EM guidemap - Delirium in the elderly

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Introduction

History of the present illness Examination

Diagnostic testing
 

Medical decision-making

Appendix

Introduction

When faced with an elderly patient with an altered mental status, an emergency physician must first determine whether the patient's previous cognitive and behavioural function was normal, or whether the patient has an underlying dementia

- a failure to determine the baseline cognitive and behavioural status of the patient will make it very difficult to determine whether recent changes in cognitive function and behaviour are due to a superimposed delirium

Dementia

 - dementia is characterised by a chronic loss of intellectual function + clear state of conciousness, and it has an insidious onset and a progressive course

- dementia is characterised by memory impairment, which may be an impaired ability to learn new information (short-term memory) and/or to recall previous information (long-term memory)

- dementia is also characterised by one-or-more of the following cognitive disturbances, which may cause a significant decline in social and occupational functioning

- the decline in these cognitive functions usually occurs gradually over months/years if due to Alzheimers disease, which is the commonest cause of dementia

(* although ~ 90% of cases of dementia are due to irreversible diseases such as Alzheimers dementia, multi-infarct dementia and chronic alcoholism => a small percentage of cases are due to reversible causes such as chronic subdurals, normal presure hydrocephalus, liver failure, hypothyroidism and vitamin B12 deficiency)

- patients often become depressed or frustrated by their impaired mental functioning and may develop signs of emotional lability, which is incorrectly attributed to delirium or a functional psychosis

- a patient suffering from early dementia should still have a clear state of consciousness and be able to focus and shift attention normally

Delirium

- delirium is mainly characterized by a clouding of conciousness with a reduced ability to focus, sustain or shift attention

- because the patient has difficulty paying attention, he may have difficulty perceiving and interpreting enviromental data, and he may misisinterpret information and not be able to think clearly

- the delirious patient often cannot solve problems logically, anticipate reactions and grasp abstract meanings

- delirium usually evolves rapidly over hours-days and is characterized by a marked fluctuation in symptoms during the course of the day with periods of hypoactivity and/or hyperactivity

- delirious patients are prone to perceptual disturbances (illusions, delusions and hallucinations), disturbances of the sleep-awake cycle with night-time agitation and daytime somnolence, and disorganized thinking, which is characterised by rambling, irrelevant or incoherent speech, poor word list generation and impaired writing

- a disturbance in short term memory (secondary to an impairment of attention and accurate data gathering) is more common than disturbances in long-term memory

- delirious patients are often highly distractable, they may also appear to be absent minded and they readily lose the thread of their conversation

- associated psychomotor features may be present:- restlessness with 'plucking and picking' gestures, slowness, slurred speech, abnormal motor movements such as asterixis and mutifocal myoclonus and hyperreflexia

- associated autonomic features may be present:- dilated pupils, tachycardia, fever, flushing, sweating, excessive pilomotor responses, diarrhea or constipation

- associated affective changes may be present:- irritability, apprehension, fear, docility, jocularity, perplexity, lethargy

- many emergency physicians use the term "confused" to describe the altered mental status of delirious patients, but it is important to also distinguish delirium from confusion, and an emergency physician should not simply use the two terms interchangeably

Confusion

- confusion is defined as a loss of one's capacity to think clearly and coherently, and it is a non-specific symptom of many different mental disorders (eg. dementia, delirium, manic psychosis) or organic pathology (eg.encephalitis or metabolic encephalopathy)

- the term "confusion", which is a symptom, should not be elevated to the level of a diagnosis

- avoid using the term "acute confusional state" as if it represents a diagnostic entity

- in the neurologic nosology, "delirium" (a disorder of overarousal) is distinguished from "acute confusional state" (a disorder of underarousal); while in the psychiatric nosology, these two syndromes are considered variants of "delirium" per se - often referred to as hyperactive/hyperalert and hypoactive/hypoalert subtypes

- both delirium and dementia are characterized by a global impairment in cognitive functioning and meticulous history-taking is sometimes required to differentiate between these two entities (concentrate your search in looking for deficits in the patient's ability to focus, sustain and shift attention in order to diagnose delirium)

- delirium may also be superimposed on an underlying dementia and clinical differentiation may be very difficult, because those demented patients often have hypoactive delirium without episodes of agitated behaviour (hypoactive/hypoalert subtype) => the patient may be withdrawn and unengaged and it may be difficult to obtain sufficient patient cooperation to formally test for deficits in attention and cognition

