Post-operative delirium in the Older Person

Presented by: C. Brymer, M. Dasgupta, L. Van Bussel & H. Park (Slides prepared by: M. Dasgupta, MD, FRCP, Laurie McKellar RN(EC), BScN, GNC(C) Lisa Van Bussell, MD, FRCP(C))

Frequent duties of a clinical clerk rotating through surgery:

Do an admission Hx and PE on an elderly individual about to go through a surgical procedure:

This should help in determining the risk for future problems that may develop (e.g. postop complications, including delirium)

Being paged to manage a confused person who has had a surgical procedure (all the residents are busy in the OR)

Case Scenario

You are called (at 3:00 AM) to assess a confused patient who is post-op day # 3 following a hip fracture repair Staff insist that he is a danger to himself and needs something now How to approach this all-too-common scenario? Could this have been prevented?

Basic objectives

To be aware of how to diagnose delirium To be able to appreciate when someone is at risk for developing post-op delirium To have an approach to management of the delirious patient

Outline - delirium (peri-operative):

Epidemiology: frequency, pathophysiology, impacts/ consequences Diagnosis: definition and manifestations, collateral history, need for inter-Disciplinary Team (IDT) approach Risk factors for surgical patient:

Patient factors operative/anesthetic factors post-operative/medical factors

Delirium prevention Management of the delirious patient:

Non-pharmacologic interventions Pharmacologic interventions

Discussion of cases

Surgery in the older adult:

Older people account for about 40% of elective surgeries and 50% of emergent surgical procedures Older people are at increased risk for postoperative medical complications (e.g. cardiac complications, etc..) Delirium is in the top three most common postoperative complications (Seymour and Vaz,1989; Liu et al.,

2000)

Delirium

Unlike other typical medical/post-operative syndromes:

There is no unifying pathophysiologic explanation underlying the delirious state It represents a common set of symptoms that can accompany virtually any acute condition (etiologically non-specific)

Brain malfunction in response to multiple factors Occurs in medical, surgical & psychiatric patientsEXTREMELY COMMON

Pathophysiology of Delirium

We really dont know why delirium happens BUT.. (Van der Mast, Neurol 1998; Marcantonio et al., 2006):

It is associated with neurotransmitter alterations (e.g. anticholinergic activity, altered serotonin synthesis, catecholamine, ie dopamine activity) Also implicated: altered melatonin levels, post-op pain and endorphins, cortisol Neurotransmitter abnormalities may result from multiple pathophysiologic processes

Associated with bad consequences:

Immediate impacts of delirium:

Difficult to care for People can get more sick (due to above factors) length of hospital stay, cost Highly distressing for patients who recall it.
(Breitbart et al ( 2002 )

risk for short and long-term functional decline, dementia, institutionalization and death (Dolan et al.,

2000; Marcantonio et al., 2000; Lundstrom et al., 2003)

Delirium- What is it?

DSM- IV-TR (Diagnostic and Statistical Manual of Mental disorders, 2000) diagnostic criteria for delirium (clinical diagnosis):

Disturbance of consciousness or awareness (reduced ability to focus/ sustain or shift attention) Change in cognition (e.g. memory, disorientation, language) or development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia Disturbance develops over a short time period (usually hours-days) and fluctuates during the day Evidence from history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequence of a general medical condition

Delirium- What is it?

Confusion Assessment Method (CAM) is a bedside diagnostic tool
CAM algorithm includes 4 key features of delirium: 1) acute onset and fluctuating course 2) inattention 3) altered LOC 4) disorganized thinking Delirium should be suspected if features 1 and 2 and either 3 or 4 are present
Inouye, S. et al (1990). Annals of Internal Medicine, 113(12)

Delirium- Clinical Manifestations

Hyperactivity and/or Hypoactivity NOTE: Delirium is often misdiagnosed as dementia &/or depression

Resistive to medical and care needs

e.g. refusing physical exam, tests, medications, pulling out IV/central lines/foley catheters/chest tubes, removing leads, oxygen, etc. Refusing bathing, eating, drinking, ambulation, OT/PT interventions

Delirium- Clinical Manifestations

Behavioural changes:

calling out, moaning, crying, physical aggression, hallucinations/paranoia, attempting to escape (high risk for falls), altered sleep

Cognitive changes:

disorientation, non-sensical speech, not following commands, etc.

