Il delirium in persona con demenza e nei bambini: un confronto

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1 Il delirium in persona con demenza e nei bambini: un confronto Alessandro Morandi Dipartimento di Riabilitazione Fondazione Teresa Camplani, Ancelle (Cremona) Venerdi 24 Agosto 2018

2 October 2012

3 Epidemiology: Prevalence of DSD Prevalence of delirium superimposed on dementia: 22% to 89% Fick DM, et al. J Am Geriatr Soc. 2002

4 2017

5 Why?

6 Outline The challenge of diagnosis Tools for DSD diagnosis Attention tests Alertness and motor fluctuations

7 Barriers to delirium detection What do you think are the main barriers to improving the detection of delirium? 0% 5% 10% 15% 20% 25% 30% 35% 40% Delerium awareness Delerium knowledge/incompetence 34,07% 32,97% Lack of education 13,19% Lack of time for assessment 8,79% Lack of diagnostic skills Ageism Ignorance Poor screening tools/ lack of familiarity/awareness of screening tools 2,20% 2,20% 3,30% 3,30% Morandi A, et al. Int Psychogeriatr 2013

8 Int Psychogeriatr 2016

9 Outline The challenge of diagnosis Tools for DSD diagnosis Attention tests Alertness and motor fluctuations

10 How do you assess for the presence of DSD? Clinical practice Research 60% 54% 50% 42% 40% 30% 25% 28% 28% 27% 20% 16% 15% 16% 10% 0% 11% 8% 3% 5% 2% 4% 3% 0% 0% DSM-5 criteria ICD- criteria CAM CAM-ICU ICDSC DRS-R-98 EEG Neuroimaging Other Richardson S et al. Int Psychogeriatr 2016

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12 GOLD STANDARD DSM-5, May 18, 2013

13 Delirium: DSM-5 criteria 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. An additional disturbance in cognition (e.g. memory deficit, disorientation, language, visuospatial ability, or perception). D. The disturbances in Criteria A and C are not better explained by a preexisting, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma. 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.

14 DSM-5 criteria: differential diagnosis The clinician must determine whether the individual has delirium; a delirium superimposed on a preexisting NCD such as that due to AD, or an NCD without delirium. The traditional distinction between delirium and dementia according to acuteness of onset and temporal course is particularly difficult in those elderly individuals who had a prior NCD that may not have been recognized, or who develop persistent cognitive impairment following an episode of delirium

15 ICD-10 criteria A. A. Clouding of consciousness, that is, reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention. B. Disturbance of cognition, manifest by both: (1) impairment of immediate recall and recent memory, with relatively intact remote memory; (2) disorientation in time, place, or person. C. At least one of the following psychomotor disturbances: (1) rapid unpredictable shifts from hypoactivity to hyperactivity; (2) increased reaction time; (3) increased or decreased flow of speech; (4) enhanced startle reaction. D. Disturbance of sleep or the sleep/wake cycle, manifest by at least one of the following: (1) insomnia, which in severe cases may involve total sleep loss, with or without daytime drowsiness, or reversal of the sleep/wake cycle; (2) nocturnal worsening of symptoms; (3) disturbing dreams and nightmares that may continue as hallucinations or illusions after awakening. E. Rapid onset and fluctuations of the symptoms over the course of the day. F. Objective evidence from history, physical and neurological examination, or laboratory tests of an underlying cerebral or systemic disease (other than psychoactive substance-related) that can be presumed to be responsible for the clinical manifestations in A to D.

