Exclusives, Patient Care

Looking Past Dementia Reveals Hidden Life Threats

You and your partner just went into service when the radio begins to chirp, “Unit 10, respond Code 3 to Seniorville Nursing Facility for an 85-year-old female with altered mental status.” You kick the truck into gear and are quickly on scene.

The patient’s nurse tells you that the patient has been at the facility for three days for rehabilitation after a hip replacement that occurred one week ago. The patient was initially OK, but over the last 24 hours has been anorexic (i.e., not eating), agitated and is refusing to allow healthcare providers to assess her. Her condition has become so severe that they believe she might become a danger to herself if she keeps rejecting care. She has been receiving 5 mg of oxycodone PO (i.e., by mouth) every six hours for pain management along with her regular list of medications. The patient has a history of dementia, hypertension, and hypothyroidism. Her baseline mental status is AAOx3/4, calm and “pleasantly confused.”

As you walk into the patient’s room, you notice the patient is laying on her right side, moaning, with her oxygen nasal cannula pushed up over her head. She wails as you approach her, and foggily accuses you of trying to hurt her. She can’t tell you her name or where she is, only that she’s in pain.

You introduce yourself and your partner, and feel her wrist for a pulse. Her skin is hot and dry, and her pulse is weak, prolonged and significantly tachycardic. Your partner attempts to get a blood pressure, and the patient screams and begins to tear the blood pressure cuff off and push your partner away. Attempting to regain control of the situation, you ask her if she remembers who you are, and all she says is that she has no clue who you are, only that you are going to hurt her.

Mentation Alteration

Patients who are in healthcare facilities are at an increased risk for sudden neurologic changes and complications which may stem from primary central nervous system (CNS) disorders, or may be secondary to underlying conditions.

Consciousness is defined as “the state of being awake and aware of one’s surroundings.”1 An alteration of consciousness may present in two forms:

  1. a patient who’s lethargic, fatigued or unresponsive (i.e., comatose), or
  2. a patient who’s anxious, agitated, or combative (i.e., delirium).1

Patients who have a baseline alteration of cognition or mentation such as dementia may be considered “at baseline” by healthcare providers, when the reality is that a severe deviation from normal may be present. In a study of patients referred to palliative care who were eventually diagnosed with delirium, 61% of patients were misdiagnosed by the referring physician.2

In a population of patients where confusion is commonly reported as “baseline,” an in-depth analysis of recent changes in environment, medications, surgery and/or other complications must be performed.

Delirium presenting in addition to dementia significantly increases the length of hospital stay, and increases the risk of mortality and institutionalization within one year. In a study of dementia patients presenting with superimposed delirium, 40% of patients with postoperative delirium had not returned to their baseline after six months.3

Acute delirium is characterized by an acute change in consciousness with confusion, short-term memory deficiency, illogical thought processes, perceptual disturbances and a rapidly changing course of presentation.1

One tool for evaluating the causes of acute delirium is the mnemonic “DELIRIUM.”

Drugs (opiates, anticholinergics, sedative-hypnotics)
Electrolyte or Physiologic Abnormalities (hypoglycemia, hyponatremia, etc.)
Lack of Drugs (withdrawal from medications)
Infection (sepsis-associated encephalopathy)
Reduced senses (presbyopia, presbycusis)
Intracranial Etiologies (stroke, intracranial pressure increase)
Urinary Retention/ Fecal Impaction
Myocardial Problems (congestive heart failure, myocardial Infarction, dysrhythmia)

The presence of delirium can increase the length of hospital stay, cost of care, and mortality. In ICU patients, every day spent in delirium increases the mortality rate by 10%.4

Managing Agitated Patients

Assessment of the patient using the Richmond Agitation Sedation Scale (RASS) can help define the level of agitation or delirium presented by your patient. The scale runs from -5 to +4, with 0 being “Alert and calm,” -5 being “unresponsive” and +4 being “combative, violent.” A visual representation of this scale is shown below.

Richmond Agitation-Sedation Scale (RASS)

Target RASS

RASS Description

+4

Combative, violent, danger to staff.

+3

Pulls or removes tube(s) or catheters; aggressive.

+2

Frequent nonpurposeful movement, fights ventilator.

+1

Anxious, apprehensive, but not aggressive

0

Alert and calm

-1

Awakens to voice (eye opening/ contact) less than 10 seconds

-2

Light sedation, briefly awakens to voice (eye opening/ contact) greater than 10 seconds

-3

Moderate sedation, movement or eye opening. No eye contact.

-4

Deep sedation, no response to voice, but movement or eye opening to physical stimulation.

-5

Unarousable, no response to voice or physical stimulation.

