HWN Suggests

Delirium in the Elderly: A Diagnosis Often Missed

It’s important to differentiate delirium from common mimics such as psychotic illness and dementia. In contrast to delirium, dementia occurs over a longer period of time, doesn’t fluctuate, and has an insidious onset. Dementia is the leading risk factor for delirium, but the two are distinct entities. Psychotic disorders are differentiated from delirium by their chronic courses with exacerbations as well as normal level of consciousness and otherwise lack of slurred speech...

In sicker geriatric patients requiring sedative drips, some evidence suggests that the use of dexmedetomidine over propofol may reduce delirium.

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  The Delirium Triage Screen (DTS)

Given its high sensitivity, the DTS is an excellent delirium rule-out screen; if negative, no additional delirium assessment is needed. If the DTS is positive, however, a more specific or confirmatory assessment is needed to rule-in delirium

  Confusion Assessment Method

Establishes ability to detect delirium in high risk settings.

 In an Emergency Setting, What Is the Best Intramuscular Pharmacological Treatment to Give to an Agitated Geriatric Patient?

Current research supports the use of olanzapine in treating elderly patients with agitation. It is then recommended to use olanzapine over haloperidol and ziprasidone for use in elderly patients. Both the intramuscular and oral administration of olanzapine seem efficacious in this patient population and offer safety advantages over other medications.

 Screening for Delirium in the Emergency Department: A Systematic Review

In summary, the recognition of delirium by providers appears to be central to the management and provision of appropriate care to affected older adults in the ED. Two delirium screening tools have been identified as being most frequently used in the literature, though only 1 tool, the CAM instrument, has undergone initial validation for use in the ED environment.

 The Seriousness of Deliriousness: Delirium in the ED

The ABIM Choosing Wisely Campaign has noted this “Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation or delirium.” Non-pharmacologic methods are by far the best to treat delirium.

 TIPS for Managing the Acutely Agitated Patient

It is rare for an older adult to develop a new psychiatric condition resulting in presentation to the ED with agitation. More frequently, an agitated geriatric patient has an underlying medical cause contributing to their altered mental status and behavioral dysregulation. Data is limited on which drugs are best; in general, it is recommended to use much lower doses than in the general population, as older adults are more susceptible to adverse events. PO medications are preferred over IV, with the recommendation to start with olanzapine 2.5-5 mg, Haldol 1-2 mg PO, or risperidone < 1 mg PO. If unable to tolerate or take PO medications, IM administration is recommended over IV.

Articles of Interest

Delirium

Quetiapine 25-50 mg PO might be the best agent...

Assessing and Managing Delirium in Older Adults

First line medications: Risperidone 1 mg PO Olanzapine 2.5-5 mg PO or IM Quetiapine 50 mg PO Haloperidol 1-2.5 mg PO or IM Ziprasidone 10 – 20 mg IM

Asynchrony EM: Dementia and Delirium in the ED

There are lots of 'sexy' neuro topics we could be starting off with, but we're starting with care of elderly patients with dementia and delirium in the emergency department. We'll look at how to differentiate between the two diagnoses (which can co-exist), talk about best practices for caring for these patients in the ED, about the burden on caregivers, and some of the more 'humanistic' aspects of dementia.

Delirium: A Marker of Vulnerability in Older People

Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors.

Dexmedetomidine: a magic bullet on its way into palliative care—a narrative review and practice recommendations

Complex situations of hyperactive delirium, severe pain or sedation might be managed through the administration of dexmedetomidine, especially if standard care was not effective or is likely to cause harm. Much caution is recommended in patients with cardiac comorbidities.

EM approach to Geriatric Patient: Pearls & Pitfalls

Avoid benzodiazepines with delirium, they can paradoxically worsen it – UNLESS patient is on chronic benzodiazepines (make sure it’s for a good reason), then consider use as it could be benzo withdrawal. Avoid Haldol – Haldol can lead to fatal reactions in Parkinson’s disease and prolonged QT interval; if neither condition is present (once you’re sure), then use a LOW dose. AVOID Haldol 5mg in anyone over 55. Use magnesium sulfate to treat long QT interva.

emDocs Cases: ED Approach to Agitation

Benzodiazepines are associated with poor outcomes, even with one dose, and should be avoided.97,98 FGAs and SGAs can be used first-line, but close evaluation of the patient’s medication list is recommended, as the combination of an antipsychotic with other QTc prolonging agents can further increase the QTc interval.

Excited Delirium: Acute Management in the ED Setting

Excited delirium syndrome is a common yet poorly characterized ED presentation with a wide differential diagnosis. Patients are often identified initially by law enforcement, but attempts to control individuals experiencing ExDS via physical, chemical, or electrical restraints are associated with an exceedingly high rate of morbidity and mortality.

How can we better detect delirium in older emergency department patients?

The ideal screening tool to detect delirium needs to be simple, rapid to perform at the bedside, and require no extra equipment. The Ottawa 3DY (O3DY) is a bedside screening tool that possesses such characteristics. When performing the O3DY, an older patient is asked the following: date, day, dlrow (spell ‘world’ backwards) and year. Any incorrect response is considered a positive screen for cognitive dysfunction. The O3DY has been previously shown to have moderate sensitivity and specificity to detect cognitive dysfunction among ED patients.

Is delirium the medical emergency we know least about?

Either haloperidol or risperidone should be started at a dose of 0.25 mg for frail elders or in patients that are naïve to the drug (or 0.5 mg otherwise). Avoid re-dosing within 4 h. Risperidone quicklets can be offered dissolved in juice or sublingually.

Pitfalls of Delirium Screening in Older Adults

Hypoactive delirium is the most common form of delirium. Delirium (whether hypoactive, hyperactive, or mixed) is associated with an increased risk of intensive care admission, prolonged hospital stay, long-term cognitive decline, and death.

Underdiagnosed Delirium on Elderly Patients in the Emergency Room

In this study Delirium was present in 22% of the 118 patients analysed and only 5.1% had the diagnosis of Delirium recorded in the medical record. This result shows that underdiagnose of Delirium is not uncommon. We, therefore, recommend the use of CAM scale in patients over 65 years old to diagnose Delirium, during their stay in the emergency service, paying special attention to patients with metabolic affections

Use 5-Part Tool to Manage Delirium and Agitation in Older ER Patients

The "ADEPT" tool for delirium and agitation provides care guidelines for emergency department clinicians.