The presence of lucid intervals with normal/near-normal cognitive functioning strongly suggests delirium and excludes the likelihood of dementia
 

Clinical differentiation between delirium and dementia
Clinical feature Delirium Dementia
Nature of onset  Abrupt onset Gradual, ill-defined onset
Rapidity of progression Rapid - hours Slow - months
Duration of condition Temporary - days Long lasting - years 
Variability of symptoms Fluctuating from hour-to-hour
Lucid intervals common		 Stable from day-to-day
No lucid intervals
Attention span  Very short, variable from moment-to-moment Unaffected in early disease, stable in chronic disease
Memory changes Short-term memory markedly affected by short attention span and increased distractibility Long-term memory poor, with no precipitous change in short-term memory capability
Disturbed sleep-wake cycle Common, varies from hour-to-hour Rare, stable from day-to-day
Clouding of consciousness due to increased distraction and poor concentration Common (defining feature) Absent
Marked psychomotor changes
(motor restlessness, mutifocal myoclonus, asterixis, hyperreflexia)		 Common Absent
Marked autonomic changes Common Absent

- there are numerous causes of delirium and many patients may have more than one cause of their delirium

(* see the appendix for a list of common causes of delirium in the elderly)

A rational approach to delirious patients mandates a rigorous search for multiple precipitating causes of delirium, which means that an emergency physician must perform a thorough clinical evaluation and an extensive diagnostic workup in all delirious patients

- the commonest causes of delirium in the elderly patient are:-

History of the present illness

- first determine the time of onset of the change in mental status and determine whether the change has been constant or fluctuating in course

- determine whether there is a diurnal pattern with increasing confusion towards the end of the day ("sundowning") and whether there are any lucid intervals

- specifically inquire about changes in the patient's degree of attentiveness - the ability to sustain a conversation or a task; the ability to concentrate and not be easily distracted

- inquire about changes in the patient's short-term memory and degree of orientation

- inquire about changes in the patient's functional status (ability to dress and groom oneself , ability to feed onself and ability to perform social tasks such as shopping and house-keeping)

- inquire about changes in the patient's emotional status

- inquire about associated hallucinations, delusions or misperceptions

- inquire about the patient's baseline mental status and determine whether the patient is normally fully oriented, cognitively intact, attentive and capable of normal social functioning

- if the patient has an abnormal baseline mental status => try and semi-quantitate the degree and time course of any mental status changes (when he last drove a car, balanced a checkbook, fed himself, dressed himself , had a coherent conversation and so on)

- inquire about any recent changes in the patient's state of physical health and whether any apparent physical illness precipitated the change in mental status

- inquire about constitutional symptoms

- inquire about specific disease symptoms suggestive of acute organ dysfunction (AMI, CHF, pneumonia, UTI, thyrotoxicosis)

- specifically inquire about headaches and focal neurological symptoms (suggestive of a SAH, subdural hematoma, CVA or tumor) or recent falls/head trauma (subdural hematoma) or incontinence or gait difficulties (hydrocephalus, frontal strokes) or psychomotor automatisms (complex partial seizures)

- specifically inquire about the use of psychotropic drugs (inluding over-the-counter medications with anti-cholinergic properties eg. decongestants and cough preperations)

- review the patients list of medications and inquire about any new medications or recent changes in drug doses (see the appendix for a list of offending drugs)

(* serotonin syndrome may be provoked by an increase in the dose of a SSRI or the addition of an interacting medication eg. dextromethorphan; and neuroleptic malignant syndrome may be induced by an increasing dose of a long-term neuroleptic agent)

- inquire about possible intentional or accidental exposure to pesticides or plant toxins or heavy metals or carbon monoxide or illicit drugs or volatile agents

- inquire about habitual (or occult) alcohol consumption

- determine whether there has been a sudden withdrawal from alcohol or sedative/hypnotic drugs (or a sudden decrease in the amount consumed)

- inquire about the patient's nutritional habits (thiamine deficiency, Vit B12 and folate deiciency)

- inquire about recent hospitalisations or cancer treatments (paraneoplastic syndrome)

- inquire about chronic illnesses (hepatic or renal failure or endocrinopathies or COPD or DM or CHF)