Delirium- complexity of diagnosis

Overlapping features between delirium, dementia & depression, and all 3Ds can co-exist If person has altered mental status, always assume delirium until proven otherwise. Delirium is a medical emergency. Differentiating the 3Ds clinically : onset, course, progression, duration, awareness, alertness, attention, orientation, memory, thinking & perception (New Zealand Guidelines Group (1998). Guidelines for the
Support and Management of People with Dementia.)

Slide is content from the London 3Ds 2008 Workshop (Screening)

Assessment of Clinical features of delirium, dementia & depression

Feature
Onset Course

Delirium/Acute Confusion
Acute/subacute depends on cause, often at twilight Short, diurnal fluctuations in symptoms; worse at night in the dark & on awakening Abrupt Hours to less than 1 month, seldom longer Reduced Fluctuates; lethargic or hypervigilant Impaired, fluctuates Fluctuates in severity, generally impaired Recent & immediate impaired Disorganized, distorted, fragmented, slow or accelerated incoherent

Dementia
Chronic, generally insidious, depends on cause Long, on diurnal effects, symptoms progressive yet relatively stable over time Slow but even Months to years Clear Generally normal Generally normal May be impaired Recent & remote impaired Difficulty with abstraction, thoughts impoverished, make poor judgments, words difficult to find Misperceptions often absent

Depression
Coincides with life changes, often abrupt Diurnal effects, typically worse in the morning; situational fluctuations but less than acute confusion Variable, rapid-slow but uneven At least 2 weeks, but can be several months to years Clear Normal Minimal impairment but distractible Selective disorientation Selective or patchy impairment, islands of intact memory Intact but with themes of hopelessness, helplessness or selfdeprecation Intact; delusions & hallucinations absent except in severe cases.

Progression Duration Awareness Alertness Attention Orientation Memory Thinking

Perception

Distorted; illusions, delusions & hallucinations, difficulty distinguishing between reality & misperceptions

(adapted in RNAO BPG Screening for Delirium, Dementia and Depression in Older Adults ( 2003)from: New Zealand Guidelines Group (1998) Guideline

for the Support and Management of People with Dementia.)

Obtain Collateral History- to sort it out

Determine baseline functional & cognitive status by seeking out a reliable informant.

Possible questions to ask:

Is he/she thinking, behaving & taking care of themselves differently than they normally do? Can you give me some examples of how he/she thinking, behaving & taking care of themselves differently than they normally do? When did this change start? Was the change gradual or abrupt?

Speak with other involved healthcare professionals (nursing, PT, OT, etc..)

Diagnosing & preventing:

To summarize- delirium:

is an acute change in cognition and alertness is one of the most common peri-operative complications makes providing care difficult and is associated with bad outcomes

Preventing delirium (pro-active approach) is more effective than managing the already delirious individual Preventing it also implies recognizing who is at risk

Management- assessing risk:

In the surgical setting, always consider

the individuals baseline inherent risk for developing peri-operative delirium the nature of the surgery and post-op complications/events

Proactively assess risk preoperatively with validated risk indices

Determining risk for post-op delirium:

In the non-cardiac elective surgery setting, patient risk-factors include (Marcantonio et al., 1994)

Age > 70, cognitive impairment, functional dependence, self reported alcohol abuse, markedly abnormal laboratory values (130>Na>150,3.0>K>6.0, or 3.3>glucose>16.7) (1 point assigned for each) Type of surgery also important (AAA repair- 2 points and non-cardiac thoracic surgery-1 point)