16 Outline The challenge of diagnosis Tools for DSD diagnosis Attention tests Alertness and motor fluctuations Instrumental evalutation

17 Delirium diagnosis methodology: Frequency and Type of Standardized Cognitive and Delirium Detection Tool Used by Reference Rater as Part of Delirium Evaluation Cognitive tests (used in 20 (61%) of 33 studies) N % of All Studies (N=33) Digit span 12 36% Months of the year backwards 7 21% Days of the week backwards 5 15% Clock drawing test 2 6% Digit cancellation test 1 3% Trail Making Test A 2 6% Trail Making Test B 2 6% Neufeld et al 2014 AmJ Ger Psych

18 Which test do you use to test attention in DSD? Clinical practice Research 50% 47% 45% 40% 35% 32% 30% 25% 20% 15% 22% 28% 16% 18% 26% 20% 19% 19% 23% 23% 14% 24% 10% 5% 6% 3% 8% 5% 0% Months of the year bacwards Months of the year forward Days of the week backwards Days of the week forward Counting 20 to Series of letter 1 Digit span forward Digit span backwards Other Richardson S et al. Int Psychogeriatr 2016

19 What attention should be tested in DSD? Attention switching 38% Divided attention 12% Working memory 10% Selective attention 21% Sustained attention 62% 0% 10% 20% 30% 40% 50% 60% 70% Richardson S et al. Int Psychogeriatr 2016

20 Test for sustained attention were best able to discriminate delirium from dementia. Digit span backwards, spatial span forwards and digit cancellation tests are currently the best available practical options for this purpose.

21 Digit span backwards

22 Spatial span forward

23 Digit cancellation test

24 Early AD Moderate-Severe AD Sustained attention Preserved (+) Deficit Divided attention Preserved (+/-) Deficit Selective attention Deficit Deficit

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27 Evaluating Attention and Noncognitive Tests of Delirium: A Prospective European Multicenter Observational Study in Elderly Patients Department of Rehabilitation, Fondazione Teresa Camplani Cremona, Italy Old age psychiatry and palliative care liaison psychiatry services in MidWest Regional Hospital Limerick, St John s Hospital Limerick and St Camillus Hospital Limerick, Ireland; Abteilung Klinische Pflegewissenschaft, Universitätsspital Basel, Switzerland Department of Psychiatry, Centro Hospitalar Universitário de Coimbra, Coimbra, Portugal; Department of Health Sciences, University of Milano-Bicocca; Geriatric Unit, S. Gerardo Hospital, Monza, Italy Morandi A, Bellelli G, Cerejeira J, Richardson S, Meagher D, Hasemann W, Davis D, MacLullich A

28 Results: attention tests Variabili Days week forward NO DEL NO DEM (n=22) DEM (n=27) DEL DEM (n=25) DEL NO DEM (N=12) P value 6.9 ± ± ± ± Days week back 7.1 ± ± ± ± Months forward 11.9 ± ± ± ± Months back 9.2 ± ± ± ± Series of letters (errors) 0.8 ± ± ± ± Digit forward 3.1 ± ± ± ± Digit backwards 1 ± ± ± ± Morandi A, et al EDA 2015

29 4AT score- item attention Prevalence of the MOTYB score and dementia in the Italian Delirium Day 2016 Bellelli G, Morandi A, et al Submitted BMC Ger 2016

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31 MOTYB: sensitivity 82.6%; 95% CI [ ], and specificity 62.5%; 95% CI [ ]

32 Outline The challenge of diagnosis Tools for DSD diagnosis Attention tests Alertness and motor fluctuations

33 How do you measure the level of alertness in DSD? Clinical practice Research 40% 35% 34% 30% 28% 29% 27% 29% 25% 20% 15% 13% 16% 10% 10% 5% 6% 4% 0% OSLA RASS m-ras Glasgow Coma Scale None Richardson S et al. Int Psychogeriatr 2016

34 Do you use a specific test to monitor motor fluctuations in DSD? Clinical practice Research 70% 60% 61% 50% 43% 40% 30% 20% 13% 13% 14% 10% 0% 4% 3% Trunk control test 6% 6% 7% 5% 5% 2% 3% 2% 2% Tinetti scale HABM RASS m-rass Actigraphy None Other Richardson S et al. Int Psychogeriatr 2016

