Treatment of delirium involves correction of the underlying medical disturbance. But how do we best think through potential causes? Dr. Aziz shares his systematic approach and clinical pearls in conducting a physical exam and ordering the appropriate work-up.
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Published On: 12/26/22
Duration: 18 minutes, 22 seconds
Referenced Article: “Assessing and Treating Delirium in Older Adults,” The Carlat Geriatric Psychiatry Report, July 2022
Dr. Aziz: Delirium is one of the most perplexing psychiatric findings in older adults. It's defined as a disturbance of attention and a change in cognition. It's important to distinguish it from other causes of altered mental status, like dementia. Delirium affects both cognition and a person's level of alertness while dementia affects cognition but preserves consciousness. In this episode we will shed some light on assessing and working up delirium in older adults.
Welcome to The Carlat Psychiatry Podcast.
This is another episode from the geriatric psychiatry team.
I’m Rehan Aziz, an associate professor of psychiatry and neurology at Hackensack-Meridian School of Medicine. I am also the associate program director for geriatric psychiatry at Jersey Shore University Medical Center in Neptune, NJ.
Zachary Davis: And I’m Zach Davis. I am a research update editor at Carlat Publishing and I’m currently applying to medical school over the 2022-2023 application cycle.
Dr. Aziz: We have some exciting news for you! You can now receive CME credit for listening to this episode and all new episodes going forward on this feed. Follow the Podcast CME Subscription link in the show notes to get access to the CME post-test for this episode and future episodes.
Zachary Davis: Let's begin by discussing how to accurately assess delirium in older adults.
Dr. Aziz, what should clinicians be looking for during an assessment and how do we uncover the source of a delirious episode?
Dr. Aziz: First and foremost, it is important to get an idea of the time frame over which the symptoms developed. Being aware of the length of an episode of delirium can provide insight when choosing the next steps of treatment and uncovering the etiology of the episode. What I will do is speak with friends and family to get an idea of when and how the episode began. For patients in the hospital, I will talk with hospital staff, especially nurses, to get their input regarding the patient's symptoms and behavior, and I will review the medical record.
Zachary Davis: So would a longer episode be considered a more critical or dangerous episode?
Dr. Aziz: It's actually hard to say. I think I get concerned when patients have an episode limb that's not resolving. because it indicates that they may not do well in the long term, that unfortunately the confusion may not fully dissipate. If it's an episode that's been brought on acutely and rapidly, then I'm concerned for life threatening causes like brain hemorrhages, metabolic disturbances and so on.
Zachary Davis: Ok, so clinicians should inquire about the time frame over which the symptoms developed, the length of an episode, and speak with friends and family. But what commonly causes delirium in older patients?
Dr. Aziz: Yeah, great question, Zach. So delirium is a relatively common cause of altered mental status and it is always caused by an underlying medical condition. In some respects, it's actually not a mental health disorder, and it belongs more in the realm of internal medicine or primary care because medical conditions are always triggering it. Mental health clinicians are often called upon to assist in managing these patients, because many of them will have behavioral and psychological symptoms that require our expertise. In older adults the most common causes are usually infections. So urinary tract infections, also known as bladder infections or pneumonia, and most recently with the pandemic we're seeing high numbers of COVID induced delirium. That's why it's important to identify the primary cause of the delay, but correcting it is going to be the primary treatment.
Zachary Davis: Ok, but there are many mental health clinicians that might not be responsible for treating core medical illnesses. What steps can they take?
Dr. Aziz: Yes, so while mental health clinicians may not be responsible for treating poor medical illnesses or even diagnosing them, we can review the work that's been done to make sure that nothing has been forgotten. We can also review medication lists to make sure that there aren't any medications prescribed that could be worsening or contributing to the delirium. In the outpatient setting, what I typically do is if I suspect a patient has delirium is I will refer them immediately, either to the emergency room or to their primary care doctor depending upon the severity of the symptoms for further assessment and testing.
Zachary Davis: Should they also pay attention to risk factors?