Patients with 0, 1, 2 & >2 points had 2 %, 8%, 13%, and 50% chance respectively of becoming delirious

Risk for Post-op delirium

Patient-centered risk in hip (elective and emergent) surgery:

Scale originally derived in the medical population (Inouye et al.,1993) has been validated in the hip surgery setting (Kalisvaart et al.,2005). Identified risk factors were: cognitive impairment, dehydration, severity of illness (APACHE II score > 15), visual impairment (20/70 or worse)

0 points had ~4% (3.8 %) chance of delirium 1-2 points had ~10% (11.1%) chance of delirium 3-4 points had ~ 40% (37.1 %) chance of developing delirium

Risk for Post-op delirium

Other risk factors in the non-cardiac surgery setting:

Multiple studies have looked at risk for developing incident (new) delirium in the non-cardiac OR setting:

Risk factors include: increasing age, cognitive impairment (****), psychotropic drug use, increasing medical co-morbidity, dependent functional status, nature of the surgery, visual impairment, depression, residence in assisted-living homes
****Strongest and most consistently found risk factorImportant to do mental status screening before the surgical procedure

Medical illness should also be treated/ controlled

Risk for Post-op delirium

Patient-centered risk in cardiac surgery:

Risk scale in cardiac surgery patients at least 60 yrs old:

(Rudolph et al.,2009),

in

prior history of CVA/ TIA (1 point) Mini Mental Status Exam (MMSE) score (<24: 2 points; 24-7: 1 point) Abnormal serum albumin (1 point) Depressive symptoms (Geriatric Depression Scale score >4: 1 point)

Increasing points- increased risk for delirium:

0 points (~10-20 %); 1 point (40-50%); 2 points (6070%); 3 or more points (80-90%)

Surgical risk factors:

The procedure matters:

Highest reported rates in post-hip fracture and emergent surgery (20-70%), bilateral knee replacements (Williams Russo et al, 1992) & vascular procedures (25-50%); close to 50% incidence in AAA repair (Schneider at al., 2002)
Mast et al., 1996)

Post CABG- earlier studies report higher rates, but recent studies report 10-30% incidences (Van der Occurs in minor surgery as well (1-4% in cataract surgery; 7% in urologic- Summers et al., 1979; Chaudhuri et

al, 1994; Milstein et al., 2002; Hamann et al., 2005;)

Surgical risk factors:

Other surgical factors:

Marcantonio et al., 1998; Bucerius J et al., 2004; Yamagata et al., 2005; Hamann et al., 2005))

blood loss and length of surgery associated with risk for delirium (Knill et al., 1991; Hofste et al., 1997;

Duppils and Wikblad, 2000)

waiting time for hip fracture surgery is associated with delirium rates (Edlund et al., 1999;

Controversy exists about other surgical factors:

Intra-operative BP changes Effect of off-pump by-pass or hypothermic techniques in cardiac surgery

Anesthetic risk factors:

Anaesthetic and other considerations:

Little evidence to suggest that either general or local anesthetics affect a persons chance of having delirium (Williams Russo et al., 1995), although there may be fewer other complications with use of local anesthetics (Rodgers et al., 2000) Peri-operative pain has been found to correlate with postoperative delirium (Lynch et al.,1998; Vaurio et al., 2006, Morrison et al., Delayed ambulation associated with delirium risk (Kamel et This continues to be an evolving field of research and new sedating agents (e.g. dexmedetomidine, an alpha2 agonist) may decrease delirium (Maldonado et al., Psychosomatics 2009; 50
(3): 206-17

2003)

al., 2003)

Post-op factors:
Non-operative, post-operative factors:

Surgical patients can also have medical problems, which need to be ruled out- e.g. post-op MI, infections, reactions to drugs, etc.. Pain or lack of pain medications, narcotics Post-op MIs often do not present with pain Unfortunately delirium is etiologically non-specific (can accompany virtually any condition) Urinary retention, constipation

Possible post-op factors:

Precipitating factors:

Precipitating agent- MULTIFACTORIAL

- Can be caused by any of multiple noxious stimuli- nonspecific: drugs, ANY medical illness, change of environment, catheter and restraint use, ICU setting, surgical setting, sleep deprivation, pain, constipation, urinary retention, environmental change, etc..)