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36 m-rass Score Termine Descrizione +4 Combattivo Disattento, apertamente ostile, aggressivo e violento, procura danno immediato allo staff +3 Molto agitato Estremamente distraibile, per ottenere il contatto oculare è necessario chiamarlo o toccarlo continuamente, non è in grado di mantenere attenzione, tira o rimuove tubi/cateteri; aggressivo nei confronti dell ambiente non delle persone +2 Lievemente agitato Facilmente distraibile, perde rapidamente l attenzione, resistente alle cure, non collaborante. Frequenti movimenti afinalistici, +1 Irrequieto Lievemente distraibile, in grado di mantenere l attenzione il più delle volte, ansioso ma collaborante, movimenti non aggressivi o vigorosi 0 Sveglio e calmo In grado di mantenere l attenzione, consapevole dell ambiente circostante, risponde prontamente e correttamente se lo si chiama o lo si tocca -1 Facilmente risvegliabile Lievemente assopito, mantiene contatto oculare > 10 secondi; non completamente sveglio, ma con risveglio duraturo (apertura degli occhi/contatto visivo allo stimolo verbale > 10 secondi) -2 Lentamente risvegliabile Molto assopito, in grado di prestare attenzione per qualche tempo, brevi risvegli con contatto visivo allo stimolo verbale <10 secondi -3 Difficile da risvegliare Sono necessari richiami o contatti ripetuti per ottenere attenzione/contatto visivo; necessari stimoli verbali o fisico per ottenere attenzione; movimento o apertura degli occhi allo stimolo verbale ma non contatto visivo -4 Incapace di stare sveglio Risvegliabile ma non in grado di prestare attenzione; nessuna risposta allo stimolo verbale ma movimenti o apertura degli occhi allo stimolo fisico -5 Non risvegliabile Nessuna risposta allo stimolo verbale né allo stimolo fisico Chester JG, et al. J Hosp Med. 2012;7:

37 Chester et al 2012 J Hosp Med

38 Morandi et al. JAMDA 2017

39 m-rass and delirium in daily clinical evalutation m-rass Day 1 Day 2 Day 3 Day 4 Day 5 m-rass 4 m-rass 3 m-rass 2 m-rass 1 m-rass 0 m-rass -1 m-rass -2 m-rass -3 m-rass -4 m-rass -5

40 m-rass and DSD in daily clinical evalutation m-rass Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 m-rass 4 m-rass 3 m-rass 2 m-rass 1 m-rass 0 m-rass -1 m-rass -2 m-rass -3 m-rass -4 m-rass -5

41 Observational scale of level of arousal (OSLA) (score 0-15) Eye opening Eye contact Posture Movement Am J Geriatr Psychiatr 2013

42 Age (Mean (SD)) Female (Number (%)) s-mmse (Median (IQR)) IQCODE (Median (IQR)) None n=34 Dementia n=28 Delirium n=21 DSD n=31 p 81 (±6) 82 (±7) 84 (±6) 84 (±7) (56%) 14 (50%) 11 (52%) 18 (58%) (26, 29) 17 (12, 21) - - < (3, 3.3) 4.1 (3.6, 5) 3 (3, 3.2) 4.5 (4, 5) <0.01 International Psychogeriatrics 2018

43 Combination of arousal and attention tests International Psychogeriatrics 2018

44 Children and elderly?

45 2012

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47 Mobility and delirium Admission Weekly Delirium resolution Discharge Diagnosis delirium Bellelli et al. JAMDA 2011 Oct;12:578-83

48 In adults, tools that rely on neurocognitive aspects can be used. However, since most of the critically ill children are less than 3 years and an important other group suffers from intellectual disabilities, we have to rely on behavioral symptoms.

