dr. peter chan, md, frcpc consult-liaison and geriatric psychiatrist, vancouver general hospital....

Dr. Peter Chan, MD, FRCPC

Consult-Liaison and Geriatric Psychiatrist,

Vancouver General Hospital.

Clinical Associate Professor,

UBC Dept. of Psychiatry

Collaborators

UBC Care for Elders ModuleDr. Martha Donnelly, MD, FRCPCDr. Ram Randhawa, MD, FRCPC

VGH Nursing Education Module (VCHA)Ms. Wendy Marr, RNMs. Maureen Shaw, RN, MN

Disclosure

Honouraria for speaker engagements:

Astra-Zeneca Eli-Lilly Janssen-Ortho

Guidelines: Categories of Evidence:

Ia Evidence from meta-analysis of randomized controlled trialsIb Evidence from at least one randomized controlled trialIIa Evidence from at least one controlled study without randomizationIIb Evidence from at least one other type of quasi-experimental

studyIII Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control

studiesIV Evidence from expert committees reports or opinions and/or clinical experience of respected authorities

Shekelle et al 1999

Guidelines: Strength of Recommendation

A Directly based on category I evidenceB Directly based on category II evidence or extrapolated recommendation from category I evidenceC Directly based on category III evidence or extrapolated recommendation from category I or II evidenceD Directly based on category IV evidence or extrapolated recommendation from category I, II, or III evidence

Shekelle et al 1999

What’s in the Guideline Background Prevention Detection, Assessment, Diagnosis &

Monitoring Management Legal and Ethical Issues Education Systems of Care Research on Delirium Future Considerations

Canadian Coalition For Senior’s Mental Health: Practice Guidelines

Predisposing FactorsInouye, SK et al. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Intern Med 1993; 119:474-481

cognitive impairment sleep deprivation immobility visual impairment hearing impairment dehydration

Screening Under-recognition, esp. in those:

Over 80 y.o. with hypoactive delirium with visual impairment and/or pre-existing dementia○ Inouye et al. Arch Int. Med 2001

No reliable screening tool to differentiate delirium and dementia

Practically, acute-onset and/or fluctuation in cognition/function/abnormal behaviours

Others signsNew onset aphasia or dysarthriaNew onset or worsening incontinence

Confusion Assessment Method (Inouye et al. Ann.Int.Med. Dec.15/90)

acute onset and fluctuation AND inattention AND disorganized thinking OR altered level of consciousness

excellent sensitivity, good specificity

Screening Instruments

We recommend…

The Confusion Assessment Method is recommended for screening on acute medical/surgical wards and in the ER (C)

CIWA-Ar is recommended for monitoring symptoms of alcohol withdrawal (C)

Precipitating Factorsin HospitalInouye and Charpentier, JAMA 1996; 275: 852-57

Physical restraints (RR=4.4)

Malnutrition (RR=4.0)

More than 3 medications added (RR=2.9)

Use of bladder catheter (RR=2.4)

Any iatrogenic event (RR=1.9)

Use of RestraintsWe recommend…

Physical restraints for geriatric patients suffering from delirium should be applied only in exceptional circumstances when: (D)

a) There is a serious risk for bodily harm to self or others OR

b) Other means for controlling behaviours leading to harm have been explored first, including pharmacologic treatments, but were ineffective AND

c) The potential benefits outweigh the potential risks of restraints

Pharmacologic ManagementWe recommend…

Psychotropic medications should be reserved for older persons with delirium that are in distress due to agitation or psychotic symptoms, in order to carry out essential investigations or treatment, and to prevent older delirious persons from endangering themselves or others. (D)

In the absence of psychotic symptoms causing distress to the patient, treatment of hypoactive delirium with psychotropic medications is not recommended (D)

The use of psychotropic medications for the specific purpose of controlling wandering in delirium is not recommended (D)

Pharmacologic Management

We recommend…

Antipsychotics are the treatment of choice to manage the symptoms of delirium (with the exception of alcohol or benzodiazepine withdrawal delirium). (B)

Haloperidol is suggested as the antipsychotic of choice based on the best available evidence to date. (B) Initial dosages are in the range of 0.25 mg- 0.5 mg. Od-bid (D)

Atypical antipsychotics may be considered as alternative agents as they have lower rates of extra-pyramidal signs. (B)

Benztropine should not be used prophylactically with haloperidol in the treatment of delirium. (D)

Pharmacologic ManagementWe recommend…

In older persons with delirium who also have Parkinson’s Disease or Lewy Body Dementia, atypical antipsychotics are preferred over typical antipsychotics. (D)

Sedative-hypnotic agents are recommended as the primary agents for managing alcohol withdrawal delirium (B). Their use in other forms of delirium should be avoided (D).