In 10-25% of cases there may not be an underlying offender found (Dubos et al., 1996; Rudberg et al., 1997); this may be even higher in the hip fracture setting (Brauer et al., 2000)

Possible Causes of delirium

I Watch Death mnemonic for possible causes of delirium:

I: W: A: T: C: H: D: E: A: T: H:

Infections Withdrawal Acute Metabolic Toxins, drugs CNS pathology Hypoxia Deficiencies Endocrine Acute Vascular Trauma Heavy Metals
( American Psychiatric Publishing, Inc., www.appi.org. Adapted from Wise (1986)

Delirium Prevention

Hard facts: we dont know how to decrease the complications related to delirium (e.g. functional decline, LTC, death), once it has occurred, and studies related to managing delirium are scarce Once delirium occurs, interventions are less effective & efficient.

(Cole, M., Dementia and Geriatric Cognitive Disorders(1999), p. 406- 411; Cole, M. et al, CMAJ ( 2002), p. 753-759; Inouye, S., Annals of Medicine (2000), p. 257-263, Holroyd-Leduc JM et al, CMAJ (2010); 182(5): 465)

Consider preventative measures from the beginning (especially if at high risk)

Prevention of Delirium

Systematic reviews suggest multifaceted geriatric assessment programs (largely non-pharmacological) may new delirium or delirium length although most trials are not RCTs (Cole et al., 1998, Tabet N et al., 2009, HolroydLeduc JM et al, 2010)

Before-after trials of nursing-based detection and prevention programs suggest they may be effective in cognition and functional outcomes
(Lundstrom et al, 1999; Milisen et al., 2001)

In a recent RCT there was a in incidence and duration of delirium in the group randomized to a multi-factorial intervention program (Lundstrom et al., 2007)

Prevention of delirium

Hospital Elder Life Program targets risk

factors for delirium

(Inouye, S. et al, NEJM (1999), p. 669-676):

Cognitive impairment e.g. orient patients Sleep deprivation e.g. keep environment quiet at night Immobility- e.g. mobilize Visual impairment e.g. provide glasses Hearing impairment e.g. provide hearing aids Dehydration watch for and treat dehydration

Geriatr Soc 2009; 57: 2029-36)

Other studies also support the benefit of non-pharmacologic approaches (Vidan et al., J Am

Management of Delirium
First line interventions are non-pharmacolgical

Identify and treat the medical cause(s) of the delirium Modify the environment & use behavioural strategies to address responsive behaviours such as:

Re-orientate and reassure patient that s/he is safe Talk slowly and calmly, use short simple sentences and instructions Distract to a topic s/he likes

Keep patient safe from self harm or harm to others Educate the patient and family about their delirium

Assessment & Management of Delirium

Determine and treat the underlying precipitant:

1997)

Multiple studies suggest that plurality of causation is common in delirium- often 3 causes found (Francis et al., 1990; Rudberg et al., Contributing factors can include:

2000)

on-going acute medical conditions- e.g. hepatic or renal failure, adverse drug reactions, dehydration (Lawlor et al., less medically acute, care-related, potentially modifiable causes (Francis et al.,1990; Inouye 1999; Brauer et al.,

2000):

E.g. urinary retention, constipation, foley catheters, the use of restraints, sensory deprivation, excessive immobility, and environmental disturbances

Assessment & Management of Delirium

Delirium the medical work-up:

The work up of delirium is largely empiric American Psychiatric Association Practice Guidelines, 1999- consensus based management approach (Am J Psychiatry May 1999; 156
(5): 1-20)