- determine whether has been any significant life-altering events and review the home enviromental conditions and the social support system
 

History-taking checklist
 Baseline mental and behavioural status
 Baseline social functioning
 Baseline occupational status
 Home enviroment and social support systems

 Change in mental status

  • time of onset
  • course and lability
  • presence of lucid intervals
  • changes in sleep-awake cycle
  • "sundowning" phenomenon
  • degree of attentiveness and distractability
  • short term memory changes
  • perceptual disturbances -illusions, hallucinations, delusions
  • emotional lability and poor capacity to modulate emotional behaviour
  • psychomotor disturbances - asterixis, myoclonus, motor restlessness
 Overt/occult alcohol or illicit drug abuse
 Any sudden withdrawal from alcohol or sedative drugs
 Any new psychotropic drugs
 Any new drugs or drug dose changes
 Any salicylate abuse
 Use of nutritional supplements or alternative medicines

 Intentional/accidental exposure to pesticides, heavy metals, plant toxins
 Intentional/accidental exposure to extreme enviromental temperatures

 Baseline nutritional status
 Baseline physical status
 Chronic illnesses or immunosuppression
 Previous history of alcoholism or Wernicke's encephalopathy
 Physical, emotional, mental disabilities
 Any recent life-altering social or emotional events

 Recent hospitalisations
 Recent surgery
 Recent cancer treatment
 Recent outpatient therapy or dialysis
 Recent depression or suicide ideation

 Recent physical illness or head injury

 Review of systems

 Specific neurological symptoms suggesting neurological disease

  • gait problems
  • incontinence
  • focal neurological signs
  • headache
  • abrupt changes in language facility
  • psychomotor automatisms 

Examination

- abnormal vital signs

- poor nutritional status (thiamine or B12 or folate deficiency, malignancy)

- signs of neglect or physical abuse (elder abuse)

- abnormal neurological examination

(* non-dominant hemisphere strokes in the blood supply territory of the inferior division of the middle cerebral artery can rarely produce delirium without any focal neurological signs; less common occurrence with isolated anterior and posterior cerebral artery ischemic strokes)

- abnormal mental status examination

- an abbreviated mini-mental status examination can be performed, but if the mental status examination is too abbreviated => risk of missing cases of delirium

- a minimal mental status assessment should at least include an assessment of i) the patient's ability to focus and sustain attention, ii) the patient's capacity to think in an organized manner and iii) the patient's short-term memory

- the standard mini mental status examination is geared towards the detection of cognitive impairment and it is not necessarily sensitive enough to detect the subtle deficits in attention associated with delirium

- using the confusion assessment method to detect a state of delirium may be more practical in the ED setting, when time-experiental constraints limit completion of a full mental status evaluation

(* see the appendix for details on the standard mini-mental status examination and confusion assessment method)

- perform a complete physical examination looking for physical evidence of common diseases that may have precipitated delirium

Diagnostic testing

Diagnostic testing is targeted toward finding possible etiological causes of the delirium, and because multiple etiological factors may concurrently be present => a broad range of screening tests is recommended

Pulse oximetry

- low (pneumonia, CHF, PE, COPD)

EKG

- tachyarrhythmia or bradyarrythmia

- cardiac ischemia or AMI or PE

- ECG signs of electrolyte disorders (potassium, calcium)

Chest X-ray

- signs of pneumonia or CHF or PE

Blood testing

- a minimal screening battery would include serum glucose, serum electrolytes, serum calcium and magnesium, serum ETOH, liver function tests, CPK and a CBC

Serum glucose

Serum electrolytes, serum calcium, magnesium, BUN and creatinine Serum liver function tests CPK CBC ABG

- hypercarbia (COPD)

- metabolic acidosis (DKA, sepsis, shock, salicylate or methanol or cyanide toxicity, uremia)

Urinalysis

- increased WBC and bacteriae (UTI)

- increased myoglobin (heat stroke, NMS)

Blood cultures

- indicated if the patient is febrile or if there is evidence/suspicion of serious bacterial infections (SBI) eg.          bacterial endocarditis

Thyroid function testing, serum ammonia, vitamin B12 levels, VDRL, urinary porphobilinogens, screens for heavy metals