Patients presenting with signs and symptoms of acute delirium should be given a thorough physical exam, and there should be an extensive review of their history and medications. Assessment for a rapidly reversible cause of their condition (i.e., hypoxemia, hypotension, hypoglycemia, etc.) should be the primary consideration.1

Once primary life-threatening conditions have been ruled out, an attempt to reverse environmental factors of delirium should be made. Attempt to help the patient understand his or her environment, remove unnecessary restraints or devices, treat for pain, and attempt to improve patient position.

Once life-threatening conditions and environmental factors contributing to the delirium have been corrected or removed, re-evaluate the patient. If delirium persists and the patient remains detrimental to their own care, pharmacologic therapy may be appropriate.

Pharmacologic Management of Delirium

Many sedative-hypnotic and behavioral medications can contribute to the altered mentation of the patient. This can increase the severity of delirium, or contribute to an exacerbation over the course of the next several days. Although alpha-2 agonists such as dexmedetomidine may be useful in the intensive care setting, these agents are not typically available to prehospital providers. Benzodiazepine sedative-hypnotics have been shown to exacerbate delirium, and have a large variation in effective dose, and adverse effects, including respiratory depression and hypotension.1

Butyrophenone antipsychotics (most commonly haloperidol) are more effective and are the most commonly carried medication for the treatment of delirium in the prehospital arena. These medications have cardiac, extrapyramidal and anticholinergic adverse effects, which must be monitored closely in the elderly population. For the acute management of combative delirium, however, these medications are safer than traditional benzodiazepines. The intramuscular route of administration is preferred over the IV route, as QT-prolongation from butyrophenone administration has been correlated with torsades de pointes in this population.5,6

The use of mechanical restraints may exacerbate delirium, cause soft tissue injuries, and decrease circulation in those with poor peripheral vasculature. The isolated use of mechanical restraints should be avoided.1

Scenario Revisited

You and your partner are able to transfer the patient to your stretcher without incident, as well as transfer her to your ambulance. After obtaining a set of vital signs, you find your patient to be pyrexic (temperature 101.5 degrees F), tachycardic (heart rate 150 bpm in atrial fibrillation), tachypneic (respiratory rate of 30), hypocapnic (18 mmHg), normoxemic (95% at 2 Lpm of O2), and relatively normotensive (118/58 mmHg). The patient is rapidly fulfilling the clinical picture of postoperative septicemia.

The patient continues to yell, tears off her capnography cannula, and is attempting to pull out her IV lines. You decide that the patient is presenting with delirium secondary to possible septicemia (i.e., sepsis-associated encephalopathy) and postoperative pain. The pain could be considered an environmental factor considering the lack of comfort on the stretcher, but careful repositioning and gentle handling haven’t decreased her complaints of pain.

You have your partner attempt to redirect her attempts to pull the IV lines, and administer 2.5 mg haloperidol intramuscularly, as well as 25 mcg fentanyl citrate via IV. Your patient calms after several minutes and you are able to perform a full physical exam, administer a fluid bolus, and begin the sepsis workup during transport.

Conclusion

Acute delirium is commonly underdiagnosed, and can be masked by chronic alterations in cognition and mentation. Delirium has many causes, and can be assessed using the acronym DELIRIUM. The most common presentations suggesting delirium over dementia are short-term memory loss, rapid fluctuation in condition, acute alteration, and a condition present that may be responsible for delirium.

Management includes searching for causes of acute alteration in mental status, negating environmental factors of delirium, and—only when necessary—reducing the patient’s threat to themselves or providers by using butyrophenones and mechanical restraints as appropriate.

References

1. Vincent JL, Abraham E, Moore FA, et al (editors): Textbook of critical care. Elsevier: Philadelphia, pp. 3–10, 2017.

2. de la Cruz M, Fan J, Yennu S, et al. The frequency of missed delirium in patients referred to palliative care in a comprehensive cancer center. Support Care Cancer. 2015;23(8):2427–2433.

3. Fick DM, Steis MR, Waller JL, et al. Delirium superimposed on dementia is associated with prolonged length of stay and poor outcomes in hospitalized older adults. J Hosp Med. 2013;8(9):500–505.

4. Pisani M, Kong S, Kasl S, et al. Days of delirium are associated with 1-year mortality in an older intensive care population. Am J Respir Crit Care Med. 2009;180(11):1092–1097.

5. Golan DE, Armstrong EJ, Armstrong AW (editors): Principles of pharmacology: The pathophysiologic basis of drug therapy. Wolters Kluwer: Philadelphia, pp. 217–220, 2017.

6. Thom RP, Mock CK, Teslyar P. Delirium in hospitalized patients: Risks and benefits of antipsychotics. Cleve Clin J Med. 2017;84(8):616–622.

Acknowledgements
The author is grateful to Dr. Michael J. Smertka for his valuable and constructive suggestions. His willingness to give his time so generously was very much appreciated.