Recommend delirious individuals undergo basic laboratory work-up: lytes, glucose, calcium, albumin, BUN, Creat, AST, ALT, bili, alk phos, Mg, PO4, CBC, EKG, CXR, ABGs (O2 sats), U/A (?Troponin in OR setting?) If clinical uncertainty persists consider: Urine C &S, Urine drug screen, VDRL, heavy metal screen, B12 and folate, ANA, urinary porphyrins, NH4, HIV, blood C & S, serum drug levels, LP, CT/MRI, EEG

Assessment and Management of Delirium

Determine underlying precipitant:

Use I WATCH DEATH mnemonic Easy things to check for: Have they moved their bowels? Have they been toileted (is there urinary retention)? Are they on restraints, or other invasive devices (catheters)? Check their MARS for drugs potentially causing delirium

Drugs:

Anticholinergics, psychotropics: TCAs, gravol, benzodiazepines, even neuroleptics (e.g. Olanzepine), antidepressants, narcotics (never give Demerol) Case reports suggest diverse drugs can be associated with delirium (e.g. quinolones, digoxin)- so consider d/cing what you dont need

Assessment and Management of Delirium

Determine underlying precipitant:

263: 1097-1101)

Studies suggest CNS causes rarely cause for delirium (Francis J et al., JAMA 1990; Advanced cancer may an exception (without known CNS mets) where meningeal involvement has been described in 5-20% of cases (Lawlor et

al., 2000; Olofsson et al. 1996; Tuma et al., 2000)

Assessment and Management of Delirium

Modify the environment and behavioural approaches: bedside manner matters

Try to re-orient delirious person Talk calmly and slowly. Give one step requests to avoid overwhelming person. Provide glasses and hearing aids Place familiar objects in room Too much/too little sensory stimulation? Modify your approach. Try to do task later when patient not resistive. Encourage family to spend time with delirious individual (unless this worsens things)

Non-pharmacologic management
Keeping patients safe- prevent complications:
Are they eating/ drinking/ aspirating?
Consider hydration with IVFs, prevent renal compromise/ failure & electrolyte imbalance, watch for aspiration pneumonia (?SLP consult?)

Are they mobilizing- will prevent deconditioning & pressure ulcers and will help with lung status
Consult PT prn If not contraindicated, mobilize and get up in chair TID

Are they restrained? Do they have unnecessary foley catheters? (both can aggravate their delirium) Are they a fall risk?

Consider discontinuing. Follow Restraint policy if restrained.

Use fall prevention strategies & monitor for falls

Non-pharmacologic management
Non-pharmacologic approaches can duration of, or complications of delirium:

Lancet 2009; 373: 1874-82)

A RCT done in the ICU showed early mobilization decreased the duration of delirium (Schweickert et al., Multifaceted intervention studies suggest that complications can be prevented:

e.g. fewer days of delirium, less delirium, and fewer falls, in both delirious and non-delirious individuals, lower post-op LOS (Lundstrom M, et al. Aging-Clinical &
Experimental Research, 2007; 19 (3): 178-86)

Other management approaches (drugs):

Pharmacological treatments - Not always required:
No evidence that medications alter complications related to delirium No RCTs demonstrate the benefit of psychotropics in non-alcohol withdrawl delirium (Crit Care Med 2010; 38: 428-37) Benzodiazepines can cause paradoxical agitation Other psychotropics can contribute to delirium and can have other significant side effects. Constant observation more effective than restraints, or sedation to keep patient safe.

Management of Delirium
Pharmacological Interventions:
Avoid psychotropic medications when possible If agitation occurs:
Speak with allied healthcare professionals to identify (and avoid if possible) triggers Modify environment and/or care approach. Flex care

In absence of psychotic symptoms or causing distress, or harmful behaviours, treatment of delirium with psychotropic medication is not recommended. Psychotropic medication to control wandering is NOT recommended.

When to use drugs?

