LaurieLaurie ArchbaldArchbald--Pannone,Pannone, M.D.,M.D., MPHMPH AssistantAssistant ProfessorProfessor GeneralGeneral Medicine,Medicine, Geriatrics,Geriatrics, andand PalliativePalliative CareCare UniversityUniversity ofof VirginiaVirginia Goals
1. Differentiate Normal Cognitive Lapse, Mild Cognitive Impairment, Delirium, & Dementia. 2. Understand initial evaluation for Dementia 3. Understand initial evaluation for Delirium
Mrs. M. is a 70 year old woman seen in ER with agitation
HPI: 2 months ago, her daughter died unexpectedly, and she has been more depressed. One week ago, she became agitated and uncooperative. PMHx: thalamic CVA, bipolar illness, chronic pain, and osteoarthritis.
Meds: tylenol with codeine, valproate, lithium, conjugated estrogens with progesterone, and aspirin. Course: She was seen in the ER, where labs and CXR were normal. A consulting psychiatrist recommended clonezapam. Course (con’t) : Despite the clonazepam, she worsened, and became uncontrollable at home. She went back to the ER, where she had a fluctuating level of consciousness. CBC, renal panel, and CXR were normal. An EKG showed a LBBB (old) with slight ST changes from last EKG. Troponin level was 2.9. On further questioning, the patient admitted that she has some shortness of breath 5 days prior. Questions: 1. How do you interpret her presentation? 2. Is her mental status due to delirium or dementia? Why?
Mr A. is a 67 yo male referred from another hospital for inpatient evaluation for “failure to respond” to therapy for depressive episode. HPI: 2 month history of depressed mood, sleeping difficulties, decreased interest in his usual activities, withdrawal from his family and friends, decreased appetite, and a 10 pound weight loss PMHx: HTN, ↑Lipids, no h/o MDD Meds: HCTZ, amlodipine, simvastatin ; “medications for mood ” were started at the referring facility, but tapered prior to transfer due to side effects and worsening depression ROSROS (per(per Mrs.Mrs. A):A): memorymemory hashas beenbeen ““gettinggetting badbad”” forfor atat leastleast severalseveral years;years; beganbegan actingacting suspicioussuspicious aboutabout thethe governmentgovernment asas longlong asas aa yearyear ago;ago; urinaryurinary retention,retention, constipation,constipation, orthostasisorthostasis,, andand pseudoparkinsonismpseudoparkinsonism,, allall resolvedresolved offoff medicationsmedications startedstarted atat previousprevious hospitalhospital PEPE:: BPBP 190/110;190/110; appearsappears sadsad andand hopeless,hopeless, difficultdifficult toto engageengage inin conversation,conversation, initiallyinitially showsshows motormotor retardation,retardation, butbut laterlater inin thethe interviewinterview becomesbecomes agitatedagitated whenwhen discussingdiscussing hishis condition;condition; orientedoriented exceptexcept toto dayday andand month;month; unableunable toto rememberremember 33 itemsitems afterafter 55 minutes;minutes; neurologicneurologic examexam isis positivepositive forfor snoutsnout reflexreflex andand bilateralbilateral graspgrasp reflexes;reflexes; remainderremainder ofof examexam isis normalnormal QuestionsQuestions:: 1.1. WhatWhat isis youryour interpretationinterpretation ofof Mr.Mr. AA’’ss presentation?presentation? 2.2. DeliriumDelirium oror dementia?dementia? Why?Why? 3.3. BasedBased onon thethe sideside effecteffect profiles,profiles, whichwhich medicationsmedications dodo youyou thinkthink werewere startedstarted atat thethe previousprevious hospital?hospital? Hint:Hint: 22 . MemoryMemory complaintcomplaint . ObjectiveObjective memorymemory impairmentimpairment (1(1--22 SDSD . NotNot everybodyeverybody dementiadementia . NoNo provenproven therapiestherapies Dementia AcquiredAcquired syndromesyndrome ofof irreversibleirreversible significantsignificant declinedecline inin memorymemory