CHAMP: Bedside Teaching

ASSESSING AGITATED DELIRIUM

Andrea Bial, MD

Teaching Trigger:

At morning bedside rounds, the team reports that an elderly patient was agitated overnight, and they feel she is delirious at present (by CAM or other criteria).

I.Clinical Questions:

  1. What are all the possible precipitating factors for delirium?
  2. What are the most likely causes in this older hospitalized patient?

Teaching Points:

  1. There are a multitude of possible causes of delirium.
  2. There is no one “gold standard” approach to the evaluation of the patient with delirium.
  3. Any approach used must be sufficiently broad to include all possibilities and yet specific enough to be able to remember and apply.
  4. Approximately half of hospitalized seniors with delirium have more than one cause of their delirium.
  5. Don’t forget in-hospital precipitating causes, eg., being awakened for vital signs, blood draws, restraint use, etc.
  6. Most common causes: medications (see below), infection, dehydration, or electrolyte imbalance.
  7. Medications/too little: think about possibility of alcohol or other drug withdrawal.
  8. Medications/too much: including, but not limited to…

Antibiotics (aminoglycosides, PCN, ceph, sulfa)

Benadryl

Benzodiazepines (triazolam, alprazolam, diazepam)

Digoxin

GI (Reglan, Bentyl)

Lithium

Narcotics

Neuroleptics

Steroids

NSAIDS (indocin)

H2 Blockers (Cimetidine)

Parkinsons drugs (Ldopa, Cogentin, Amantadine)

  1. Do not overlook anticholinergic properties of medications!

AntivertIpratropium

AtaraxLevsin

AtropineOxybutynin

BentylPhenergan

BenadrylQuinidine

CogentinTolterodine

ElavilWelbutrin

FlexerilZyprexa

  1. Conditions frequently causing/contributing to delirium:
  2. CNS: head trauma, seizures, vascular diseases
  3. Metabolic: uremia, liver failure, anemia, hypoxia, hypoglycemia, thiamine deficiency, dehydration, electrolyte imbalance, acid-base imbalance
  4. Cardiopulmonary: MI, arrhythmia, shock, respiratory failure, CHF
  5. Systemic illness: infection, neoplasm, trauma, sensory deprivation, postoperative state

II.Clinical Questions:

  1. What are the important parts of the evaluation in a newly delirious older patient?
  2. Why are historical questions focused on prior history of dementia or suspected memory problems important?

Teaching Points:

  1. Systematic Approach
  2. The evaluation and management frequently need to occur simultaneously (e.g., patient may be agitated and need to be calmed down, as you also investigate the cause of his/her delirium).
  3. History: need to get a complete history from the patient (although may be the least helpful source), the family or friends, and the nurse (and possibly other hospital folks—don’t overlook such sources as the patient’s roommate).
  4. Focus on when the delirious behavior started (i.e., when the patient became inattentive with disorganized thinking and/or altered level of consciousness).
  5. Focus on whether or not there is a history of dementia, or any suspected memory problems.
  6. Need a history of sundowning and dementia to diagnose sundowning; this is a diagnosis of exclusion!
  7. Remember there is a close relationship between dementia and delirium.
  8. Those diagnosed with dementia are at increased risk of delirium when in the hospital.
  9. Those diagnosed with delirium (without previous diagnosis of dementia) are at increased risk of developing dementia after discharge.
  10. Remember also that delirium and dementia with agitation are not the same, although the evaluation and management may be similar.
  11. Physical Exam
  12. Need to do a complete exam, from head to toe, including rolling patient over to look at sacral area for decubitus ulcers.
  13. If new focal finding found, proceed to next logical step (e.g., if patient is febrile with a new cough, then you might culture, get CXR and treat for pneumonia).
  14. If new focal neurologic finding is discovered, then proceed with head CT. There is no evidence to support the routine ordering of head CTs in hospitalized seniors with delirium.
  15. Medications (also see above)
  16. Do a complete review of patient’s medication list, noting any new medications or any recent dose changes.
  17. Do not assume that because a patient is only on his/her “home” list of medicines that one of them could not be contributing to the delirium; you need to gather further history to ensure patient was actually taking what was prescribed.
  18. Additional tests
  19. Order additional tests that are indicated by findings in history or exam.
  20. May need to “pan-test” if no obvious etiologies found; focus on CBC, BMP, LFTs, thyroid studies, B12, urinalysis, drug levels, urine tox levels, CXR, EKG.
  21. Consider EEG, head CT

III.Clinical Question:

What is the significance of recognizing and making the diagnosis of delirium in the aging patient?

Teaching Points:

  1. Patients diagnosed with delirium are at increased risk for:
  2. longer hospitalizations
  3. more in-house comorbidity (falls, pressure sores, new incontinence)
  4. greater rate of discharge to Long-Term Care Facilities
  5. later diagnosis of dementia
  6. higher mortality rate post-discharge
  7. Dictate diagnosis of delirium on discharge summary.