Dr. Aziz: Definitely. The best treatment for delirium is prevention. Paying attention to risk factors can help prevent or shorten the course of delirium. Predisposing risk factors increase the risk of delirium while precipitating risk factors trigger delirium. You can refer to the contributing causes of delirium table in the transcript to learn more about risk factors and causes of delirium.
Zachary Davis: I will definitely check that out. Are there any other medical procedures or assessments that can help provide information toward the origin of a patient’s altered mental status?
Dr. Aziz: We can learn a lot just by observing the patients, so watching them as they come into the exam room, watching them in the exam room. I would pay careful attention to the patients head, eyes and skin. Beginning with the head we can look for signs of head trauma which could suggest a hemorrhage or another injury that could be contributing to the confusion. There's something called battle sign. This is bruising behind the ear, and that can actually indicate a possible skull fracture.
While looking at the eyes, I look at the pupil size. Small pupils can suggest opioid toxicity and dilated pupils or widened pupils are seen with anticholinergic toxicity and we know that anticholinergic medications can actually trigger or pause delirium. Bulging eyes can be a sign of hyperthyroidism, infection or trauma. Some patients might have paralysis of outward eye movements and that can be an indicator of wernickes encephalopathy, which is a complication of alcohol use disorder caused by thiamine deficiency. And finally, yellow eyes indicate liver failure due to increased levels of bilirubin, which can also trigger delirium.
Lastly, I'd look at the skin. Jaundice or yellowing at the skin, suggests the presence of liver disease. Dry or rough skin is seen in hypothyroidism. Darkened or bronze skin can indicate Addison's disease. Also, keep an eye for drug patches. Some, like fentanyl or scopolamine, can also contribute to altered mental status.
Zachary Davis: Alright. So just to quickly summarize: Observing the length of an episode and the time frame over which the symptoms developed provides information regarding the time frame over which the symptoms developed. Paying attention to risk factors can help prevent or shorten the course of delirium. And a focused physical exam of the head, eyes, and skin can provide information about the origin of a patient’s AMS.
Can a neurological examination tell us anything about a patient’s altered mental status? If so, what should clinicians look out for?
Dr. Aziz: So Zach, in assessing patients with learned cognitive testing, is really critical in making that diagnosis and should always be done. Clinicians should look out for disorientation and impaired attention. Impaired attention is actually the hallmark of delirium.
There are a couple of different ways to assess it, so one is by asking the patient to repeat the days of the week backwards starting with Sunday as well as to provide the specific day of the week. In one study, if both answers were incorrect, this screen had 93% sensitivity and 64% specificity in picking up delirium.
Other tests that I'll administer are the mini mental status exam, the Montreal Cognitive Assessment, and a test that I really like, called the 3D Cam. And Cam, stands for Confusion Assessment Method. This test is available online and actually makes it very easy to assess for and diagnose delirium.
Zachary Davis: Are there other psychiatric disorders that can also cause altered mental status?
Dr. Aziz: Yes, so the big one is actually dementia, and it's important to be able to differentiate delirium from dementia. In delirium, what we're seeing is an active medical issue I mentioned earlier. Bladder infections, pneumonia are top causes. We're seeing a disturbance that comes on rapidly. Dementia is a little bit different. Usually, dementia has a chronic progressive course, so it takes years to develop and progresses slowly over many years. Patients don't have an active medical cause of the dementia. And then the other hallmark I mentioned earlier was that in delirium we see deficits and level of attention. In dementia we don't see that. Usually people have a clear level of consciousness, meaning that they're alert.
Zachary Davis: Since delirium in older adults is often due to a combination of factors, how should providers best tailor their workups?