andand otherother cognitivecognitive functioningfunctioning sufficientsufficient toto affectaffect dailydaily livingliving MemoryMemory impairmentimpairment presentpresent inin earliestearliest stagesstages GradualGradual onsetonset withwith progressiveprogressive declinedecline inin cognitivecognitive functioningfunctioning MotorMotor andand sensorysensory functionsfunctions areare sparedspared untiluntil latelate stagesstages Prevalence of dementia is age dependent 45 40 35 30 Percent 25 of Age Group 20 15 10 5 0 65-69 70-74 75-79 80-84 85-89 90-94 95-99 Age (years) Adapted from Ritchie K. Kildea D. Is senile dementia “age-related” or “ageing-related"? evidence from meta-analysis of dementia prevalence in the oldest old. Lancet. 1995; 346:931-934. Domain Occasional Normal Lapses Symptom of dementia Memory Forgetting an acquaintance’s Unexplained confusion in familiar name settings Language Finding the right word Forgetting simple words Performance of Leaving the kettle on the boil Forgetting to serve a meal just familiar tasks prepared Judgment Choosing to wear a light sweater Wearing a bathrobe to the store on a cold night Abstract Having trouble balancing the Not recognizing numbers, inability thinking checkbook to do basic calculations Misplacing Losing car keys, glasses Putting the iron in the freezer objects Personality Gradual change with age or Sudden dramatic change e.g easy circumstances going to suspicious Mood and Getting the blues in a sad Rapid mood swings for no apparent behavior situation reason RequiresRequires autopsyautopsy Generalized cerebral cortical atrophy Widespread cortical neuritic (or senile) plaques Neurofibrillary tangles 1.1. MultipleMultiple cognitivecognitive deficits:deficits: MemoryMemory impairmentimpairment plusplus ≥≥11 i. aphasiaaphasia :: languagelanguage disturbancedisturbance ii. apraxiaapraxia :: impairedimpaired abilityability toto carrycarry motormotor activitiesactivities despitedespite intactintact motormotor functionfunction iii. agnosiaagnosia :: failurefailure toto recognizerecognize oror identifyidentify objectsobjects despitedespite intactintact sensorysensory functionfunction iv. executiveexecutive functioningfunctioning :: planning,planning, organizing,organizing, sequencingsequencing 2.2. DeficitsDeficits significantsignificant functionalfunctional impairmentimpairment (ADL,(ADL, IADL)IADL) 3.3. NotNot duedue toto CNSCNS disorders,disorders, delirium,delirium, oror psychiatricpsychiatric illnessillness AlzheimerAlzheimer’’ss dementiadementia (75%)(75%) VascularVascular dementiadementia (15(15––25%)25%) OtherOther (memory(memory deficitdeficit AND)AND) Dementia with Lewy Bodies Fluctuating attention, extrapyramidal signs, psychosis (hallucinations) Speech/ language disorder, disinhibition, hyperorality Huntington’s Disease Executive dysfunction, chorea Creutzfeldt-Jakob Disease Ataxia, myoclonus, language disturbance Pseudodementia (toxic – metabolic disorders, Depression) HistoryHistory ADLsADLs,, falls,falls, cardiac,cardiac, volume,volume, ETOH,ETOH, medsmeds PhysicalPhysical examinationexamination VitalsVitals NeurologicNeurologic GaitGait (ex.(ex. TimedTimed GetGet upup && go)go) MentalMental statusstatus evaluationevaluation Folstein’s MMSE (***)(***) NeuropsychologicalNeuropsychological testingtesting CBC Serum B12 TSH-reflex Comprehensive metabolic panel Renal, Lytes, LFTs Structural imaging on initial evaluation Functional imaging (PET) may be helpful if type of dementia uncertain Syphilis screening – if patients is or was high risk AAN Dementia Guidelines (2001) .. StructuralStructural (CT,(CT, MRI)MRI) . Atrophy,Atrophy, VascularVascular disease,disease, WhiteWhite mattermatter diseasedisease . CouldCould findfind spacespace occupyingoccupying lesionlesion .. FunctionalFunctional (PET)(PET) . ADAD -- parietalparietal