Week 1 Module B: Instructions
 Please view video 2 and review charts
prior to starting this module.
 When you see this slide, put the mouse
pointer over it and right click.
 In the menu of options, click "full screen."
 This opens the presentation. To advance
the slides, either use the mouse or the
arrow keys on the keyboard.
Week 1 Module A: Instructions
 For each question, please choose one
answer that best addresses the question and
then hit “click here.”
 For those slides where there are "click
here" instructions, please do so or else you
might skip over slides.
Week 1 Module B: Question 1
 Mrs. Rivera has now been in the hospital for one
full day; she was sent to BMC straight from
clinic. What is the ICD-9 diagnosis of her
cognitive status in video clip 2?
 A. Δ MS click here
 B. Dementia with sundowning click here
 C. Delirium click here
 D. Acute mental status change click here
Delirium Takes Various Forms
 It’s obvious that Mrs. Rivera has hyperactive
delirium now:
– 25% of all delirium cases are hyperactive
 However, there is also a hypoactive form:
– Less recognized or appropriately treated
 Mixed: with hypo- and hyperactive features
 Additional features include emotional and
psychotic symptoms
Week 1 Module B: Question 2
 Your initial evaluation of the etiologies of Mrs.
Rivera’s delirium should include all of the
following EXCEPT:
 A. Complete history, including what prn meds
were given overnight click here
 B. Vital signs and oxygen saturation click here
 C. Complete physical exam, including
neurological exam click here
 D. CT scan of head click here
Always see the delirious
hospital patient!
 When the nurse pages you about an
agitated, hyperactive delirious patient,
resist the urge to order medications or
restraints over the phone.
 GO EXAMINE THE PATIENT
BEFORE TAKING ACTION
Evaluation begins with history
& physical
 Focus on time course of cognitive changes
esp. their association with other symptoms
or events
 Medication review, including OTC drugs,
alcohol, prn meds
 Vital signs, oxygen saturation
 General medical evaluation
 Neurologic and mental status examination
Week 1 Module B: Question 3
 Mrs. Rivera has a temp of 101.2 despite one day
of antibiotic treatment, no nuchal rigidity, rales in
the left base, and a non-focal neuro exam. She
has not received any prn medications recently.
 Given her history and exam findings, the
following tests are appropriate to order as part of
the initial evaluation EXCEPT:
 (go to next slide)
Week 1 Module B: Question 3
continued
 A. CBC click here
 B. BMP click here
 C. UA and urine C&S click here
 D. TSH click here
 E. EKG click here
Evaluation: Laboratory Testing
 Base on history and physical
 Think of possible precipitating factors and let this
guide your choice of testing
 Include electrolytes, renal function tests, CBC,
and UA for every patient (these are high yield)
 Cerebral imaging rarely helpful, except for head
trauma or new focal neuro findings
 EEG and CSF rarely helpful, except for
associated seizure activity or signs of meningitis
Management: General Principles
 Requires interdisciplinary effort by MDs,
nurses, family, others (such as PT)
 Multifactorial approach is most successful
because multiple factors contribute to
delirium in most cases
 Failure to diagnose and manage delirium:
life-threatening complications, loss of
function, costly
Keys to Effective Management
 TREAT THE UNDERLYING DISEASE
 Address contributing factors
– Including medications: see if you can reduce
or eliminate suspected contributors
Week 1 Module B: Question 4
 Because Mrs. Rivera is agitated, initial
management should include all of the following
EXCEPT:
 A. Wrist restraints and Posey vest click here
 B. Asking family members to stay with her click
here
 C. Removal of the Foley catheter click here
 D. Placing her in a cardiac chair at the nurses
station click here
Always try nonpharmacologic
measures first
Nonpharmacologic Management








