Opiate overdose due to excessive use of oxycodone Subdural hematoma



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  • Opiate overdose due to excessive use of oxycodone

  • Subdural hematoma

  • Medication-induced delirium

  • Alcohol intoxication

  • Dementia-related sundown phenomenon



Acute onset, altered level of consciousness, and memory impairment.

  • Acute onset, altered level of consciousness, and memory impairment.

  • Acute onset, disorganized thinking, and inattention.

  • Acute onset, altered level of consciousness, and executive dysfunction.

  • Acute onset, inattention, and hallucinations.

  • Acute onset, hypervigilant, and disorganized thinking.



CBC.

  • CBC.

  • Electrolytes.

  • Blood sugar.

  • Urine analysis.

  • CT of the head.



Describe a systematic approach to assessing an older patient presenting with altered mental status

  • Describe a systematic approach to assessing an older patient presenting with altered mental status

  • Recognize negative consequences of missed diagnosis of delirium

  • Describe distinguishing features of delirium and dementia

  • Identify risk factors of delirium

  • Discuss the diagnosis and management of delirium in the ED setting.



Common in ED, and more than 25% of older ED patients are cognitively impaired

  • Common in ED, and more than 25% of older ED patients are cognitively impaired

  • Frequently missed and recognized only 28-38% of the time

  • Broadly categorized as delirium or cognitive impairment without delirium

  • Approx. 10% of older ED patients suffer from delirium and identification is really poor (16-36% of cases)



Level of consciousness or arousal

  • Level of consciousness or arousal

  • Cognition: content of consciousness



Consciousness is the ability of a person to be able to receive information, process that information, and then act upon it. A normal level of consciousness consists of a patient who is alert and attentive

  • Consciousness is the ability of a person to be able to receive information, process that information, and then act upon it. A normal level of consciousness consists of a patient who is alert and attentive

    • Hyperalert/vigilant - Stupor
    • Normal - Coma
    • Lethargic/somnolent
  • Tools: AVPU, GCS, RASS( Richmond agitation assessment scale)



Orientation: place, time, person

  • Orientation: place, time, person

  • Attention: Attention refers to the person’s ability to focus on a given task ,such as naming the months backwards or spelling ‘‘world’’ backwards or digit span test

  • Memory: New and old memory

  • Executive function: Ability to judge a situation, shift parameters, plan, and appropriately take action

  • Tools: Mini Cog, MMSE, Six Item Screener



IF an older adult presents to an ED, THEN the ED provider should carry out and document a cognitive assessment (such as an indication of level of alertness and orientation or an indication of abnormal or intact cognitive status) or document why a cognitive assessment did not occur

  • IF an older adult presents to an ED, THEN the ED provider should carry out and document a cognitive assessment (such as an indication of level of alertness and orientation or an indication of abnormal or intact cognitive status) or document why a cognitive assessment did not occur

  • IF an older adult is found to have cognitive impairment, THEN an ED care provider should document whether there has been an acute change in mental status from baseline (or document an attempt to do so).





DLB is the second most common subtype of dementia (after Alzheimer’s disease) and affects 15% to 25% of elderly patients with dementia

  • DLB is the second most common subtype of dementia (after Alzheimer’s disease) and affects 15% to 25% of elderly patients with dementia

  • Characterized by a rapid decline and fluctuation in cognition, attention, and level of consciousness

  • Perceptual disturbances are frequently observed in patients with DLB

  • Patients with DLB have parkinsonian motor symptoms, such as cog wheeling, shuffling gait, stiff movements, and reduced arm swing during walking.



“Acute confusional state”

  • “Acute confusional state”

  • “Acute brain failure”

  • “Sundowning”

  • “Encephalopathy”

  • “ICU psychosis”



Powerful prognostic marker associated with in-hospital and long term mortality

  • Powerful prognostic marker associated with in-hospital and long term mortality

  • Increased mortality risk in patients who are discharged home from ED with delirium

  • Poses a significant threat to the quality of life

  • Costs more that $100 billion in direct and indirect charges



DSM-IV-TR

  • DSM-IV-TR

    • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention.
    • A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established, or evolving dementia.
    • The disturbance develops over a short period of time and tends to fluctuate during the course of the day.
    • There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.


Acute onset

  • Acute onset

  • Fluctuating course

  • Inattention

  • Disorganized thinking

  • Altered level of consciousness



Hyperactive

  • Hyperactive

    • Agitation, combativeness, restlessness, hallucinations
    • Easiest to recognize (loud, disruptive patients)
  • Hypoactive

    • Depressed, sedated, somnolent and even lethargic
    • More likely to go unrecognized (“good patients”)
  • Mixed

    • Features of both hypo and hyperactive delirium


Can be split into two categories

  • Can be split into two categories

    • Predisposing factors
      • “Pre-hospitalization”
      • Can alert the physician/staff to risk but are often non modifiable in the acute setting
      • For at risk patients, efforts can focus on prevention
    • Precipitating factors
      • “Post-hospitalization”
      • Often iatrogenic
      • Often modifiable
      • Often preventable




Demographics

  • Demographics

    • Advancing Age
    • Male gender
  • Co-Morbidity

    • Dementia
    • No./severity of co-morbid conditions
    • Functional impairment
  • Sensory impairment

    • Hearing
    • Visual


Systemic

  • Systemic

    • Infection
    • Inadequate pain control
    • Trauma
  • Metabolic

    • Electrolyte disturbance
    • Hepatic or renal failure
    • Hypoglycemia
  • Medications and drugs

    • Meds and meds changes
    • Drugs or drug withdrawal


Sedatives-hypnotics

  • Sedatives-hypnotics

    • Benzodiazepines
    • Antihistamines
  • Narcotics

  • H 2 blocking agents

  • Antiparkinsonian meds

  • Anticonvulsants



Confusion Assessment Method (CAM)

