Treating Delirium & Agitation in the Emergency Room, 2015 | EB Medicine
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Managing Delirium In The Emergency Department: Tools For Targeting Underlying Etiology

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Epidemiology
  6. Pathophysiology And Subtypes
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
    3. Screening Tools
  10. Diagnostic Studies
  11. Management
    1. Medical Management
    2. Nonpharmacological Management
      1. Verbal De-escalation
      2. Physical Restraints
      3. Multicomponent Protocols
    3. Pharmacological Management
      1. Typical Antipsychotics
      2. Atypical Antipsychotics
      3. Benzodiazepines
      4. Ketamine
      5. Combination Therapy
  12. Controversies And Cutting Edge
    1. Risk Stratification Tools
    2. Triage Tools
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls For Delirium In The Emergency Departmen
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Diagnosing And Managing Delirium In The Emergency Department
  19. Tables and Figures
    1. Table 1. Precipitating Factors For Delirium
    2. Table 2. Delirium Versus Dementia
    3. Table 3. Vulnerability Factors In Delirium
    4. Table 4. Emergency Department Evaluation Of Delirium
    5. Table 5. Medications For Management Of Delirium And Acute Agitation
    6. Figure 1. Richmond Agitation-Sedation Scale
  20. References

Abstract

Delirium represents the complex junction between vulnerable patients, medical conditions, and environmental factors. Given the varied presentations of this disorder and the emergency department clinical environment, recognition and treatment may be challenging. Delirium can be diagnosed using validated standardized screening tools such as the Confusion Assessment Method. Management of delirium is directed towards rapidly treating the underlying medical condition while preventing and managing the behavioral symptoms with nonpharmacological (first-line) and pharmacological (second-line) interventions. In the severely agitated patient, pharmacological treatment tailored to the patient’s age and comorbidities may be required as the initial treatment to facilitate evaluation and management of the underlying medical condition. Effective risk stratification and triage tools can positively impact patient and staff safety, as well as patient outcomes.

Case Presentations

It is the beginning of another Saturday night shift, and as you walk in, you see security and the outgoing attending wrestling a large 20-something-year-old man to the bed. He is yelling about a government conspiracy and his right to freedom of speech. A nurse injects medicine into his left deltoid. You are looking forward to the sign-out on this gentleman and wonder what he was injected with and whether there was another way to manage him.

As your colleagues manage the young man, you scan the board and see that the next patient to be seen is a 79-year-old lady who presents for altered mental status. As you approach the bed, you do not see anyone with her. You begin to take her history, and observe that she seems a bit lethargic and is tangential in her thinking. She is able to tell you that she lives with her husband and has a history of high blood pressure and confusion. She then mentions that you look like a friend of hers from work and asks whether you are married. You see your colleagues finishing up with their patient, so you extricate yourself and return to the physician station wondering why this patient is so lethargic and why her attention is so decreased.

Finally, just as rounds are about to begin, you see an intubated patient in the first resuscitation bay starting to buck at his vent. You notice his hands and feet are in 4-point restraints. After inquiring about the reason for his visit, you are informed that he is a chronic alcoholic who had been attempting to detoxify at home and has come in today in delirium tremens, requiring intubation and large doses of benzodiazepines. You are concerned about the 4-point restraints, which you know are not favored, and you wonder if there was a better (and safer) way to manage the patient’s agitation.

Introduction

Delirium is a complex neuropsychiatric disorder that often manifests secondary to a discrete medical condition. The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) describes delirium as an acute (usually developing over hours or a few days) and/or fluctuating disturbance in attention and cognition due to a medical condition, intoxicating substance, or multiple etiologies.

In the younger population, delirium encompasses common chief complaints such as agitation and altered mental status.2,3 Among the elderly population, it is estimated that 7% to 24% of patients presenting to the emergency department (ED) will have delirium, and up to 80% of critically ill intensive care patients will have delirium.4 A diagnosis of delirium carries with it significant morbidity and mortality, in addition to increased utilization of resources.5–9

Studies have shown that most emergency clinicians do not screen for or document their findings of delirium.10-12 Because of this lack of screening and the fluctuating course of the condition, the overall incidence of delirium in the ED is unknown. Some posit that emergency clinicians are aware of the impact of delirium on patient outcomes but are not knowledgeable about its diagnosis and management.13

Emergency clinicians are trained to manage the overt signs of delirium while concurrently searching for its underlying etiology. However, gaps in screening, knowledge, and understanding contribute to a missed diagnosis rate in the range of 54% to 89%.4,14 Additional complicating factors include the varied presentations of these patients and the inherent time and environmental pressures of the ED clinical environment. Diagnostic accuracy has been poor, and much of the emergency medicine literature on delirium is focused on the issue of recognition. Regarding the prevention and management of delirium in the ED, current guidelines are generalized from inpatient and postoperative studies. This issue of Emergency Medicine Practice focuses on the challenge of evaluating and managing the patient with delirium in the ED using the best available evidence from the literature.

Critical Appraisal Of The Literature

A literature search was performed on PubMed using the search terms delirium OR agitation OR acute confusion AND emergency. Additional references were obtained from the bibliographies of the articles reviewed. A search of the Cochrane Database of Systematic Reviews yielded several reviews regarding the pharmacological management of delirium, as well as 1 review of multicomponent interventions for preventing delirium in hospitalized patients, and 1 study protocol for interventions to prevent delirium in patients in institutional long-term care.