Reserve psychotropic medications for older persons with delirium who are distressed due to agitation or psychotic symptoms in order: To carry out essential investigations or treatment. To prevent delirious older person from endangering themselves or others.
CCSMH National Guidelines for Seniors Mental Health: The Assessment and Treatment of Delirium (2006), p.16)

Management of Delirium
Pharmacological Interventions:
When psychotrophic medication used:
Aim for monotherapy, lowest effective dose and taper as soon as possible Monitor for any side effects(CCSMH National Guidelines for Seniors Mental Health: The Assessment and Treatment of Delirium (2006), p.16)

e.g. arm/leg tone, neuroleptic malignant syndrome, postural BPs drops (seroquel) and QTc interval

Use medication with low side-effect profile. Titrate with very small increments Trial for short periods, re-evaluate need for drugs regularly

Management of Delirium
Pharmacological Interventions:
Few studies to determine optimal doses of anti-psychotics in treatment of delirium. Anti-psychotics drug of choice in treatment of delirium
2008). (Ozbolt et al.,

No RCTs to show us that psychotropics improve outcomes for delirium Haloperidol (typical antipsychotic) suggested as anti-psychotic of choice and continues to be first line agent for treatment of symptoms of delirium.
Starting dose of Haldol: 0.25-0.5 mg PRN, increase gradually as needed Use of benztropine and related medications should be avoided in delirium due to anti-cholinergic effects, and should not be started as prophylaxis with haloperidol. (CCSMH National Guidelines for Seniors Mental
Health:The Assessment and Treatment of Delirium(2006), p.42)

Management of Delirium
Pharmacological Interventions

Neuroleptics:

A recent RCT suggested that haldol prophylaxis may delirium duration and length of hospital stay in individuals without delirium pre-operatively, prior to hip surgery, if they are at increased risk for delirium (Kalisvaart et al., 2005)
Given the possible toxicity of neuroleptic use, caution should be exerted, and these results should be verified before prophylactic use becomes recommended

The effect on long or short term functional outcomes is unknown

Management of Delirium
Pharmacological Interventions:

Atypical anti-psychotics:

reasonable alternative agents for older persons with delirium due to fewer EPS side effect (consider especially for individuals sensitive to dopamine- e.g. Parkinsons disease, Lewy body dementia). Slight increase risk of stroke and all-cause mortality with atypical anti-psychotics in persons with dementia.

(CCSMH National Guidelines for Seniors Mental Health: The Assessment and Treatment of Delirium (2006), p.43)

Management of Delirium
Pharmacological Interventions:
Atypical anti-psychotics
(contd)

Clozapine for delirium not recommended because of possible serious hematologic side effects. Studies limited risperidone- most evidence among atypicals in treating symptoms of delirium in adult population Risperidone produces less sedation and negligible anticholinergic effects Quetiapine has fewer parkinsonian side effects but can cause drowsiness and postural BP drops
(CCSMH National Guidelines for Seniors Mental Health: The Assessment andTreatment of Delirium (2006), p.43)

Assessment and Management of Delirium

Pharmacological Interventions: Atypical anti-psychotics
(contd)

Olanzapine can produce over-sedation and gait disturbances, and may have anti-cholinergic side effects, especially at higher doses (Breitbart et al., 2002) Concerns about weight gain, glucose dysregulation and hypercholesterolemia likely less with short duration of treatment; however, use with caution in persons with diabetes mellitus as there is risk of hyperglycemia
(CCSMH National Guidelines for Seniors Mental Health: The Assessment and Treatment of Delirium (2006), p.43)

Assessment and Management of Delirium

Pharmacological Interventions: Atypical anti-psychotics
(contd)

Suggested initial dosing ranges (start low & go slow approach):

Quetiapine:
Start at 6.25-12.5 mg OD-BID, for a few days if person is very frail and elderly Monitor postural BP & P, and if stable, increase slowly

