Correct answer: All of the above

Rationale

According to the American Delirium Society, patients aged 65 years and older, those with sensory impairment, or who have baseline cognitive loss are significantly at risk for developing delirium in the hospital. In addition, severe illness, fracture, infections, and recent surgical intervention can contribute to the delirium predisposition. Cardiac interventions are also associated with delirium risk.¹

Case continued

The nursing staff report surprise at the patient’s sudden episode of agitation because “he has been completely calm otherwise, and was sleeping all day.”

Question 2 of 11

How do we identify delirium in a patient who is calm? Look for waxing and waning consciousness and orientation You can’t; you have to wait until the patient is agitated Observe changes in circadian rhythm; these may herald the onset of delirium Wait until the patient is hallucinating A and C B and D

Correct answer: A and C

Rationale

Delirium can present in three subtypes: hyperactive, hypoactive, and mixed. Delirium is not simply the presence of agitation. Rather, it is a combination of cognitive disturbance, impairment of consciousness, circadian rhythm disruption, psychomotor disturbance, and emotional dysregulation.²

Case continued

The patient is eventually transferred to the cardiac stepdown unit. The nursing staff reports that patient has “not slept the entire admission” and that he has been progressively more agitated and irritable. They note that he was given oxycodone 5 mg every 4 hours for pain and was given lorazepam 2 mg IV once in the evening for acute agitation and anxious distress.

Question 3 of 11

What are some concerns about lorazepam treatment in patients with delirium? Lorazepam is directly associated with the probability of transitioning to delirium Lorazepam is not directly deliriogenic, but it can lead to sleep and wake disturbances Lorazepam is not deliriogenic and can reduce agitation. It is safe in ICU setting.

Correct answer: Lorazepam is directly associated with the probability of transitioning to delirium

Discussion

Lorazepam is associated with an increased probability to transition to delirium, and it is considered an independent risk factor in the transition to delirium. At low doses, there is an incremental risk; at doses above 20 mg a day, the risk plateaus to almost a 1.0 probability.³

Case continued

What are some key questions to ask this patient to determine the probability of experiencing delirium?

Question 4 of 11

What are some key questions to ask this patient to determine the probability of experiencing delirium? What is your favorite color? Do you have a family history of psychosis? Can you tell me who your most admired world leader is? Can you name the months of the year backward?

Correct answer: Can you name the months of the year backward?

Discussion

Asking the patient to name the months of the year backward is a good test of the patient’s attention and concentration. Studies have shown that orientation and concentration testing are the most sensitive and specific tests for delirium in a hospital setting.

Nursing staff can assist in the diagnosis of delirium by guiding the patient through the brief Confusion Assessment Method (bCAM) or the Confusion Assessment Method-ICU.⁴ Alternative tests for delirium include the “4AT” and the Stanford Proxy Test for Delirium.

Case continued

The patient assessment indicates that he is suffering from delirium and agitation (he is restless, yelling and cursing) and needs therapy. Traditionally, haloperidol is used to address agitation in delirium, but the QTc interval is prolonged at 550 milliseconds, based on the Bazett’s QTc correction formula. A recalculation using the Hodges formulation finds that the QTc interval is still high at 520 milliseconds. Haloperidol, concerningly, has been associated with a relative risk increase of QT prolongation of 1.26, and therefore should be avoided in cases with QT prolongation.⁵

Question 5 of 11

Given this patient’s prolonged QTc interval, what other treatments can be used acutely to treat his agitation? Lorazepam Aripiprazole Ziprazidone Propofol

Correct answer: Aripiprazole

Rationale

Aripiprazole has been shown to be effective at reducing agitation owing to its dopamine receptor dopamine receptor 2 antagonism. In addition, it is one of the only antipsychotics not associated with QTc prolongation.^6-9 Traditionally, an electrocardiogram will automatically read the QTc using the Bazett’s formulation, but this does not accommodate well in cases of tachycardia. Often, using Hodges Formula, the QTc can be calculated to accommodate an increase in ventricular rate.

Case continued

The patient calms down following administration of aripiprazole

Question 6 of 11

After treating this patient’s agitation, what is the best way to treat his delirium? Treat him with divalproex (Depakote) based on his body weight and then continue for a level of around 60 mg/kg/day. Start haloperidol IV infusion at a dose of about 2 mg/hour and monitor the patient with cardiac telemetry Engage in behavioral modifications including reregulating his sleep-wake cycle, reorientation, encouraging physical therapy, and, especially, mobilize the patient! Keep him awake for 24 hours to allow his body time to naturally make enough melatonin for sleep.

Correct answer: Engage in behavioral modifications including reregulating his sleep-wake cycle, reorientation, encouraging physical therapy, and, especially, mobilize the patient!

Rationale

The guidelines based out of American College of Critical Care Medicine indicate that the use of early mobility, engagement, and behavioral modifications are the most appropriate means of reducing the risk of delirium and reducing time of delirium.¹⁰ Physical therapy, early mobilization, and family involvement with reorientation was shown in a study of surgical ICUs to increase rates of survival by 15% and reduce days of delirium.¹¹

Case continued

The next morning, the patient has displayed some intermittent agitation. You discuss with your team possible causes. One resident asks if the patient was drinking before he came in. It has been 5 days since admission. Before admission, the patient had been drinking at least four 12-ounce beers daily. His vitals are currently stable, but there is a slight tremor on examination and mild hyperreflexia.

