Published On: 06/05/2023
Duration: 16 minutes, 05 seconds
Dr. Hendrick: Delirium is one of the most serious problems facing hospitalized patients. It nearly doubles a patient’s risk of death and often produces irreversible cognitive and functional impairment. It is extremely common, occurring in approximately one in five inpatients, with even higher rates among patients in surgery units and ICUs. Despite the high prevalence, more than half of delirium cases go undetected.
In this podcast, we will review key points in the diagnosis, workup, and management of this acute confusional state.
Welcome to The Carlat Psychiatry Podcast
This is a special episode from The Carlat Hospital Psychiatry Report.
I’m Dr. Victoria Hendrick, the Editor-in-Chief of The Carlat Hospital Psychiatry Report, and a clinical professor at the David Geffen School of Medicine at UCLA. I’m also the director of inpatient psychiatry at Olive View -- UCLA Medical Center.
Prabhjot Gill: And I’m Prabhjot Gill, I am the podcast content coordinator at Carlat Publishing and I will also be attending graduate school this year to receive my doctorate in psychology.
To effectively identify and treat delirium, we must have a thorough understanding of its clinical features. Delirium describes an acute change from a patient's baseline mental status, and is marked by inattention, disorientation, and thought disorganization.
Dr. Hendrick: Symptoms fluctuate throughout the day and patients may appear lucid for brief periods. Additionally, their sleep-wake cycles are often disrupted, and they may demonstrate a broad range of emotions or experience hallucinations.
Prabhjot Gill: Dr. Hendrick, what are the different classifications of delirium?
Dr. Hendrick: Delirium is categorized into hypoactive, hyperactive, and mixed. Patients experiencing hypoactive delirium may go undetected since they appear withdrawn and may seem to be resting peacefully. When we receive a consult for "depression," we make sure to evaluate the patient for hypoactive delirium. On the other hand, patients experiencing hyperactive delirium require close attention on medical or surgical floors. These patients are agitated and hypervigilant, and often are combative or refuse care. We consider a consult for "psychosis" or "mania" to actually be a hyperactively delirious patient until proven otherwise. Patients in a mixed delirium state alternate between the hypoactive and hyperactive states.
Prabhjot Gill: Certain factors put individuals at greater risk for developing this condition. They include a history of delirium, being over the age of 65, having preexisting cognitive impairment or dementia, taking multiple medications, and having underlying medical conditions. These are what we refer to as predisposing risk factors.
Dr. Hendrick: In addition to these predisposing factors, there are certain triggers, known as precipitating factors, that directly contribute to the onset of delirium. They include taking certain medications like anticholinergics or opioids, having acute medical conditions such as meningitis, sepsis, or stroke, undergoing surgery, experiencing dehydration, being physically restrained, going through alcohol or drug withdrawal, or experiencing prolonged sleep deprivation. The more risk factors present, the greater the likelihood of delirium occurring.
Prabhjot Gill: So Dr. Hendrick, how should clinicians approach identifying and evaluating for delirium?
Dr. Hendrick: First, it's important to speak with the provider taking care of the patient and to carefully review the patient’s chart, paying close attention to recent changes in their vital signs, labs, and medications. When we go into the patient's room, we start with basic questions about their comfort in the hospital, food intake, etc as we attempt to build rapport. These questions help us assess the patient's level of alertness and cognitive impairment as well as any distrust or paranoia. Patients often don't remember everything clearly, so it's also useful to get collateral history from nurses, therapists, or family members.
Prabhjot Gill: Diagnosing delirium can be complicated due to its fluctuating course. Patients may present with normal mental status for one healthcare provider, but be sleepy, disorganized, or wildly confused for another, so, repeat evaluations are critical to make an accurate diagnosis. Dr. Hendrick are there any tools you recommend using to improve delirium screening and diagnosis?