Dr. Aziz: That's a great question, Zach, and I'm glad that you asked it. First you highlighted that delirium is often multifactorial so we're not just looking for one cause we're looking for multiple causes. So don't stop once you've come across the first thing that you think might be contributing to the patients delirium and keep looking for other causes. What I will do is systematically assess the patient from a medical and psychiatric lens looking for active medical or psychiatric conditions that could be contributing to the delirium. I will then assess the patient’s medications to see if there are any, such as anticholinergic medications that could be causing their altered mental status. I will also review or discuss with the patient what over the counter products they're using, because some can also contribute to confusion. Don't forget about substance use. Many of our older patients are starting to use substances. It increased rates than previous generations, including cannabis. So I will ask patients about their substance use as well as consult data from prescription drug monitoring programs which tell us about what controlled substances a patient may be prescribed. Additionally, I will check drug levels and obtain alcohol and urine tox screens.
Zachary Davis: Are there any specific labs you recommend ordering?
Dr. Aziz: So the standard workup includes checking a complete blood count, a basic metabolic panel, glucose, liver function tests, urinalysis and culture, urine toxicology and alcohol levels, vitamin B12 folate, and thyroid stimulating hormone.
Zachary Davis: Could you walk through each lab and talk about key features we should be looking out for?
Dr. Aziz: Sure Zach, so let's start with the complete blood count. This is an assessment of the patient’s hemoglobin, hematocrit, white blood cells, and platelets. Elevated white blood cells can indicate an infection, but keep in mind, older adults may not always have an elevated white blood cell count when sick due to their age.
The basic metabolic panel is an accounting of the patient’s glucose, kidney function, and electrolytes like sodium. Sodium levels, either high levels or low levels can contribute to delirium. So can calcium. So these are things we need to monitor for.
Kidney dysfunction can also contribute to confusion by causing a buildup of toxic chemicals like urea.
A glucose test helps you check immediately for hypoglycemia, meaning too little sugar or hyperglycemia, meaning too much sugar. Hypoglycemia can be quickly reversed with orange juice and crackers, and sometimes if that is the only cause of the delirium, it can result in rapid improvement of symptoms.
In looking at liver function tests, I'll pay attention to the ammonia level and bilirubin levels. If either one is too high, it can contribute to the patient’s confusion.
So another critical test is urine analysis and culture since urinary tract infections commonly cause delirium in older adults. On a urinalysis, we might see white blood cells and other abnormalities. The test will often automatically reflect a culture, meaning that if the urinalysis suggests an infection then it will be grown in a culture medium which will tell us what specific bacteria has been detected and what antibiotics it is sensitive to. It's worth mentioning that many older adults will have asymptomatic urinary tract infections. The current thinking is that these do not contribute to delirium and are not necessarily treated, so we are only treating or recommending treatment for urinary tract infections that are associated with symptoms such as increased urinary frequency, painful urination, and so on.
Finally, be aware that when measuring thyroid stimulating hormone, also known as TSH, both hyper and hypothyroidism, can cause altered mental status in older adults.
Zachary Davis: Besides the standard customary lab workup, are there any other tests you recommend ordering
Dr. Aziz: In select cases I might consider ordering a syphilis test. Syphilis unfortunately has been making a comeback, and each year I'm seeing one or two positive cases of syphilis. Luckily, most strains are still susceptible to penicillin. I might also consider ordering HIV and EKG, chest X-ray, antinuclear antibody test, a lumbar puncture, EEG and head CAT scan or brain MRI based on the patient’s presenting symptoms.
Zachary Davis: In this podcast, we discussed the time frame of delirium, predisposing and precipitating risk factors, differential diagnoses, labs, and how providers can use physical and neurological exams to learn about the origin of a patient's altered mental status.
Dr. Aziz: The newsletter clinical update is available for subscribers to read in The Carlat Geriatric Psychiatry Report. Hopefully, people will check it out. Subscribers get print issues in the mail and email notifications when new issues are available on the website. Subscriptions also come with full access to all the articles on the website and CME credits.
Zachary Davis: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.
Dr. Aziz: Yes, the newsletters and books we produce depend entirely on reader support. There are no ads and our authors don’t receive industry funding. That helps us to bring you unbiased information that you can trust.
Zachary Davis: And don’t forget, you can now earn CME credits for listening to our podcasts. Just click the link in the description to access the CME post-test for this episode.
As always, thanks for listening and have a great day!