Risperidone 0.25 mg daily to bid Olanzapine 1.25-2.5 mg daily

Assessment and Management of Delirium

Pharmacological Interventions:

Cholinesterase Inhibitors
Increasing interest in use for treatment of symptoms of delirium. Case reports support use of rivastigmine in lithium toxicity induced delirium and in prolonged delirium. Promising, but more research needed to guide clinical practice.
(CCSMH National Guidelines for Seniors Mental Health: The Assessment and Treatment of Delirium (2006),p.44)

Assessment and Management of Delirium

Pharmacological Management
(contd)

Management of Alcohol Withdrawal Delirium (AWD): Rule out other concurrent physical causes for delirium
(CCSMH National Guidelines for Seniors Mental Health: The Assessment and Treatment of Delirium (2006),p. 45)

Benzodiazepines as monotherapy are reserved for older persons with delirium caused by withdrawl from alcohol/ sedative-hypnotics Shorter acting benzodiazepines (i.e., lorazepam) agents of choice in the elderly. Anti-psychotics may be added if psychosis cannot be adequately controlled with benzodiazepines alone. Taper Benzodiazepines following AWD rather than abruptly stopping Give Thiamine
(CCSMH National Guidelines for Seniors Mental Health: The Assessment and Treatment of Delirium (2006),p. 17)

Delirium - Conclusions:
Delirium occurs in all specialties and healthcare sectors Surgical patients are often older with multiple medical conditions Delirium is one of the most common post-operative complications encountered Risk/causes of post-op delirium can involve patient, operative, and post-op factors Must obtain collateral history to obtain baseline mental status, and use an interdisciplinary approach to diagnose and care for a delirious person Management requires a systematic approach since anything can contribute to delirium

Delirium - Conclusions:
Preventive and non-pharmacologic interventions are first line before pharmacological therapies Little evidence presently that psychotropics improve outcomes

Psychotropics have well known side effects Use psychotropics only when needed Neuroleptics (haldol or Risperidone) in low doses for aggression or psychosis; Quetiapine reasonable option Monitor tone & for NMS, postural hypotension, QTc interval Start with low dose, increase slowly, constantly review need for psychotropics and wean asap when delirium resolves

Benzodiazepines only indicated in specific casesalcohol or benzodiazepine withdrawl

Case 1

A 78 year old man is admitted for elective AAA repair PMH: MI (3 years ago), DM II, OA Meds: Glyburide, ASA, metoprolol, tylenol #3 (typically takes 2 before bed) What is important to do/ask to assess his risk for post-op delirium?

Case 2

A 67 year old man is admitted for elective right knee replacement (arthorplasty) PMH: AAA repair (with post-op delirium), CAD, MI (3 years ago), heavy EtOH use with withdrawl, GERD, HTN Possible h/o depression/ anxiety- started on Nortryptiline 6 months ago (on 75 mg OD) Although was independent in ADLs, wife relays 6 month h/o memory decline (once he mistook his grand-dtr for his m-i-l)

Case 2

Now 8 days post-op, and very confused, hallucinating, requiring restraints because of safety concerns (fear of falling) When we saw him, he was restrained and thought he was in a gay bar, and his speech was illogical and nonsensical What would you do next?

Case 2

MARS review- receiving lorazepam up to 6 times per day (EtOH withdrawl initial indication), on baclofen, tylenol 650 mg qid, nortryptiline 75 mg OD, norvasc, metoprolol No BM in 8 days Recent urinary retention Recent labs otherwise WNL What would you do now?