Dr. Hendrick: Yes definitely. There are several useful tools available to improve delirium screening and diagnosis. One commonly used tool is the Confusion Assessment Method (CAM), which is widely recognized around the world and has high sensitivity and specificity (>90%) and inter-rater reliability. There’s also a shortened version known as the 3-Minute Diagnostic Assessment CAM (3D-CAM). For critically ill patients in the ICU, we use the CAM-ICU. Another good tool is the 4 A's Test (4AT), which is a brief (<2 minutes) screening instrument that requires no special training and is available in multiple languages. The four A's in the 4AT test stand for Alertness, Attention, Abbreviated Mental Test 4 (AMT-4), and Acute change. Although its sensitivity and specificity are slightly lower than the CAM, it remains a valuable option. Other tests of attention can also be helpful, such as asking the patient to spell "world" backwards, subtract serial 7s or 3s, repeat a span of digits, or recite the days of the week or the months of the year in reverse order.
Prabhjot Gill: How can clinicians go about figuring out what's causing a patient's delirium?
Dr. Hendrick: To begin, we start with a physical and neurological exam, looking at vital signs, medications (new or recently stopped), and whether the patient has been using alcohol or drugs. We also check for possible infections, metabolic or electrolyte issues, and make sure to rule out any life-threatening causes like Wernicke's encephalopathy, hypoxia, hypoglycemia, hypertension, hyper/hypothermia, intracerebral hemorrhage, meningitis/encephalitis, poisoning, and status epilepticus. If available, we also look through the nursing notes and flowsheets for any indicators of pain, bowel or bladder function, and recent malnutrition or dehydration.
Prabhjot Gill: We’ve talked about the causes and features of delirium, but what can be done to prevent and treat it?
Dr. Hendrick: To reduce the incidence of delirium, nonpharmacologic and multicomponent strategies are very effective, especially in non-ICU patients. Orientation and cognitive stimulation, as well as sleep enhancement, are two of the most important strategies. So, we provide patients with adequate lighting, signs, calendars, and clocks to help them stay oriented to time, place, person, and your role. And, we encourage activities that stimulate their cognitive abilities, such as reminiscing, and we facilitate regular visits from family and friends.For sleep enhancement, we try to avoid medical or nursing procedures during sleep whenever possible, and schedule medications in a way that won’t disrupt sleep. It’s also important to reduce nighttime noise levels. We strongly recommend using melatonin (1-5 mg PO at bedtime) or ramelteon (8 mg PO at bedtime) to help patients maintain regular sleep patterns in the hospital.
Prabhjot Gill: Can you tell me more about early mobilization, hydration, infection prevention, and nutrition assistance?
Dr. Hendrick: Absolutely. Early mobilization is crucial and encourages patients to move around as soon as possible after surgery. We recommend regular ambulation and keep walking aids, like canes or walkers, nearby. Range-of-motion exercises are also helpful.Hydration is another important strategy. We encourage patients to drink fluids and, if necessary, we provide IV fluids. However, for patients with comorbidities like heart failure or renal disease, it's important to seek advice on fluid balance.
Infection prevention is also key. We look for and treat any infections, avoid unnecessary catheterizations, and implement infection control procedures to prevent the spread of infections.
Lastly, regarding nutrition assistance, we seek advice from the hospital dietician. For patients with dentures, we make sure they fit properly so patients can maintain proper nutrition.
Prabhjot Gill: We also recommend several other strategies.Firstly, it's important to assess oxygenation status by checking for hypoxia and monitoring oxygen saturation.
Pain management is another important strategy. Assess for pain, especially for patients with communication difficulties. Monitor pain management in patients with known or suspected pain.
Review the patient's medication list for both types and number of medications as part of the psychoactive medication review strategy.
Lastly, work on resolving reversible causes of vision and hearing impairment. For example, ensure hearing and visual aids are available, working, and being used by patients.
Dr. Hendrick: And remember that if patients become delirious despite these interventions, it is still important to continue the strategies we mentioned to prevent further worsening of the delirium.Moving on to treatment, the first-line approach is to quickly address any underlying medical causes.
