 1999:377-393. Schmidt AW et al. Eur J Pharmacol.2001;425:197-201. α1 55- HT1A HT2C Receptor occupancy (%) Quetiapine 5HT2 & D2 Occupancy O1ccupancy 00 90 80 70 60 D2 occupancy 5­HT2 occupancy 50 40 30 20 10 0 0 200 400 600 Quetiapine (mg/d) 800 IM Ziprasidone vs IM Haloperidol: QTc IM Interval at Cmax Interval Injection 2 (4 hours after 1st injection) Injection 1 15 10 5 6 4.6 0 change from baseline (ms) 20 Mean (95% CI) QTc interval Mean (95% CI) QTc interval change from baseline (ms) 20 15 14.7 12.8 10 5 0 IM ziprasidone 20 mg (n=25) IM haloperidol 7.5 mg (n=24) *IM ziprasidone 30 mg is 50% above recommended dose. IM ziprasidone 30 mg* (n=25) IM haloperidol 10 mg (n=24) Adapted from Miceli et al. APA poster. 2002. Preliminary data may not reflect final findings and results from the respective studies. Risks of Using v Not Using Atypical Antipsychotics Atypical • Increased mortality in elderly patients Increased with dementia-related psychosis • • • 17 placebo controlled trials Modal duration of 10 weeks Risk of death in treated patients 1.7 times Risk that seen in placebo treated patients that • Varied cause • CV (H...
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