 - performed on a selective basis prn

Serum and urine drug screens

- serum salicylate and other drug levels (digoxin, theophylline, lithium) prn

CT scan of the head

- indicated for patients who present with a headache, or focal neurological signs, or a history of head trauma or physical abuse, or suspected strokes or space-occupying lesions or hydrocephalus, or if there is no other etiological explanation for the altered mental status after preliminary metabolic testing

Lumbar puncture

- definitely indicated in the febrile patient with clinical signs of meningitis; or if no other focal source of infection is detected

- probably indicated if the fever is presumed to be due to a hyperpyrexia syndrome, but meningitis cannot be excluded

- may be indicated in the febrile patient with evidence of a focal infection outside the CNS if meningitis cannot be excluded

- indicated in the delirious HIV-positive patient, even if afebrile

Medical decision-making

Attention should first be directed at stabilization of the vital signs, treatment of the precipitating causes, and physical/chemical restraints prn

- stabilize the vital signs and give supplemental oxygen prn

- exclude hypoglycemia by dextrostix testing and treat any hypoglycemia prn

- give thiamine empirically (especially if Wernicke's encephalopathy is likely)

- give naloxone if opiate toxicity is possible or evident

- promptly treat any precipitating causes eg. hypoxia, hyperpyrexia, cerebral hypoperfusion, metabolic derangements, poisonings, meningitis, cardiac or renal or liver failure or acute endocrinopathies

- use physical restaints temporarily for combative patients to minimize self-harm (document their indication, time-limit the order, and follow hospital protocols for frequent visual checks of the patient)

- chemical sedation is preferable, especially if agitation is extreme or long-lasting

- haloperidol is often the drug-of-choice (except in the neuroleptic malignant syndrome)

- halperidol can be given IV and titrated to effect - initial dose of 0.5-1.0 mg IV => double the dose every 20-30 minutes prn

- a haloperidol infusion can be used if large doses (> 10mg) are required to obtain and/or maintain control

- haloperidol should be used cautiously in patients with a prolonged QT interval, because there is some evidence that neuroleptic agents may cause torsade des pointes (some physicians would discontinue haloperidol if the QTc interval lengthens by > 25%)

- droperidol is faster acting, but may be more likely to cause hypotension (secondary to a greater degree of secondary alpha blockade)

- small doses of lorazepam (0.5-1mg) can be titrated IV in addition to haloperidol

- some physicians use benzodiazepines alone, but there is a substantial risk of over-sedation, disinhibition, ataxia and increased confusion

- a benzodiazepine may be the drug-of-choice when the delirium is secondary to withdrawal from alcohol or sedative/hypnotic agents

- minimize sensory overload by limiting the number of care-givers and ensuring a quiet enviroment; and allow family members to remain in constant/frequent attendance

- do not leave patients unattended in the hallway and ensure that the bed side-rails are up
 

Checklist of enviromental and social factors that can help manage a delirious patient
  • provide frequent support and orientation
  • communicate clearly and concisely
  • give repeated verbal reminders of the day, time, location
  • give repeated reminders of the identity of key individuals, such as members of the treatment team and relatives
  • provide clear signposts to patient's location including a clock, calendar, chart with the day's schedule
  • have familiar objects from the patient's home in the room
  • ensure consistency in staff (for example, a key nurse)
  • use television or radio for relaxation and to help the patient maintain contact with the outside world
  • involve family and caregivers to encourage feelings of security and orientation
  • provide an unambiguous environment
  • simplify care area by removing unnecessary objects
  • consider using single rooms to aid rest and avoid extremes of sensory experience
  • avoid using medical jargon in patient's presence because it may encourage paranoia
  • ensure that lighting is adequate to reduce misperceptions
  • control sources of excess noise (such as staff, equipment, visitors)
  • identify and correct sensory impairments; ensure patients have their glasses, hearing aid, dentures
  • consider whether an interpreter is needed
  • encourage self care and participation in treatment
  • arrange treatments to allow maximum periods of uninterrupted sleep

Most elderly patients with altered mental status should be admitted to hospital - unless the cause is readily treatable (eg. hypoglycemia or known complex partial seizure disorder or reversible drug intoxication) and the home support system optimal

- individualize the management of demented patients, who are brought to the ED because family resources are stretched to the breaking point (if you cannot detect any overt evidence of delirium)

