1. health and fitness
2. disease

“Doctor, why does my skin turn yellow?”
Dr. Wong Yuet Lin
Dr
Lin, Elaine
Department of Medicine and Geriatrics
United Christian Hospital
F/75 Madam LSC
o
o
o
o
o
o
o
P
Premorbid
bid
community dwelling elderly
stick walker
independent activity of daily living
Social history
widow, living with son in public housing estate
attending day care center six times per week
illiterate
worked as amah, retired in 1991
Good
G
d evening,
i
doctors……
Past medical history and Medications
o
o
o
o
o
o
o
o
o
o
o
o
o
P t Medical
Past
M di l History
Hi t
hypertension
diabetes mellutis
hyperlipidaemia
yp
p
old ischemic stroke with good recovery 2005
- CT brain : right brainstem infarct
- EMS 20, MFAC 6, BBS 35
OA knee
thyroid abscess (2000)
bereavement (2000)
- psychiatric assessment : MMSE 17, poor attention during test
f
ld
t ti off hist
ti
- no formal
documentation
history off d
dementia
bilateral hearing loss refuse hearing aids
Medication before admission
aspirin 80mg daily
adalat retard 40mg bd
zocor 5mg nocte
metformin 750mg tds
amaryl 4mg om
Admission to surgical ward (20 Jan 2010)……
o
o
o
o
o
o
o
o
o
o
o
o
History
sudden onset of yellowing of skin for few days, noted by day care center nurse
self
lf noted
t d ttea color
l urine
i and
d pale
l stool
t l
no right upper quadrant pain
no fever/chills/rigor
no recent weight loss
denied history of herbs, over-the-counter medication or health supplement
no travel history
Physical examination
deep jaundice
hepatomegaly 4cm below right costal margin
no stigmata of chronic liver disease
orientated, no sign of hepatic encephalopathy
vital signs stable
Blood test results after admission……
Before admission
On admission to
surgical ward
( 20 Jan 2010 )
After admission
( 21 Jan 2010 )
Bil
8
190
243
ALT/AST
11/--
840/1079
1032/--
ALP/GGT
59/--
220/155
207/--
INR
--
1.4
1.3
Albumin
43
31
25
Hb
11.7
9.8
10.7
Platelet
340
209
317
WCC
83
8.3
76
7.6
62
6.2
Ur/Cr
4.4/76
11/150
3.9/93
Na
145
135
137
K
43
4.3
42
4.2
41
4.1
One day after admission (21 Jan 10)……
o
o
o
Bedside ultrasound abdomen by surgical colleagues
gallbladder wall thickened, not distended
pr minent intra-hepatic
prominent
intra hepatic ducts,
ducts c
common
mm n bile duct 1cm
no stone
LFT static
Afebrile, Vital sign stable
OGD arranged : chronic duodenal ulcer at D1, acute gastritis
Hypoglycemia noted : metformin/amaryl off
Take over to medical team two days after
admission (22 Jan 2010)……
Constrast CT abdomen : no mass, no biliary obstruction
Medical team was consulted for management of acute hepatitis
o
o
o
o
Patient was assessed at 4pm
deep jaundice, hepatomegaly 4cm below right costal margin
Hstix 19.8 after OHA off, subcutaneous actrapid was given
Vital signs stable, afebrile
orientated, cheerful, relevant speech, communicable with hearing aids
Patient : doctor, why does my skin turn yellow ?
D t : it’s
Doctor
it’ because
b
there
th
is
i some problem
bl
with
ith your liver,
li
we
will transfer you to our unit for further management.
Patient : I understand, thanks doctor.
Patient was transferred to medical ward at 5pm
o
o
o
Notes written by medical nursing staff
transfer in from surgical
g
ward,, reason for transfer explained
p
to son
vital sign stable, afebrile, Hstix recheck 12
orientated, went to toilet with son’s accompany
Something happened at that
night……
night
Midnight of 23 Jan 10
Nursing notes
o
o
o
o
o
2am :
patient tried tto climb from
fr m bed
GCS 14/15, disorientated to time and place, confused speech, safety vest applied
on call medical officer informed, patient assessed, vital sign stable, blood test ordered
4am :
patient used her knife to cut the safety vest, agitated
security guard called, patient was put on physical restrainer
What happen? What’s the diagnosis?
 Hepatic encephalopathy?
 Undocumented history of dementia with BPSD?
 Acute stroke?
 Delirium?
Morning round at 23 Jan 10 (three days
after admission )……
Patient on physical restrain
disorientated, confused speech, inattention, not agitated, occassionally could follow one step
command, four limbs power around 4
Refuse breakfast, Hstix 6
Fever up to 38 degree, urine stix positive
Found acute retention of urine (400ml)
Bowel opening daily
Psychiatric notes in 2000 reviewed
- illiterate, work as amah, retired in 1991
- personality : introverted, few friends, dependent on husband, anxiety prone
- low mood after husband’s death
- MMSE 17 ( 3,3,3,1,2,2,1,2,0,0,0 ), poor concentration during test
- diagnosis : bereavement
- plan : counseling given, follow up prn
Son contacted via phone and premorbid cognitive state reviewed
Underlying
dementia?
MCI?
- poor memory for one year
- orientation good
- no history
off d
delusion
or h
hallucination
hi
l i
ll i
i
- no depressive or irritable mood, no reverse sleep cycle
- no history of fall, hygiene good
Investigation result after confusion……..