Presence of family members
Interpersonal contact and reorientation
Provide visual and hearing aids if needed
Remove indwelling devices (such as Foley
catheters) ASAP
Wrap IV lines in kerlix (so patient can’t see
them)
Mobilize patient as soon as possible
Keep patient awake during the daytime
Provide uninterrupted sleep at night
Week 1 Module B: Question 5
 Despite the presence of family members,
removal of the Foley catheter, and giving
Mrs. Rivera her glasses, she remains
agitated and refuses to take her meds. The
most appropriate next management step is:
 A. lorazepam 2 mg IV click here
 B. haloperidol 1 mg IV click here
 C. haloperidol 5 mg IV click here
Pharmacologic Management
 Reserved for patients at risk for harm of self
or others
– Including refusal to take potentially life-saving
treatment
 Use LOW DOSE antipsychotic agents
 Remember: haloperidol and other antipsychotics
have side effects
–
–
–
–
Anticholinergic
Orthostatic hypotension
Extrapyramidal side effects and acute dystonias
Can prolong the QT interval
Management: Hyperactive,
Agitated Delirium
 Avoid pharmacologic or physical restraints
 If absolutely necessary, use haloperidol
(IV, IM, or PO)
– For mild delirium: 0.25-0.5 mg PO or 0.1250.25 mg IV/IM
– For severe delirium: 0.5-1 mg IV/IM repeated
every 30 min until patient is calm (total dose =
loading dose)
Key Points about
Antipsychotic Use
 Patients who have never been exposed to
haloperidol or antipsychotics in the past
will usually only need less than 5 mg as a
total loading dose
 If patient is willing to take PO, try low
doses of atypical antipsychotics such as
olanzepine and risperidone
– lower risk of extrapyramidal side effects than
haloperidol
What about Ativan (lorazepam)?
 Second line agent
 Reserve for:
– Sedative and ETOH withdrawal
– Parkinson’s Disease
– Neuroleptic Malignant Syndrome
AVOID RESTRAINTS AT ALL
COSTS:
Measure of LAST(!!!) resort
Can delirium be prevented?
YES! Prevention is possible.
 Find patients who do not have delirium with 1-4
of the following predisposing characteristics :
– Visual impairment (worse than 20/70 corrected)
– Severe illness
– Cognitive impairment (MMSE<24/30)
– High BUN/Cr ratio (>18)
– (Inouye SK et al. Ann Intern Med. 1993; 119:474-481)
 Give them the following targeted interventions:
Prevention=Good Hospital Care for the
Elderly Patient (Inouye SK et al. NEJM. 1999;340:669-76)
RISK FACTOR
INTERVENTION
Cognitive impairment
Orientation protocol, cognitively
stimulating activities 3x/day
Sleep deprivation
Nonpharmacologic protocol, noise
reduction, schedule adjustments
Immobility
Ambulation or active ROM
exercises; minimize equipment
Visual impairment
Glasses or magnifying lens,
adaptive equipment
Hearing impairment
Portable amplifying devices,
earwax disimpaction
Dehydration
Early recognition and volume
repletion
A Multicomponent Intervention to
Prevent Delirium
(Inouye SK et al. NEJM. 1999;340:669-76)
Outcome
(n=852)
st
1
delirium
episode
Total days
delirium
# delirium
episodes
Interv.
group
9.9%
Usual care Statistical
group
analysis
15%
OR=0.60
(95% CI
0.39 to 0.92)
105
161
P=0.02
62
90
P=0.03
Take Home Points: Delirium in
the Elderly
 A multifactorial syndrome arising from a
patient’s predisposing vulnerability and
precipitating insults
 Delirium can be diagnosed with high sensitivity
and specificity using the CAM
 Prevention should be our goal
 If delirium occurs, treat the underlying causes
 Try nonpharmacologic approaches first
 Use low dose antipsychotics in severe cases
 Avoid physical restraints
References and Resources





Inouye SK. Delirium in hospitalized older patients. Clinics in Geriatric
Medicine.14(4):745-64, 1998.
American Psychiatric Association: Practice Guideline for the Treatment of Patients
with Delirium, May 1999.
Inouye SK et al. A Predictive Model for Delirium in Hospitalized Elderly Medical
Patients Based on Admission Characteristics. Ann Intern Med. 119:474-481, 1993.