andand temporaltemporal deficitsdeficits . VascularVascular -- focal,focal, asymmetric,asymmetric, cortical,cortical, oror subcorticalsubcortical . PDPD w/dementiaw/dementia -- parietalparietal . DepressionDepression -- frontalfrontal oror globalglobal AcetylcholinesteraseAcetylcholinesterase inhibitorsinhibitors ((AChEIAChEI)) FDAFDA approvedapproved DonezepilDonezepil (Aricept)(Aricept) RivastigmineRivastigmine (Exelon)(Exelon) GalantamineGalantamine ((ReminylReminyl )) DelayDelay progressiveprogressive cognitivecognitive declinedecline DelayDelay nursingnursing homehome placementplacement NMDA (Memantine-N-methyl- D-aspartate) receptor antagonist Decrease over stimulation of the NMDA receptor by glutamate (implicated in neurodegenerative disorders) Approved by FDA for moderate to severe AD Recent study – Memantine treatment in patients with moderate to severe Alzheimer’s Disease already receiving Donepezil which resulted in moderate improvement in cognition and activities of daily living BehavioralBehavioral symptomssymptoms AtypicalAtypical antipsychoticsantipsychotics areare effectiveeffective forfor psychosis in AD psychosis in AD LessLess sideside--effectseffects thanthan typicalstypicals AntidepressantsAntidepressants forfor depressivedepressive symptomssymptoms depresseddepressed mood,mood, appetiteappetite loss,loss, insomnia,insomnia, fatigue,fatigue, irritability,irritability, agitationagitation SSRISSRI preferredpreferred AvoidAvoid anticholinergicsanticholinergics (ex.(ex. tricyclictricyclic antidepressants)antidepressants) 7070 yearyear oldold womanwoman seenseen inin Mild Cognitive Impairment, clinicclinic forfor concernconcern aboutabout Delirium, or Dementia? ‘‘memorymemory ’’.. SheShe reportsreports increasingincreasing difficultydifficulty rememberingremembering thethe namesnames ofof peoplepeople sheshe usedused toto workwork withwith whenwhen sheshe bumpsbumps intointo them in town.town. OftenOften walkswalks intointo aa roomroom ofof herher househouse andand forgetsforgets whatwhat sheshe waswas lookinglooking for.for. SheShe eveneven drovedrove homehome fromfrom churchchurch onceonce andand whenwhen sheshe pulledpulled inin toto herher driveway,driveway, sheshe couldncouldn’’tt rememberremember whichwhich roadroad sheshe hadhad takentaken toto getget home.home. 6767 yoyo femalefemale withwith historyhistory ofof Mild Cognitive Impairment, Delirium, or Dementia? HTNHTN presentspresents toto youryour clinicclinic withwith complaintscomplaints ofof ““memorymemory lossloss””.. HerHer familyfamily hashas notednoted aa generalgeneral declinedecline inin herher hygiene.hygiene. AlthoughAlthough theythey reportreport thatthat sheshe hashas beenbeen lessless availableavailable toto themthem overover thethe lastlast severalseveral months,months, theythey alsoalso admitadmit thatthat herher memorymemory problemsproblems beganbegan aa fewfew yearsyears ago.ago. SheShe isis widowedwidowed andand liveslives alone.alone. 8585 yoyo malemale withwith h/oh/o HTN,HTN, MildMild CognitiveCognitive Impairment,Impairment, Delirium,Delirium, oror Dementia?Dementia? dyslipidemiadyslipidemia ,, DMDM presentspresents toto clinicclinic inin thethe presencepresence ofof hishis son.son. HeHe hashas hadhad memorymemory deficitsdeficits overover thethe 22 weeksweeks whichwhich beganbegan acutelyacutely andand havehave notnot improved.improved. TheThe sonson relatesrelates thatthat untiluntil 22 weeksweeks ago,ago, hishis fatherfather hadhad anan excellentexcellent memory.memory. Delirium Latin, “off the track” Reported by Hippocrates 1 of most common psychiatric disorders in patients with medical illness especially in elderly patients Undetected up to 84% of by medical team Potentially lethal if untreated Francis J, Martin D, etal. JAMA 1990; 263: 1097-101. Inouye, SK. Am J Med 1994; 