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
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
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.
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
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.
