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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,CHAMPDelirium Part 2:Evaluation & Management,Andrea Bial, M.D.,University of Chicago,Goals,Develop a plan for teaching a,Systematic Approach to the Evaluation,of hospitalized older patient with delirium.,Develop a plan for teaching an appropriate,Treatment Plan,for the hospitalized older patient with delirium,Overnight Events: Morning Rounds at the Bedside,75yo W admit 2d ago w/ COPD, bronchitis,Intern reports: o/n she pulled out her IV, thought she was at home,X-cover ordered Prosom 1mg & po abx,Currently, pt w/o c/o. Doesnt recall events of previous night.,PE: sleepy, arouseable,37.6 148/62 88 20 93%2L,Lungs w/ faint wheeze bilat,Rest w/o change,Labs WBC 13.2, diff P; H/H stable,Overnight, contd,Overnight, contd,A/P #1) COPDcont nebs, steroids, po abx,#2) HTNstable on meds,#3) Confusionadd risperdal 1mg QHS prn,#4) Dispawait PT/OT,No one “gold standard” approach,Multiple Mnemonics,(e.g., Delirium),& algorithms,Need individualized,systematic,approach to avoid missing potential causes,Few studies exist specifically looking at causes,Systematic Approach to the Evaluation of Delirium,Francis (1990),Large teaching hospital,General medicine patients (n=229),Delirium developed in 22% (n=50),Determined cause(s) as: definite, probable, or possible,18 (36%) w/ one,definite,cause,(Drug toxicity, then infection=fluid/lyte imbalance),10 (20%) w/ one,probable,cause,22 (44%) w/ 1 cause; 62,possible,etiologies (2.8/pt),Evaluation of Delirium: Causes,DELIRIUM,Evaluation,Management,History,(,dementia,?) and,Physical Exam,(,head to toe),FOCAL EXAM:,Do appropriate next,step (e.g.,fever,cx),THEN, review meds&,Order other tests,NON-FOCAL EXAM:,Review meds,Order addnl tests,Treat Findings &,Manage symptoms,Treat Findings &,Manage symptoms,NON-AGITATED,PATIENT:,Non-Pharmacologic,treatment,AGITATED,PATIENT:,Non-Pharmacologic,& Pharmacologic tx,Evaluation:Dementia Teaching Points,Hx,of dementia?,Hx,of,sundowning,?,Agitated dementia, delirium,4. Importance of considering,dx,:,DEMENTIA DELIRIUM,Evaluation: Physical Exam,Head to toe:,Vitals (temp, HR, RR, BP, pulse ox, pain),Head(CVA, bleed, meningitis, sz, blind, deaf),Lung(pneumonia, PE, CHF),Chest(ischemia, CHF, arrhythmia),Abd(ischemia, impaction, bleed),GU(UTI, retention),Extrem (pain, volume status, CVA),Skin(pressure ulcer, volume status),No evidence to support routine ordering,Order if:,new focal finding(s) on exam,head trauma,suspicion of encephalitis,no other identifiable causes found,Evaluation: Head CT?,Evaluation: Medication Review,Too little (alcohol or other drug w/d),Francis (1990) 1/50pts (2%),Lawlor (2000) 4/71pts (6%),Too much,narcotics, neuroleptics, anticholinergics, antiemetics,Francis 1990, Schor 1992, Lawlor 2000,Evaluation: Medication List,Antibiotics (aminogly, PCN, ceph, sulfa),Benadryl,Benzodiazepines (triazolam, alprazolam, diazepam),Digoxin,GI (Reglan, Bentyl),Lithium,Narcotics,Neuroleptics,Steroids,NSAIDs (Indocin),H2 Blockers (Cimetidine,),Parkinsons drugs (Levodopa, Benztropine, Amantadine),Tricyclics,Evaluation: Medication List,Antibiotics (aminogly, PCN, ceph, sulfa),Benadryl,Benzodiazepines,(triazolam, alprazolam, diazepam),Digoxin,GI (Reglan, Bentyl),Lithium,Narcotics,Neuroleptics,Steroids,NSAIDs (Indocin),H2 Blockers (Cimetidine,),Parkinsons drugs (Levodopa, Benztropine, Amantadine),Tricyclics,Evaluation: Medications, contd,Anticholinergic properties frequently overlooked:,Elavil,(amitriptyline),Flexeril,(cyclobenzaprine),Cogentin,(benztropine),Atarax/Vistaril,(hydroxyzine),Bentyl,(dicyclomine),Welbutrin/Zyban,(bupropion),Ditropan,(oxybutynin),Antivert,(meclizine),Detrol,(tolterodine),Ipratropium,(atrovent),Benadryl,(diphenhydramine),Phenergan,(promethazine),Zyprexa,(olanzapine),Atropine,Levsin,(hyoscyamine),Quinidine,Evaluation: Additional tests,Labs,CBC, lytes, liver, renal,Consider