Pharmacologic Management: Guidelines

Frequency:• Regular vs. Prn; nighttime dosing

Dosages:

haloperidol 0.25-0.5 bid (watch QTc) risperidone initiated at 0.25 mg od-bid olanzapine at 1.25-2.5 mg per day quetiapine at 12.5-50 mg per day

Haloperidol in Delirium Management

“Evidence” based on 1 RCT (Breitbart 1996)AIDS Dementia population

Comparator to atypicals (3 RCT’s in Cochrane)

Prolonged QTc, especially I.V.– baseline ECG

Risk of Extrapyramidal Symptoms, esp. elderly>4.5 mg/day in Cochrane Review

Loxapine in Delirium Management

Conventional antipsychotic with atypical properties Singh et al Journal of Psychiatry and Neuroscience, 21:29-35

Mid-potency in D2 receptor blockade

Effect on D1, D4, 5-HT2, NMDA receptors

Parenteral IM/SC (IV in monitored setting)

Widespread use in Vancouver Over 3500 VGH inpatients with Delirium since 1989 Use in all settings, including CCU, CSICU, ICU, ACE units Dosing 5-150 mg/d (B.I.D. dosing at 1600h and 2000h)

Subsequent Considerations

Risks of Atypical AntipsychoticsMortalityCVA or related eventsMetabolic syndrome (less likely if short duration)

Use of Cholinesterase Inhibitors

Treatment of Hypoactive Delirium

Summary of Key Points in Managing Geriatric Delirium

Screening is important in identifying cases.

Haloperidol is recommended based on available evidence, but atypicals are alternatives, esp. in those sensitive. Loxapine a viable alternative.

The elderly can have prolonged delirium, and slower to recover in cognition and function when delirium has cleared.

Guideline and Literature Review

1. American Psychiatric Association. Practice guideline for the treatment of patients with delirium. 1999.

2. British Geriatrics Society. Guidelines for the diagnosis and management of delirium in the elderly. 1999-2000

3. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med 2002;30(3):119-41.

4. Management of alcohol withdrawal delirium: an evidence-based guideline. Arch Intern Med 2004;164(13):1405-12.

5. Iowa Veterans Affairs Nursing Research Consortium. Research-based protocol: acute confusion/delirium. Iowa City, Iowa: The University of Iowa Gerontological Nursing Interventions Research Centre: Research Dissemination Core; 1998.

6. Screening for delirium, dementia and depression in older adults. Toronto (ON): Registered Nurses Association of Ontario; 2003.

7. Caregiving strategies for older adults with delirium, dementia and depression. Toronto (ON): Registered Nurses Association of Ontario; 2004.

8. Sharon Inouye. Delirium in Older Persons. NEJM 354:1157-1165 March 16, 2006 Number 11

9. Gregory Fricchione. Postoperative Delirium. Am J Psychiatry 165:803-812, July 2008

Web Resources Care for Elders Interactive Delirium Module

UBC Division of Geriatric Psychiatrywww.careforelders.ca

VIHA Delirium informationhttp://www.viha.ca/ppo/learning/delirium

Virginia Case StudyCare for Elders Interactive Delirium Module

A Quality Improvement Project

M. McKnight, H. Nagi, K. Ng, C. Reid, P. TamSponsored by Dr. A. Hill and Dr. P. Lee

Delirium Working Group

Why: Problem of idiosyncratic & disparate patterns of practice

Mission: Use literature & expert opinion to establish best practice Standardize approach to patient careImplement best practice through PPOs and staff education

Collaboration of experts at VGH and the region, established Nov 2006

Geriatricians& Internists

Psychiatrists& Geri-psychiatrists

Intensivists

GeneralSurgeons

Nurses

1

1

2

2

33

PRISME: Maureen Shaw, RN, MN

P - PAINR- RESTRAINT, RETENTIONI - INFECTIONS - SENSORY IMPAIRMENT,

SLEEPLESSNESSM - MEDICATION, METABOLICE - ENVIRONMENT, EMOTIONS

PPO: Pg 1

PPO: Pg 1

PPO: Pg 2

PPO: Pg 2