49 The American Geriatrics Society (AGS) encourages the incorporation of 6 behavioral domains (ie, facial expressions, verbalizations/ vocalizations, body movements, changes in interpersonal interactions, changes in activity patterns/routines and mental status changes) when conducting pain assessments among seniors with dementia. AGS Panel on Persistent Pain in Older Persons. J Am Geriatr Soc. 2002;50:S205 S224

50 pscam-icu Feature 2 / American Geriatric Society Facial expressions Verbalizations/ vocalizations body movements Feature 4/ American Geriatric Society Changes in interpersonal interactions Changes in activity patterns/routines and mental status changes Smith HA et al. Crit Care Med. 2016

51 Behavioral observation to diagnose delirium in preverbal children and dementia patients facial expressions verbalizations/ vocalizations body movements changes in interpersonal interactions changes in activity patterns/routines and mental status changes

52 Delirium in dementia patients and children. Overlap and possible role for future diagnosis Variable Age (years/months) DSD cohort (N=35)* Infant cohort (N=80) 84 (82-87) 10 (7-16) 36 (30-39) Mild dementia 15 (43%) - - Moderate dementia 13 (37%) - - Severe dementia 7 (20%) - - PRISM Score - 6 (0-12) 6.5 (5-14) Preschool cohort (N=32) *Cohort of elderly patients with DSD, Department of Rehabilitation, F Camplani, Cremona (Italy) ** Cohort of infant and preschool children, Vanderbilt University, Nashville (USA) Morandi A, et al EDA 2014

53 Morandi A, et al EDA 2014 Symptoms of delirium

54 The 4ATd scale a new tool to assess delirium superimposed on moderate-severe dementia Eleonora Grossi 1, Elena Lucchi 1,2, Bianca Faraci 1, J.Severgnini 1, Enrico Mossello 3, Antonio Cherubini 4, Simona Gentile 1,2, Alasdair MacLullich, 5 Heidi Smith, 6 Pratik Pandharipande, 6 Marco Trabucchi, 2 Giuseppe Bellelli 2,7, Alessandro Morandi 1,2 1 Department of Rehabilitation, Fondazione Camplani Casa di Cura Ancelle della Carità, Cremona, Italy; 2 Geriatric Research Group, Brescia, Italy; 3 University of Florence, Carreggi University Hospital, Italy; 4 IRCCS INRCA Ancona, Italy; 5 University of Edinburgh, Scotland; 6 Vanderbilt University, Nashville, USA; 7 Geriatric Clinic, University of Milan-Bicocca

55 Background From verbal comunication to non-verbal observation Create, standardize, validate a new tool DSM5

56 Methods 4ATd Score Ranges 0-12 The 4AT structure is maintained by analyzing the four basic elements: alertness, attention, disorganized brain, acute change It includes illustrated and mirror-cards It is based on observation of the patient interaction with the proposed material. Validity vs DSM5: sensitivity and specificity, negative/positive predictive value, Interrater Reliability

57 Preliminary Data N (%) M±Ds Total 77 (100,00) DEL 27 (35,00) NO DEL N (%) 50 (65,00) Age 85,09±6,25 84,62±6,33 85,96 ± 6,12 Gender (F, N (%)) 44 (57,10) 16 (20,8) 28 (36,3) Years of school 6,24±3,00 6,65±3,26 5,06±1,69 Rehabilitation setting 37 (48,00) 5 (18,50) 32 (48,10) Acute Hospital 40 (52,00) 22 (81,50) 18 (52,00) Years of illness 4,19±2,98 5,05±3,79 3,34±1,51 Nr of drugs 7,32±3,15 7,82±3,25 6,41±2,78 IADL lost 6,64±1,83 6,20±1,88 7,48±1,40 ADL lost 4,30±1,99 4,08±2,08 4,70±1,79 AD8 7,49±0,79 7,45±0,85 7,57±0,68

58 Results Preliminary data show a high 4ATd score in patients with DSD. The maximum sensitivity and statistical specificity (82%) is at a score of 4. Per cut-off > 4: Sensibilità 0,815 Specificità 0,82

59 Conclusions The challenge of diagnosis Attention testing More attention on motor fluctuations Overlapping research studies (children and elderly)