97:278-88 Disturbance of consciousness reduced ability to focus, sustain, or shift attention Cognitive change memory deficit, disorientation, language disturbance or Development of perceptual disturbance hallucinations, delusions, illusions Not accounted for by preexisting, established, evolving dementia Rapid onset – usually hours to days Evidence that delirium is the direct physiological consequence of a general medical condition, medication side effect, or substance intoxication or withdrawal Earliest manifestations change in level of awareness and ability to focus, sustain, or shift attention Often subtle May precede more flagrant signs by one or more days Distractibility – often evident in conversation Symptoms are unstable Vary between morning and night May miss the diagnosis if rely on single point assessment Caregiver reports, patient “isn’t acting quite right” – should be taken seriously quite right” – should be taken seriously History from caregivers and family of baseline UnderUnder--recognition,recognition, misdiagnosismisdiagnosis –– majormajor problemsproblems PhysiciansPhysicians recognizerecognize <20%<20% ofof casescases ofof deliriumdelirium MonitoringMonitoring mentalmental statusstatus criticalcritical toto earlyearly diagnosisdiagnosis PerformPerform briefbrief cognitivecognitive testingtesting (i.e.(i.e. MMSE)MMSE) asas baselinebaseline FormalFormal mentalmental statusstatus testingtesting (MMSE)(MMSE) –– moremore importantimportant thanthan scorescore isis patientpatient’’ss overalloverall attentivenessattentiveness andand accessibilityaccessibility whilewhile performingperforming test,test, cancan useuse ConfusionConfusion AssessmentAssessment MethodMethod (CAM)(CAM) Francis J, Martin D, et al. JAMA 1990; 263: 1097-101. Inouye, SK.. Am J Med 1994; 97:278-88. Test Directions Scoring Digit Span Ask pt to listen carefully Inability to and repeat series of random repeat a string numbers, read in normal of at least 5 voice, rate one digit per digits – sec. probable impairment Vigilance Read a list of 60 letters, Count errors of “A” test among which the letter “A” omission and appears at greater than commission. random frequency, pt asked More than 2 to indicate whenever target errors - letter spoken abnormal DiagnosisDiagnosis ofof DeliriumDelirium requiresrequires presencepresence ofof featuresfeatures 11 andand 2,2, ANDAND eithereither 33 OROR 44 11 -- AcuteAcute changechange inin mentalmental statusstatus andand fluctuatingfluctuating coursecourse 22 -- InattentionInattention 33 -- DisorganizedDisorganized thinkingthinking 44 -- AlteredAltered levellevel ofof consciousnessconsciousness Provides a brief, structured, validated, and standardized assessment of patient By using CAM – physicians achieve 94-100% sensitivity and 90- 95% specificity in diagnosing delirium and high inter-rater reliability CAM requires less than 5 minutes to administer Standard screening device in clinical studies Modified version for ICU setting (behavioral observation and non-verbal communication) Goldman: Cecil Textbook of Medicine. 22nd edition. 2004 PsychomotorPsychomotor activityactivity HyperactiveHyperactive (25%)(25%) agitation,agitation, increasedincreased psychomotorpsychomotor activityactivity HypoactiveHypoactive (25%)(25%) decreaseddecreased psychomotorpsychomotor activityactivity MixedMixed (35%)(35%) psychomotorpsychomotor activityactivity w/w/ hyperhyper-- && hypohypo --activeactive featuresfeatures NormalNormal (15%)(15%) psychomotorpsychomotor activityactivity normalnormal ExactExact unknown,unknown, severalseveral hypotheseshypotheses corticalcortical mechanisms,mechanisms, subcorticalsubcortical mechanisms,mechanisms, alterationsalterations inin neurotransmittersneurotransmitters andand cytokinescytokines MultipleMultiple etiologiesetiologies LikelyLikely multiplemultiple