Question 7 of 11

What is the best next step for managing this patient? Give 2 mg of lorazepam and then start an alcohol withdrawal protocol with lorazepam as needed Start lorazepam taper Consider valproic acid treatment at 250-500 mg twice daily Consider neurontin treatment at 300-600 mg 3 times daily A and B C and D

Correct answer: C and D

Rationale

The risk of alcohol withdrawal is very high within 5 days of the last drink. In particular, within 72 hours, there is a high risk for seizures, and within 5 days, there is a high risk for autonomic instability and delirium tremens.¹² Often, especially in medically ill patients, there is difficulty using benzodiazepines, such as lorazepam, for alcohol withdrawal therapy in a patient who has concurrent delirium. In the psychiatry field, there has been a change of practice emphasizing the use of a “benzo sparing” protocol to address potential alcohol withdrawal and for deliriolysis. Both neurontin and valproic acid are effective treatments to reduce withdrawal symptoms, prevent autonomic instability and seizures, and act as a deliriolytic agent.

Case continued

The patient’s family is very worried about their loved one and asks questions about delirium.

Question 8 of 11

Which of the following is the best explanation of delirium for them? It is a normal part of being in the hospital after surgery It is an acute brain failure caused by neurotransmitter dysregulation in the setting of severe stress and inflammation It is a form of schizophrenia It could have long-term sequela and can herald possible neurocognitive impairment B and D B and C

Correct answer: B and D

Rationale

Delirium is not a normal part of hospitalization. It has been defined by experts as an acute brain failure most likely due to a combination of neuronal aging, neuroinflammation, oxidative stress, neuroendocrine dysregulation and circadian rhythm disruption. It can have long-term effects if not treated, including potential for significant cognitive impairment, particularly in the elderly. In a prospective study of 812 patients who acquired delirium while hospitalized in the ICU, they had notable cognitive declines 12 months after hospitalization.¹³

Case continued

Your patient is delighted by the rapid resolution of this flare and requests to be placed on long-term minocycline 100 mg twice daily after hearing about this option on a patient support forum.

Question 9 of 11

What is the best response regarding minocycline therapy in this patient? It is not too common and only happens in really sick patients It is very common and often underreported It is difficult to specify the frequency of delirium because it has multiple subtypes

Correct answer: It is very common and often underreported

Rationale

Delirium is incredibly common. It is expected that on a regular nursing floor approximately 10% to 30% of patients will struggle with delirium, and in the ICU or in patients who are terminally ill, the frequency increases to 60% to 80%.¹⁴ It is not well reported, which is problematic for interventions

Question 10 of 11

The family requests information on how they can help their loved one. Which of the following is the most appropriate response? There is nothing you can do. We just have to wait You can engage with your loved one, motivate physical therapy, and keep them oriented You can sit very quietly and let them rest. Your presence is enough You should just go home. You are making his delirium worse

Correct answer: You can engage with your loved one, motivate physical therapy, and keep them oriented

Rationale

Family engagement as seen in the “ABCDEF” bundle (Awakening and Breathing Coordination, Choice of drugs, Delirium monitoring and management, Early mobility, and Family engagement)¹⁰ has been associated with decreased mortality and increased days free of delirium. We encourage families to motivate their loves ones mobility, provide reorientation, and engage with the treatment teams. In a study of data from seven California hospitals, patient’s whose families were engaged with care had more days alive and free of delirium.¹¹

Case continued

You and your team decide to prescribe valproic acid at 250 mg twice daily to address delirium and potential alcohol withdrawal. Within 2 days, the patient is no longer agitated and has not required any haloperidol. You also work to engage the family in providing reorientation and physical therapy to improve mobility. Within a few days, there is discussion about discharging the patient from the hospital to home care.

Question 11 of 11

The family requests information on how they can help their loved one. Which of the following is the most appropriate response? Reduced inpatient stay Reduced overall cost Reduced caregiver burden and empowered family Reduced risk of falls All of the above.

Correct answer: All of the above

Rationale

Delirium management is essential in reducing overall costs. In the United States, the costs of delirium are incredibly high, with estimates of $32.9 billion for national health care costs and personal costs to patients and families of $44,000.¹⁵ It is essential that practitioners use early interventions and a behavioral approach to treat delirium.

KEY POINTS

• Delirium is a common, acute brain failure condition resulting from severe illness and hospitalization.
• Delirium consists of alterations in attention, cognition, and awareness.
• Delirium is believed to be caused by neurotransmitter dysregulation due to multiple stressors including neuronal degenerations, alterations in neurotransmitter pathways, neuroendocrine disruption, and changes in the circadian rhythm.
• Screening tools are necessary to detect delirium in the medical setting.
• Multimodal interventions (nonpharmacological and pharmacological) can be used for symptomatic treatment of delirium.
• Delirium has high cost for families, patients, and the health care system.