  • Confusion Assessment Method (CAM)

  • CAM- ICU

  • Delirium Symptom Interview (DSI)

  • Delirium rating scale

  • Memorial Delirium Assessment Scale (MDAS)

  • Nursing Delirium Screening Scale (NuDESc)





    • Scale based on degree of consciousness
    • Visual recognition to test attention and short-term memory
    • Head nodding and hand movements as responses
    • Sensitivity and specificity comparable to the basic CAM








Widespread imbalance of neurotransmitters & disruption of synaptic communication resulting from

  • Widespread imbalance of neurotransmitters & disruption of synaptic communication resulting from

    • Drugs
    • Hypoxemia, metabolic derangements → global impairment of cerebral metabolism → decreased synthesis and release of neurotransmitters
    • Systemic inflammation → activation of microglia→ increased cytokine levels
  • Some studies support the notion that CNS blood flow may be disrupted during delirium



History:

  • History:

    • Time course of mental status changes
    • Baseline mental status and cognition
    • History of trauma, fall
    • Medication review, any recent changes
    • Alcohol abuse
  • Physical exam:

    • Vital signs
    • Emphasis on neurologic including mental status, cardiovascular, pulmonary exam
    • Signs of infection, volume status


Delirium

  • Delirium

  • Structural CNS process

  • Non-convulsive status epilepticus

  • Psychiatric illness



Search and treat the underlying cause

  • Search and treat the underlying cause

  • Create a safe environment for the patient and staff

  • Psychotropic meds reserved for patients in distress due to severe agitation or psychotic symptoms

  • Aim for monotherapy, lowest effective dose, and tapering as soon as possible

  • Antipsychotics are the treatment of choice

  • Use of Benzodiazepines should be avoided

    • Reserved for delirium caused by withdrawal from alcohol/sedatives hypnotics


Haloperidol is suggested as the antipsychotic of choice based on the best available evidence to date

  • Haloperidol is suggested as the antipsychotic of choice based on the best available evidence to date

    • Haloperidol, 0.25-1.0 mg IM/PO: evaluate effect in 30 minutes to 1 hour. Administer additional doses until agitation is controlled (max 3-5mg/24 hours)
    • Clinical endpoint should be an awake but manageable patient
    • A subsequent maintenance dose consisting of ½ loading dose over 24 hours in divided doses - taper 2-3 days
    • Baseline EKG is recommended prior to initiation of IV Haldol to measure baseline QT interval
  • Atypical antipsychotics may be considered as alternative agents, lower rates of extra pyramidal signs

    • Risperidone: 0.25 - 0.5 mg PO or oral dissolvable, q8-12 hrs
    • Olanzapine: 2.5 - 5 mg IM q1h prn, 2.5 - 5 mg PO QD
    • Quetiapine: 12.5 - 25 mg PO q8-12 hrs prn, 12.5 - 25 mg PO BID


Discontinue or decrease drugs

  • Discontinue or decrease drugs

  • Supportive care and reorientation

  • Glasses/hearing aids

  • Attention to patient concerns & fears

  • Remove immobilizing lines and devices

  • Avoid restraints



Low threshold for admission

  • Low threshold for admission

  • Delirious patients discharged from ED more likely to return and be hospitalized

  • When admitted to the hospital, admission to a specialized geriatric unit preferable

  • Regardless of patient disposition, delirium detected in ED should be communicated to the physician at next stage of care



3. IF an older adult presenting to an ED is found to have cognitive impairment that is a change from baseline and is discharged home, THEN the ED provider should document the following:

  • 3. IF an older adult presenting to an ED is found to have cognitive impairment that is a change from baseline and is discharged home, THEN the ED provider should document the following:

    • Support in the home environment to manage the patient’s care
    • A plan for medical follow-up


In any patient with a change in mental status consider delirium as possible diagnosis

  • In any patient with a change in mental status consider delirium as possible diagnosis

  • Consider altered mental state to be acute until proven otherwise

  • Delirium is very common in the ED and is often missed

  • Missing delirium can result in loss of a window of opportunity to diagnosis and treat reversible medical and surgical conditions that can present as delirium



Terrell KM, Hustey FM, Hwang U, et al. Quality indicators for geriatric emergency care. Acad Emerg Med 2009;16(5):441-449.

  • Terrell KM, Hustey FM, Hwang U, et al. Quality indicators for geriatric emergency care. Acad Emerg Med 2009;16(5):441-449.

  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000.

  • Han JH, Zimmerman EE, Cutler N, et al. Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes. Acad Emerg Med 2009;16(3):193–200.

  • Inouye SK, Charpentier PA. Precipitating factors for delirium in hospitalized elderly persons: Predictive model and interrelationship with baseline vulnerability. JAMA 1996;275(1):852-857.

  • Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: The Confusion Assessment Method: A new method for detection of delirium. Ann Intern Med 1990;113(12):941-948.



Pompei P, Foreman M, Cassel CK, et al. Detecting delirium among hospitalized older patients. Arch Intern Med 1995;155(3):301-307.

  • Pompei P, Foreman M, Cassel CK, et al. Detecting delirium among hospitalized older patients. Arch Intern Med 1995;155(3):301-307.

  • Ely EW, Margolin R, Francis J, et al. Evaluation of delirium in critically ill patients: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001;29(7):1370-1379.

  • Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166(10):1338-1344.

  • Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: Reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003;289(22):2983-2991.

  • Gunther ML, Morandi A, Ely EW. Pathophysiology of delirium in the intensive care unit. Crit Care Clin 2008;24(1):45-65.

  • Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: Diagnosis, prevention and treatment. Nat Rev Neurol 2009;5(4):210-220.





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