pathwayspathways forfor diseasedisease UnlikelyUnlikely singlesingle mechanismmechanism isis thethe causecause Predisposing Factors Precipitating Factors Advanced age Medications Dementia Drug/Medication withdrawal Parkinson’s disease Infections Functional/physical impairment in Immobility/restraint use ADLs Dehydration/Malnutrition High medical co-morbidity Electrolyte disturbances History of alcohol abuse Anemia Male Gender Uncontrolled pain Sensory Impairment (hearing or Urinary retention vision) Fecal impaction History of CVA Sleep disturbances History of Delirium Environmental changes Intracranial events Acute cardiac or pulmonary events Dementia 22-89% of patients with delirium have dementia, but can’t diagnose dementia when delirious Depression Acute psychiatric syndromes/psychosis All can co-exist with acute delirious states When in doubt: think delirium (as can be reversible), rule out common medical etiologies Fick, DM, et al. J Am Geriatr Soc 2002; 50:1723. Feature Delirium Dementia Onset Acute Insidious Course Fluctuating Progressive Duration Hours to months Months to years Consciousness Reduced Clear Attention Impaired Normal - early stages Orientation Impaired Impaired Memory Impaired Impaired Thinking Disorganized Impoverished Perception (ex. Present Often absent early hallucinations) Speech Incoherent Word finding difficulty UsuallyUsually multifactorialmultifactorial etiologyetiology Therefore,Therefore, solvingsolving oneone factorfactor maymay notnot resolveresolve thethe deliriumdelirium ResultsResults fromfrom interrelationshipinterrelationship ofof precipitatingprecipitating factorsfactors SuperimposedSuperimposed onon aa susceptiblesusceptible hosthost (predisposing(predisposing conditions)conditions) DeliriumDelirium maymay bebe thethe ONLYONLY findingfinding suggestingsuggesting acuteacute illnessillness inin olderolder dementeddemented patientspatients Goldman: Cecil Textbook of Medicine, 22nd ed. 2004 B. Anticholinergics Antibiotics Anticonvulsants (ie. Sedative hypnotics (benzodiazepines) Phenytoin) Narcotics (opioid analgesics – Alcohol esp. Demerol) Barbiturates Parkinson’s agents (ie. Digoxin Levodopa-carbidopa, Centrally acting dopamine agonists, antihypertensive agents (ie. amantadine) Methyldopa, reserpine) H2 blocking agents Corticosteroids Antipsychotics (ie. Clozapine) Antiemetics Lithium OTC agents (ie. Benadryl, Antidepressants (ie. TCAs) herbal medications) Infections Pulmonary respiratory, urinary, CNS hypoxemia, asthma or COPD infections, skin and soft tissue exacerbation, pulmonary embolus, infections, joint and bone pneumonia infections, HIV, post-operative infections, sepsis Neurologic Head trauma, cerebral Metabolic disturbance hemorrhage, TIA/CVA, CNS electrolyte imbalances, tumor or infection, seizure, dehydration, hypo- or hyper- encephalopathy glycemia , end organ failure (ie. hepatic or renal), hypoxia, acid- base disturbance, endocrine Other disorders malnutrition, fecal impaction, urinary retention, sleep deprivation, stress, post-operative Cardiovascular/Hypo-perfusion state, pain, states medication/drug/alcohol CHF, MI, cardiogenic shock, withdrawal, poisoning/toxic arrhythmia, anemia causes, over-stimulation (ie ICU or unfamiliar environment) ComprehensiveComprehensive historyhistory Cognitive impairment, perceptual problems, time course, associated symptoms, medications, substance abuse PhysicalPhysical andand psychiatricpsychiatric assessmentassessment Vital signs including O2 sats FunctionalFunctional statusstatus –– presentpresent comparedcompared toto baseline?baseline? BedsideBedside assessmentassessment techniquestechniques forfor memorymemory andand attentionattention MMSE, CAM, Digit Span, days of the week backwards, vigilance “a” test History,History, PE,PE, andand workwork--upup –– hashas 80%80% diagnosticdiagnostic