Appendix

Commonest causes of delirium in the elderly
 
Infectious Endocrinopathies
 
Sepsis Hypothyroidsim
Cerebral abscess Hyperthyroidism
Meningitis Hypoparathyroidism
Encephalitis Hyperparathyroidism
HIV CNS infection Glucocorticoid excess
Neurosyphilis Adrenal insufficiency
 
Pharmacologic/poisoning Enviromental
 
Medication reaction/interaction Hypothermia
Polypharmacy
Neuroleptic malignant syndrome		 Hyperthermia
Lithium toxicity
Salicylate toxicity		 Primary neurological disorder
Anticholinergic toxicity CVA
Serotonin syndrome Space-occupying lesion
Alcohol or illicit drugs Subdural hematoma
Carbon monoxide poisoning Subarachnoid hemorrhage
Complex partial epilepsy
Metabolic Complex migraine
Temporal arteritis
Hypoglycemia
Hyperglycemia		 Normal pressure hydrocephalus
Hepatic failure
Renal failure		 Substance abuse
Dehydration Alcohol (s)
Hypercalcemia Cocaine
Hypocalcemia
Hypernatremia		 Amphetamines
Hyponatremia
Hypermagnesemia		 Cardiovascular disease
Hypomagnesemia Cardiac ischemia/AMI
Vitamin B 12 deficiency CHF
Arrhythmias
Pulmonary Hypertensive encephalopathy

Hypoxia
Hypercarbia		 Paraneoplastic syndrome

Common medications contributing to altered mental status
 
Anti-convulsants Sedatives/hypnotics Narcotics
Antihistamines Antidepressants Muscle relaxants
Cimetidine Clonidine Corticosteroids
Digoxin Theophylline NSIAD's
Levadopa Beta blockers Salicylates
Antimicrobials Antispasmodics Antihypertensives
Caffeine - coffee, cola Phenylpropanolamine Ocular cycloplegics
Acyclovir Amantidine Sympathomimetics
Lithium Chlorpropramide   

Mini mental status examination

Maximum score

                    Orientation

            5                  What is the (year) (season) (date) (day) (month)
            5                  Where are we (city) (state) (country) (hospital) (floor)

                    Registration

            3                   Name three objects => ask the patient for all three after
                                 you have said them

                    Attention

            5                   Serial 7's back from 100 (stop after 5 correct answers)

                    Recall

            3                   Ask for the three objects repeated above

                    Language and praxis

            2                   Name two subjects: pen and watch
            1                   Ask the patient to say: no "ifs,ands, or buts"
            3                   Three stage verbal command: " take this paper in
                                 your right hand, fold it and place it on the bed"
            1                   Read and obey the following command: "close your eyes"
            1                   Write a sentence: must contain a noun, verb and subject
            1                   Copy a diagram of overlapping pentagrams

A score of  30 is normal and changes of the score allows monitoring of progress

Dysnomia (inability to name objects correctly) and dysgraphia (impaired writing ability) may be the most sensitive tests for detecting delirium

Confusion assessment method

Acute onset + fluctuating course + inattention

OR

Disorganized thinking

An abbreviated mini mental status exmination
 
Action Tests
 
"Who are you?"
"Where are you?"
"What's the month of the year?"		 Orientation
       
Show the patient a pen and ask:
"What is this and what is it used for?"		 Ability to focus attention, to concentrate, to be able to name objects, and to use abtract thought
      
Tell the patient to remember the "pen" and state that you will ask him to recall the object later in the interview Short-term memory
     
Write " close your eyes" on a piece of paper and tell the patient to follow the command Ability to comprehend written language
     
Draw two overlapping circles on a piece of paper and tell the patient to copy the design Constructional apraxia and fine motor coordination and the ability to sustain attention

Disclaimer: My EM guidemaps reflect my personal approach to problem-solving/managing clinical cases in an ED setting and they should not be regarded as the standard of care. They merely represent the personal opinions of the author and they should only be used in clinical practice if the reader-user has substantial reason to believe that the clinical advice contained in the guidemaps is valid and accurate. The guidemaps are not meant to be "authoritative" and the reader-user should consult standard medical textbooks and expert opinion articles/guidelines for more authoritative advice. The reader-user should particularly confirm all drug doses, their indications and contra-indications, prior to their use.