Clinical policies in the National Guidelines Clearinghouse (www.guideline.gov) and the American College of Emergency Physicians (ACEP) were also searched. Emergency medicine societies weighing in on the diagnosis and management of delirium include ACEP, the Society of Academic Emergency Medicine (SAEM), the Emergency Nurses Association (ENA), and the American Association of Emergency Psychiatry (AAEP). In 1999, ACEP published the “Clinical Policy for the Initial Approach to Patients Presenting with Altered Mental Status,” which critically reviewed the literature and provided an evaluation framework; however, it did not address specific pharmacological interventions for delirium. While altered mental status, as a chief complaint, is not sensitive, it has been noted to be specific for delirium, when documented.3 In 2013, ACEP, the American Geriatrics Society, ENA, and SAEM jointly published “Geriatric Emergency Department Guidelines,” which included recommendations regarding the workup and management of delirium in elderly patients presenting to the ED.15

Various regional and national guidelines for the diagnosis and management of delirium in inpatient settings also exist. Within these guidelines, specific delirium recommendations for the ED are rare, but they can be found in the United Kingdom’s National Institute for Health and Care Excellence (NICE) 2010 guideline, “Delirium: Diagnosis, Prevention and Management,” and in “Delirium: Model of Care,” from the Department of Health of the State of Western Australia.

Overall, the evidence to guide the screening and diagnosis of delirium in the ED is robust, while the literature regarding the subsequent management of delirium in the ED is less exhaustive and more reliant on expert consensus or data extrapolated from inpatient settings. The populations studied in the literature skew heavily towards the elderly patient.

The emergency medicine literature reflects the realities of the ED practice environment, with an emphasis on the management of the acutely agitated patient, in contrast to the work done in other specialties that focuses on prevention and management of delirium in the elderly patient. This dichotomy provides unique challenges in the interpretation of the existing evidence.

Risk Management Pitfalls For Delirium In The Emergency Department

  1. “I thought that this was the patient’s baseline dementia.”
    Dementia is a common confounder for delirium, but it is also a major risk factor for the development of delirium, as the neurologic pathology follows similar pathways. Demented patients are a higher-yield group for delirium screening and they benefit from additional attention and specialized care.
  2. “I didn’t have time to do a delirium screen on this patient.”
    While the time pressures of the ED environment are uniquely challenging, brief tools have been developed for ED use; specifically, the short version of the CAM takes about 2 minutes to administer.
  3. “The patient was agitated, so we sedated and restrained him and put him in the corner.”
    Agitated patients often have underlying metabolic disturbances. Once sedated, they are at risk for respiratory depression and, if placed on supplemental oxygen, would benefit from additional ventilatory monitoring in the form of end-tidal CO2 monitoring. Furthermore, if the patient meets criteria for excited delirium syndrome, there is an increased chance of arrhythmia.
  4. “We did not find anything wrong with the patient, so we sent him home with our usual discharge instructions.”
    While a certain subset of delirious patients are appropriate for discharge, overall, there is an increased risk of recidivism, morbidity, and mortality, especially in the elderly patient. At the very least, many of these patients have an increased need for coordination of care and may benefit from team-based services such as medication reconciliation, geriatric consultation, home-based assessment, and establishment of support networks.
  5. “Our elderly patient had a urinary tract infection, so we admitted her to the floor with a urinary catheter.”
    While often indicated, urinary catheters are a known precipitant for delirium and should be avoided, when possible. Admitted patients may benefit from a team-based approach to prevent delirium and other geriatric syndromes. Many hospitals currently have specialized geriatric wards or delirium units that may be more appropriate for elderly patients at risk for delirium.
  6. “Our elderly patient had mild pneumonia and confusion, so I discharged her.”
    While pneumonia severity scoring systems do not supersede clinical judgment, they include factors such as age and mental status changes that indicate poorer outcomes and warrant increased consideration for admission.
  7. “He was agitated, so we restrained him right away.”
    Providing visual and hearing assistive devices should be attempted first. Alternative nonpharmacological techniques include verbal de-escalation, show of force, one-to-one observation, decreased environmental stimulation, food or drink, limiting tethering and medical procedures, reorienting and cognitively stimulating patients, verbal orientation from family members, and avoiding medications known to precipitate delirium. If patient or staff safety is a concern, restraints and pharmacological agents may be indicated as first-line treatment.
  8. “The patient had a psychiatric history, so we assumed this was his usual psychosis.”
    Patients with an episode of acute psychosis may be difficult to distinguish from patients with delirium due to a medical etiology, and they are easy to dismiss as having a strictly functional diagnosis. However, these patients are also at increased risk for delirium, and, specifically, excited delirium syndrome is associated with baseline psychiatric comorbidity. Pay particular attention to the patient's baseline, usual episodes, changes in attention, cognition, and the time course of these changes, as well as any signs or symptoms pointing to a medical diagnosis.
  9. “The patient said he was fine and did not know why he was even in the hospital.”
    Patients with delirium often have baseline confusion, and it is vital to the workup to obtain corroborating information via proxy. A specific timeline of cognitive change is high-yield, as acute alterations or fluctuation are a hallmark of delirium.
  10. “The patient said she was not prescribed any new medications.”
    Medications are a particularly prevalent cause of delirium, especially in older patients. Even without new prescriptions, it is important to obtain a detailed medication history as changes in dosages and interactions with over-the-counter medications can lead to unintended delirium.

Tables And Figures

Table 1. Precipitating Factors For Delirium

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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Publication Information
Authors

Nelson Wong, MD; Gallane Abraham, MD

Publication Date

October 1, 2015

CME Expiration Date

November 1, 2018

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