yield,yield, ifif donedone appropriatelyappropriately Targeted based on history and physical exam CBC with diff Comprehensive chemistries UA/ UCx (not reflex) TSH - reflex B12 levels Drug levels Serum: digoxin, theophylline, phenytoin, valproate, EtOH Urine: drugs of abuse screen, methadone requested separately LP with CSF analysis – consider if CNS infection is suspected CXR – if pulmonary etiology suspected Cerebral imaging – head trauma or focal neurological findings EEG – in cases of suspected seizure activity KeyKey stepssteps inin managementmanagement ofof deliriumdelirium IdentifyIdentify andand treattreat underlyingunderlying medicalmedical illness/etiologyillness/etiology ManageManage behavioralbehavioral problemsproblems AvoidanceAvoidance ofof factorsfactors knownknown toto causecause oror aggravateaggravate deliriumdelirium AvoidAvoid complicationscomplications ofof deliriumdelirium ProvideProvide supportive,supportive, restorative,restorative, andand rehabilitativerehabilitative carecare forfor patientpatient Counsel,Counsel, support,support, andand educeducateate thethe patientpatient andand familyfamily Provide quiet, well-lit room for patient Avoid excessive noise, stimulation Encourage familiar faces (family, caregivers) for reassurance Provide orientation Correct sensory impairment(s) Communicate in a succinct, direct style Attentive nursing care, observation Discontinue non-essential medications Avoid restraints (physical, pharmacological, urinary catheters, IVs) Geriatric medicine consultation Direct specific medical treatment to underlying medical condition Pharmacologic management of behavioral problems – most challenging aspect of delirium therapy Reserve medications for acute agitation or aggression, delusions, hallucinations, drug or alcohol withdrawal – when patient presents a harm to self or others Avoid medications for behavioral problems if at all possible because most medications can make the delirium worse No FDA approved medication to treat delirium AntipsychoticAntipsychotic agentsagents FirstFirst lineline medicationmedication CautiousCautious trialtrial atat lowlow initialinitial dosedose IfIf subsequentsubsequent dosingdosing increasesincreases necessary,necessary, makemake changeschanges gradualgradual andand incrementalincremental DocumentDocument andand assessassess targettarget symptomssymptoms andand responseresponse toto treatmenttreatment (necessary)(necessary) DiscontinueDiscontinue medicationsmedications asas soonsoon asas possiblepossible FrequentFrequent rere--assessmentassessment Haldol – use low dose – 0.25–0.50 mgmg po or 0.125–0.25 mg IV/IM with careful reassessment of patient prior to additonal dosing Potential side effects – hypotension, sedation, akathisia (motor restlessness), anticholinergic effects, and extrapyramidal effects Atypical antipsychotics – risperidone, olanzapine, queitiapine – fewer side effects with similar efficacy Benzodiazepines – reserve for alcohol and BDZ withdrawal delirium PainPain andand deliriumdelirium havehave aa closeclose relationshiprelationship –– oftenoften unrecognizedunrecognized ProspectiveProspective studystudy –– higherhigher painpain scoresscores onon secondsecond postpost-- operativeoperative dayday associatedassociated wiwithth increasedincreased incidenceincidence ofof deliriumdelirium OpioidsOpioids –– havehave lowlow riskrisk forfor producingproducing deliriumdelirium withwith exceptionexception ofof Demerol,Demerol, therefore,therefore, physiciansphysicians shouldshould notnot hesitatehesitate toto provideprovide adequateadequate dosesdoses toto patientspatients withwith significantsignificant painpain DeliriumDelirium isis associatedassociated withwith poorpoor patientpatient outcomesoutcomes IncreasedIncreased mortalitymortality 2x2x increaseincrease 11 andand 66 