Case 3

Mrs. P- 76 year old woman on the Plastics service (s/p excision of facial SCC, seen 5 days post-op)- RFR- weakness, confusion, falls Intermittent confusion throughout hospital stay

e.g. called husband telling him I have to go to the hospital e.g. at times thought her husband was her father

C/O severe pain

Case 3

Collateral history

declining STM for one and half years, worse in last 3-4 months (e.g. forgetting what she ate in the AM or where she went the day before) declining ability to do certain IADLs (e.g. meal preparation) largely because of back pain

Case 3

PMH: HTN, DM, CRF, severe DDD, h/o right parotid lymphoma (radiated 1999), prior DVT x 2 Present drugs: tylenol PRN, percocet PRN (not received in days), bromazepam 6 mg QHS, ranitidine 150 mg OD, amlodipine 7.5 mg, thyroxine 0.1 mg, detrol 1 mg BID, dyazide, multivits, glyburide, amitryptiline 100 mg OD, metoprolol 75 mg BID, coumadin

Case 3

O/E- pleasant, alert and cooperative, not depressed Fatigued- with only partial co-operation with cognitive testing- 7/10 on orientation, 1/3 on 5 min recall, -1 on WORLD backwards (attention), preseverative, problems misplacing hands on clock Neuro- non-focal except for cognitive problems
Qs: What does she have? Would this have been expected? What next?

Selected References:

American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC, 1994. American Psychiatric Association. (1999). The American Journal of Psychiatry, (Supplement), 156(5). American Psychiatric Publishing, Inc., www.appi.org. Adapted from Wise (1986) Brauer C, Morrison RS, Silberzweig SB et al. The cause of delirium in patients with hip fracture. Arch Intern Med. 2000; 160: 1856-60. Breitbart W., Tremblay A., Gibson C. An open trial of olanzapine for the treatment of delirium in hospitalized cancer patients. Psychosomatics. 43(3)(pp 175-182), 2002 Breitbart W., Tremblay A., Gibson C. The Delirium Experience: Delirium Recall and Delirium-related distress in Hospitalized patients with cancer, their spouses/caregivers and their nurses. Psychosomatics. 43(3)(pp 183194), 2002 Bucerius J, Gummert JF, Borger MA et al. Predictors of delirium after cardiac surgery delirium: effect of beating-heart (off pump) surgery. J Thorac & Cardiovasc Surg 2004; 127 (1): 57-64. CCSMH (Canadian Coalition for Seniors Mental Health) National Guidelines for Seniors Mental Health-The Assessment and Treatment of Delirium, 2006. Chaudhuri S, Mahar RS, Gurunadh VS. Delirium after cataract extraction: a prospective study. J Indian Med Assoc 1994; 92 (8): 268-9

Selected References:

Cole MG, Primeau FJ & Elie M. Delirium: prevention, treatment, and outcome studies. J Geriatr Psychiatry Neurol 1998; 11: 126-137. Cole, M. (1999). Delirium: Effectiveness of systematic interventions. Dementia and Geriatric Cognitive Disorders, 10, 406-411. Cole, M. G., McCusker, J., Bellavance, G., Primeau, B. J., Bailey, R. F., Bonnycastle, J. J., et al. (2002). Systematic detection and multidisciplinary care of delirium in older medical inpatients: A randomized trial. Canadian Medical Association Journal, 167(7), 753-759 Dolan MM, Hawkes WG, Zimmerman SI, et al. Delirium on Hospital admission in aged hip fracture patients: prediction of mortality and 2-year functional outcomes. J Gerontol (Med Sci) Sep 2000; 55A (9): M527M534. Duppils GS, Wikblad K. Acute confusional states in patients undergoing hip surgery. A prospective observation study. Gerontology 2000; 46: 3643. Edelstein DM, Aharonoff GB, Karp A et al. Effect of postoperative delirium on outcome after hip fracture. Clinical Orthopaedics & Related Research 2004; 422: 195-200 Edlund A, Lundstrom M, Lundstrom G et al. Clinical profile of delirium in patients treated for femoral neck fractures. Dement Geriatr Cogn Disord 1999; 10: 325-29 Edlund A, Lundstrom M, Brannstrom B et al. Delirium before and after operation for femoral neck fracture. J Am. Geriatr Soc 2001; 49: 13351340

Selected References:

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