Inouye SK et al. A Multicomponent Intervention to Prevent Delirium in Hospitalized
Older Patients. NEJM. 340(9): 669-76, 1999.
Delirium. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine,
Teaching Slides. Volume 1, Fifth Edition. Blackwell Publishing, copyright American
Geriatrics Society, 2003.
 click here to end
Delirium is the diagnosis with
an ICD-9 code
 Because Mrs. Rivera’s MMSE is 22/30, it is
possible that she may have dementia and that her
agitation could be due to the “sundowning”
phenomenon.
 However, “sundowning” does not have an ICD-9
code.
 Again, assume delirium until proven otherwise,
as it may be the only manifestation of acute lifethreatening illness in elders.
 click here for the correct answer
Delirium is the diagnosis with
an ICD-9 code.
 Oftentimes, you will see Δ MS or acute
mental status change written in chart notes.
 However, these entities do not have ICD-9
codes.
 Delirium has its own ICD-9 codes:
– Delirium = 780.09
– Acute delirium = 293.0
 click here for the next slide
Correct answer.
 Yes, this is delirium.
 ICD-9 code = 780.09
 click here for the next slide
Initial evaluation should always
include…
 A complete history: including what
medications were given prn during the last
24 hours.
 A comprehensive physical exam: including
vital signs, skin examination to look for
pressure sores, and neurological and
mental status examinations (i.e. CAM)
 click here for the correct answer
Correct answer.
 A head CT scan should be ordered only after you
have obtained a history and done a physical exam
of the delirious patient.
 If the history is suggestive of a fall with possible
head trauma, then a CT scan is warranted.
 If the physical exam reveals focal neuro deficits,
then a CT scan is appropriate.
 click here for the next slide
This test is appropriate to order.
 For all delirious elderly patients, order a basic
metabolic profile (sodium disorders, hypo- or
hyperglycemia, hypercalcemia, and prerenal
azotemia).
 Given the likely presence of infection, checking a
CBC is warranted.
 Given Mrs. Rivera’s persistent fever and Foley
catheter, check a UA and urine culture.
 An EKG is appropriate given her risk factors for
cardiac ischemia (HTN, age > 65).
 click here for the correct answer
Correct answer.
 Of the choices for testing, checking a TSH
level is the least likely to yield an etiology
given the time course of her symptoms.
 Usually, cognitive changes of hypo- and
hyperthyroidism worsen gradually over
time.
 click here for the next slide
Nonpharmacologic measures
should always be initiated first.
 Since Mrs. Rivera is yelling out for her daughter,
asking family members to stay with her might
calm her down.
 Does Mrs. Rivera really need the Foley catheter?
Probably not, and it’s likely to be one source of
her agitated delirium.
 Sometimes placing agitated patients in cardiac
chairs by the nursing station (without any
physical restraints) can calm them down.
 click here for the correct answer
Correct answer.
 Pharmacologic and physical restraints are
last-resort measures.
 They should never be used before
nonpharmacologic interventions are
attempted.
 click here for the next slide
Avoid benzodiazepines
 Mrs. Rivera is agitated now, not anxious.
 Therefore, lorazepam is not the ideal medication
choice.
 Furthermore, 2 mg of lorazepam is too high an
initial starting dose.
 Remember: benzodiazepines increase falls risk in
elderly patients (another reason to avoid this class
of meds).
 click here for the correct answer
Start low, go slow.
 Haloperidol 5 mg is too large a dose to use
in an elderly patient who is not accustomed
to taking antipsychotic medications.
 You are likely to make Mrs. Rivera quite
lethargic with this dose.
 click here for the correct answer
Correct answer.
 Haloperidol 1 mg IV is a reasonable
medication and dose to give at this time.
 Because Mrs. Rivera has never taken
antipsychotic medications in the past, a
small dose of haloperidol will likely be
sufficient to calm her down.
 click here for the next slide
End of Week 1 Module B