monthmonth mortalitymortality toto bebe 14%14% andand 22%,22%, respectivelyrespectively 3x3x riskrisk ofof deathdeath afterafter controllingcontrolling forfor prepre--existingexisting coco-- morbidities,morbidities, severityseverity ofof illness,illness, useuse ofof sedatives/analgesicssedatives/analgesics InIn hospitalhospital fatalityfatality ratesrates 2525--33%33% comparablecomparable toto MI,MI, sepsissepsis Goldman: Cecil Textbook of Medicine, 22nd ed. 2004 B. Saunders Company.Cole, Mg et al. CMAJ 1993; 49:41. Pandharipande P, et al. Crit Care 2005;33(12):A45. ProlongedProlonged hospitalhospital staystay 33--5x5x riskrisk ofof nosocomialnosocomial complicationscomplications Increased health care expenditures PoorPoor recoveryrecovery postpost--dischargedischarge Increased need for post-acute nursing home placement Increased risk of death up to 2yrs after discharge SymptomsSymptoms persistpersist weeksweeks –– monthsmonths ≥6 months in 80% of patients CaregiverCaregiver burdenburden UnderUnder--treatmenttreatment ofof deliriumdelirium –– commoncommon problemproblem EstimatedEstimated 96%96% ofof patientspatients withwith deliriumdelirium werewere dischargeddischarged fromfrom thethe hospitalhospital withwith unresolvedunresolved symptomssymptoms In 20% of these cases, symptoms resolved within 6 months of discharge Suggests prevalence of delirium in community and post-acute settings is higher than expected Recommend PCPs and LTC physicians evaluating geriatric patients screen for delirium Educate family, caregivers, and patient regarding etiology and course of disease signs/symptoms and risk factors for delirium Sudden changes in mental function NOT expected with progressive dementia Requires prompt medical attention Realistic evaluation of caregiver resources since weeks to months and may not reach previous baseline May require sub-acute rehabilitative environment until delirium resolves 8282 yoyo whitewhite malemale PMHPMH mildmild dementia,dementia, HTN,HTN, BPHBPH AdmittedAdmitted toto hospitalhospital s/ps/p MVCMVC onon TraumaTrauma ServiceService –– wifewife andand dogdog killedkilled inin collisioncollision AcuteAcute injuriesinjuries –– multiplemultiple ribrib fractures,fractures, rightright hiphip fracture,fracture, rightright sidedsided pneumothoraxpneumothorax s/ps/p chestchest tubetube SurgicalSurgical interventionintervention –– rightright hemiarthroplastyhemiarthroplasty hospitalhospital dayday 22 PostPost--opop analgesiaanalgesia –– MorphineMorphine PCA,PCA, PercocetPercocet prnprn HDHD #3#3 –– ptpt becamebecame confused,confused, agitated,agitated, combativecombative andand resistentresistent toto carecare Psychiatry consulted – MMSE 23/30; diagnosis – delirium – prescribed – Seroquel 50mg QAM, 25mg Qnoon, 50mg QHS; 4 point physical restraints Pt became somnolent - poor po intake/nutrition led to NG tube placement; immobility led to functional decline and sacral ulcers Primary team was recommending PEG placement to patient’s family family HD #9 – Geriatrics consultation – found the patient very somnolent, mental status/LOC waxed and waned, confused, inattentive – diagnosis of acute delirium – multifactorial – medications, acute illness, constipation (post-op ileus), restraints, malnutrition Geriatrics recommendations – taper and d/c Seroquel, remove restraints, one-on-one sitter and family support; re-orientation, treat constipation, nutrition, PT – mobilize once more alert; avoid PEG placement Primary team reluctant to decrease or d/c Seroquel as prescribed by psychiatry but they had not revisited the patient Once Seroquel and restraints were discontinued – patient became more alert, attentive, less confused – oriented to situation and place – able to sit up, participate in therapy, tolerate po and removal of NG tube – within days – ready to d/c to rehabilitation