Akutt forvirring hos eldre = delirium

Transkript

1 Akutt forvirring hos eldre = delirium Torgeir Bruun Wyller Professor / overlege Geriatrisk avdeling, Oslo universitetssykehus TBW2017

2 Foto: Rita Romskaug

3 Hippokrates Noe nytt under solen? Hippokrates, f.kr When in continued fevers occur difficulty of breathing and delirium, it is a fatal sign (Aphorisms, IV,L). TBW2017 In acute fevers, pneumonia ( ); if they (the arms) move before the face, hunt in the empty air, pluck nap from the bedclothes, pick up bits, and snatch chaff from the walls - all these signs are bad, in fact deadly (Prognostic, IV)

4 Hva er delirium? TBW2017

5 DSM-5-kriteriene for delirium A A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). B The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day. C D An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability, or perception). The disturbances in Criteria A and C are not better explained by a pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma. TBW 2017 E There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal, or exposure to a toxin, or is due to multiple etiologies

6 TBW 2017

7 Bevissthet - conciousness Forslag til tankemodell Kognisjon Oppmerksomhet attention TBW 2017 Våkenhet, mental aktivering, årvåkenhet awareness, arousal

8 Observasjonssakala for bevissthetsnivå Observational Scale of Level of Arousal (OSLA) Tieges Oversatt Fylles et al, Am J Geriatr Psychiatry 2013 til norsk: Neerland, Ahmed, Watne, Hov, Wyller ut etter at man har tilsett pasienten pasienten trenger ikke medvirke TBW 2017

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10 Eksempler på oppmerksomhetstester Telle baklengs fra 20 til 1 Enhver feil er patologisk Tallrekker forlengs Bør klare minst fem siffer Tallrekker Årets Ukens baklengs måneder baklengs dager baklengs Bør Bør Bør klare minst tre siffer nå frem til juli klare alle TBW 2017 SAVEAHAART Bør oppfatte alle fire A ene

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12 Delirium er vanlig TBW 2017

13 -Cork University Hospital, Ireland: 407 beds -15 May ,6 % hadde delirium Ryan DJ, BMJ Open Jan 7;3

14 Delirium er alvorlig TBW 2017

15 Davis; Brain 2012 TBW 2017

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17 Medikamentell behandling TBW 2017

18 The drugs we (often) use.. Off label use no drugs with delirium as indication The drugs are potentially harmful Effect on delirium? TBW 2017

19 «early intervention with low-dose treatment for short periods 1-2 weeks is prudent for many patients.» «present evidence do not support the use of antipsychotics for prevention or treatment of delirium»

20 Prevention: 7 studies no significant effect on incidence All (19 studies): No association with duration, severity, hospital/icu LOS, mortality

21 Other drugs? «No adequately trials to support the use of bzd. ( ) cannot be recommended»

22 Inclusion: When extubation was considered inappropriate because of agitation/delirium 1 2 end-point: more ventilator-free hours at 7 days (p=.01) end-point: accelerated resolution of delirium (23 vs 40 hours,p=.01) Reade, MC. JAMA 2016

23 Ikke-medikamentelle tiltak virker! Identifisere Optimalisere Optimalisere Medikamentsanering Adekvat Beroligende Gjentatt Forebygge og behandle utløsende årsak(er) komorbiditet fysiologi analgesi nærvær informasjon forstoppelse / urinretensjon TBW 2017

24 Forskning på delirium TBW 2017

25 µmol/l Phe Tyr Met Trp * * * * * 0 No Inc Pre No Inc Pre No Inc Pre No Inc Pre

26 Oppsummering Delirium kjennetegnes av raskt innsettende svikt i våkenhet, oppmerksomhet og kognisjon Delirium har per definisjon en somatisk årsak Prognosen er mer alvorlig enn tidligere antatt Patofysiologien er ukjent Ikke-medikamentelle tiltak har antakelig effekt Alle aktuelle legemidler gjør trolig like stor skade som nytte, men sentraltvirkende sympaticushemmere er for tiden lovende