In some cases, agitated patients with hyperactive or mixed delirium may not respond to non-pharmacologic strategies or verbal redirection. Antipsychotics are the most frequently used class of medications for delirium treatment, despite lacking FDA approval for this indication. However, studies have shown limited effectiveness on mortality or the duration and severity of delirium.
Prabhjot Gill: If antipsychotics are shown to have limited effectiveness, is there any reason to use antipsychotic medications for delirium?
Dr. Hendrick: They can still be helpful for patients who are acutely agitated and at risk of harming themselves or others; or are distressed, often due to severe anxiety or psychotic symptoms such as paranoia or hallucinations; or have not responded to attempts at verbal redirection or other behavioral strategies.
Prabhjot Gill: Which antipsychotics do you recommend?
Dr. Hendrick: Typical and atypical antipsychotics are both useful, with the choice of medication influenced by availability, route of administration, and staff familiarity. For most patients, the gold standard is to start with haloperidol IV as needed (in cardiac-monitored settings, given the risk of QT prolongation and torsades de pointes), with a dosage of 0.5-5 mg based on age, size, and severity of agitation. However, if the initial dose is ineffective after 20-30 minutes, subsequent doses can be doubled until the patient is calm. In older patients, we typically start with lower doses and use caution for patients with Parkinsonism, HIV-associated dementia, or evidence of Lewy body disease. In these cases, we often use olanzapine, with a dose of 2.5-5 mg that can be given IM or in a dissolvable oral form if necessary. If there is any concern for active or recent neuroleptic malignant syndrome, we avoid antipsychotics entirely. We obtain a baseline ECG to assess and trend QTc when we use antipsychotics, although in emergent situations, we must weigh the risk of QT prolongation against the risks to patient or staff safety.
Prabhjot Gill: What are the potential risks associated with using antipsychotics to manage agitation in delirious patients?
Dr. Hendrick: Great question. Given their potential sedative effects, antipsychotics can give us a false sense of reassurance that the delirium has been effectively “treated,” while the medical issues remain unaddressed. This can lead to a transition towards a more hypoactive delirium, with associated risks such as aspiration and immobility.
Prabhjot Gill: And what should clinicians do if antipsychotics are contraindicated?
Dr. Hendrick: If antipsychotics are contraindicated, maybe because of cardiac comorbidities or QT prolongation, there are alternative initial treatments we can use, like Valproic acid. We start it at 125-250 mg three times daily, and it can be administered IV if necessary. This medication provides additional benefits for patients with delirium who have a history of mood disorder, traumatic brain injury, or dementia. In addition, you can also consider alpha-2 agonists such as dexmedetomidine; or clonidine 0.1-0.2 mg every six hours, especially when transitioning patients from dexmedetomidine in non-ICU settings. Trazodone, starting at 25-50 mg at bedtime, is a useful option for targeting both agitation and sleep cycle disturbances. It is worth noting that we generally avoid benzodiazepines as they can worsen delirium, and we only use them in cases of delirium secondary to alcohol or sedative/hypnotic withdrawal. The FDA’s recent FDA approval of a sublingual formulation of dexmedetomidine (Igalmi) is likely to expand its use to other settings beyond emergency rooms and ICUs, such as medical and psychiatric inpatient units.
Prabhjot Gill: Overall, remember that delirium is a common yet frequently missed condition in hospitalized patients. It's linked with functional and cognitive decline and a significantly elevated risk of death. Non-pharmacologic, multi-component interventions, including cognitive stimulation, frequent reorientation, and sleep improvement, are highly effective in preventing its onset. Use medications sparingly, primarily to keep patients and staff safe and to help patients be more comfortable, while you work to identify and treat the underlying cause.
Dr. Hendrick: The newsletter clinical update is available for subscribers to read in The Carlat Hospital 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.
Prabhjot Gill: And everything from Carlat Publishing is independently researched and produced. There’s no funding from the pharmaceutical industry.
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Prabhjot Gill: And don’t forget, you can now earn CME credits for listening to our podcasts.
As always, thanks for listening and have a great day!