TSH, B12, cortisol, ammonia, abg,Drug levels (digoxin, etc),Urine tox,UA,CXR,EKG,EEG,Evaluation: EEG,Since 1950s, recommendations for EEGs,Usually: generalized slowing,Sensitivity 75%,Management: Non-Pharmacologic,Cognition,: orientation board (carry pen!) & open drapes during day,Sleep,: minimize deprivation (no 2am labs, no o/n BS/vitals if able, give meds when awake),Mobility,: OOB,chair asap, PT/OT, no foley/restraints,Vision,: glasses,HOH,: get aids; adapt environment; stethoscope trick,Dehydration,: po fluids; observe at mealtime; avoid “Boost at nightstand”,Observation,: Involve family (rotate members) or get sitter; move pt to room close to RN station,Management: Non-Pharmacologic Restraint Use,Avoid whenever possible,Increase risk of falls, injury, & delirium,Use only in emergency, for as short a duration as possible with frequent re-evaluations, and d/c asap,Absolutely no “sheeting”,Management: Pharmacologic,No RCT of treating delirium in hosp pt,Extrapolation from other populations studied (AIDS, NHs, outpatient AD, ),See Table in handout,Typical: Haldol, (Chlorpromazine),Advantages:,min sedating,less,BP,Disadvantages:,sz risk,more EPS side effects,QT,risk of Torsades,Dose:,0.25-0.5mg po, IM, IV,can repeat 30 mins x1, then q4h,t1/2=21h (10-38); peak 4-6h,(IV not FDA-approved; short duration of action),APA 1999,Management: PharmacologicAntipsychotics,Management: PharmacologicAntipsychotics, contd,Atypical Antipsychotics,Advantages: less EPS,+/- sedation,Disadvantages:, BP,weight gain, BS,no evidence: short-term,mx (infection, CVS),Management: PharmacologicAntipsychotics, contd,Atypical Antipsychotic Doses:,Risperidone:0.25-0.5mg po bid t1/2=20-30h,Olanzapine/Zyprexa: 2.5-5mg po qd t1/2=30 (21-54h),Quetiapine/Seroquel: 25mg po bid t1/2=6h,(better in PD pts),Management: PharmacologicBenzodiazepines,Used best in w/d of EtOH or benzos,(also consider use in PD, NMS),Lorazepam 0.5-1mg po, IM, IV q4-6,t,1/2,=12h,(no adjustment needed for liver or renal dz),Management: PharmacologicBottom Line,Try to avoid meds, but if needed:,Use Haldol in acute settings,Use risperidone for regular use (unless PD: quetiapine),Use lorazepam for w/d,Back to case!,75yo W admit,2d ago,w/ COPD, bronchitis,Intern reports: o/n she pulled out her IV, thought she was a home,X-cover ordered,Prosom 1mg,& po abx,Currently, pt w/o c/o.,Doesnt recall events of previous night.,PE: sleepy, arouseable,37.6 148/62 88 20,93%2L,Lungs w/ faint wheeze bilat,Rest w/o change,Labs,WBC 13.2, diff P,; H/H stable,Na 133, BUN 26, Cr,A/P #1) COPDcont,nebs,steroids, po,abx,#2) HTNstable on meds,#3) Confusionadd,risperdal 1mg QHS prn,#3),Disp,await PT/OT,Teaching Points,Ask: What do you think caused last nights events?,Was a h/o dementia missed?,(dementia,/delirium relationship; role of MMSE;,further family,hx,),Was her PE different at the time x-cover was called?,(systematic evaluation/head-to-toe),Did we start or alter dose of any medications?,(nebs, steroids,abx,),Teaching Points, contd,Ask: Is she delirious now?,Discuss use of CAM,(comfort of tool;,dx,of delirium in chart),Discuss outcomes of delirium,(increases: LOS, healthcare costs,mx,d/c,to LTCF),Discuss use of,Prosom,(and other,benzos,) in delirium,Teaching Points, contd,Ask: Is there anything we should do today to follow-up on her confusion?,Discuss further studies that may or may not be needed,(CXR? UA? Repeat Na?),Discuss the non-pharmacologic measures that should be put into place,(orient board, fluids, mobility, drapes, HS nebs & labs),Discuss use of,risperidone,(and other,antipsychotics,) in delirium,Recommended Reading,Inouye SK. Delirium in older persons. NEJM 2006;354:1157-65,Schneider LS et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimers disease. NEJM 2006;355:1525-38.,Sink KM et al. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA 2005;293:596-608.,
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