Before admission
Admission
( 20 Jan
2010 )
After
admission
( 21 Jan
2010 )
After confusion
(23 Jan 10 )
25 Jan 10
Bil
8
190
243
244
250
ALT/AST
11/--
840/107
9
1032/--
844/713
553/--
ALP/GGT
59/
59/--
220/15
5
207/
207/--
194/
194/--
181/
181/--
INR
--
1.4
1.3
1.4
1.3
Albumin
43
31
25
27
28
Hb
11.7
9.8
10.7
10.0
10.1
Platelet
340
209
317
313
373
WCC
8.3
7.6
6.2
8.2
12.1
Ur/Cr
4.4/76
11/150
3.9/93
5.2/124
5.8/11
6
Na
145
135
137
135
138
K
4.3
4.2
4.1
4.2
4.2
ammonia level normal
Urgent CT brain : small vessels
disease, bilateral lacunar infarct
MSU : wcc scanty, no growth
Blood culture
: negative
MMSE
2000
orientation
registration
Calculation
C
l l i and
d
attention
Recall
Language
Visual
construction
T t l marks
Total
k
(poor attention)
After
confusion
3,3
3
3
3
1
0,0
0
0
2
0
2
2,1
2,0,0,0
2
2,1
1,0,1,0
17
9
Diagnosis and Plan
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o
Provisional Diagnosis
Delirium
Acute hepatitis
?Urinary
?
r nary tract infection
nf ct on ?f
?feverr due
u to acut
acute h
hepatitis
pat t s
?Underlying dementia ?MCI
Plan
put on zinacef
sit out, avoid physical restrain
physiotherapy referred for early mobilization
encourage oral intake, dietician referred
 Whyy does this ladyy developp delirium?




Can this be prevented ?
Should we start haloperidol?
What will be her prognosis?
What
her acute
Wh t is the
th cause
s of
fh
t hepatitis?
h
titis?
Progress in subsequent days……
o
o
o
o
o
o
o
o
o
o
o
24 Jan 10 morning round (one days after acute confusion)……
confusion)
fragmented sleep last night
sit out while assessment, still disorientation, poor attention, confused speech
fever persist, vital sign stable
finish 1/3 breakfast
Physiotherapist/Occupational therapist : power 4/5 over four limbs, transfer barely independent,
walk with stick with mild assistance, EMS 7, MFAC 4, BI 64
25 Jan 10 morning round (two days after acute confusion)……
confusion)
sleep well last night
still disorientated but decreased confused speech, attention improved
keep on PT/OT training
26 Jan 10 morning round (three days after acute confusion)……
orientated, cooperative, no more confused speech
finished whole bowel of congee 350ml during breakfast
stick walker under supervision, increased stability
Patient was transferred to convalescence hospital for further
rehabilitation and monitoring of liver function at 28 Jan 10…….
10
B f
Before
reviewing
i in p
patient
ti nt’ss progress
p
ss
Let’s have a discussion of today’s topic………
Delirium - Review
Why do
Wh
d patients
ti t d
develop
l
delirium?
• Concept
C
t off delirium
d li i
• DSM-IV criteria
• Pathophysiology of delirium
• Risk
Ri k factor
f
model
d l for
f development
d l
off d
delirium
li i
Concept of delirium
Phenomenon of delirium first recognized as early as first
century CE by Celsus
Clear description of this term : Hippocrate’s writing 2500 ago
DSM-IV-TR
DSM
IV TR criteria :
most commonly used gold standard nowaday
Acute mental disorder :
acute onset, daily fluctuating course, inattention and
other cognitive impairment
Accompany by presence of acute medical illness
Diagnosis
g
of delirium according
g to
DSM-IV-TR criteria
All four criteria (A-D) are required to confirm a diagnosis of
d li i
delirium
General diagnostic
g
criteria (A-C)
(A) Disturbance of consciousness (that is, reduced clarity of awareness of the environment) with
reduced ability to focus, sustain, or shift attention
(B) A change in cognition (such as memory deficit, disorientation, language disturbance) or the
development of a perceptual disturbance that is not better accounted for by a pre-existing,
t bli h d or evolving
l i d
ti
established,
dementia
(C) The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate
during the course of the day
*Diagnostic and Statistical Manual of Mental Disorders,
4th edition, text revision (DSM-IV-TR®) American Psychiatric Publishing, Inc., Arlington, VA)
DSM-IV classification of
causes of delirium
Criteria D
o
o
o
o
For delirium due to a general medical condition
(D) Evidence from the history, physical examination, or laboratory findings indicates that the
disturbance is caused by the direct physiological consequences of a general medical condition
F substance
For
b
intoxication
i
i
i d
delirium
li i
(D) Evidence from the history, physical examination, or laboratory findings indicates that of either (1)
the symptoms in Criteria A and B developed during substance intoxication, or (2) medication use is
etiologically related to the disturbance
For substance withdrawal delirium
(D) History, physical examination, or laboratory findings indicate that the symptoms in Criteria A and
B developed during, or shortly after, a withdrawal syndrome
For delirium due to multiple etiologies  commonly seen in elderly
(D) History,
History physical examination
examination, or laboratory findings indicate that the delirium has more than one
etiology (for example, more than one etiological general medical condition, a general medical condition
plus substance intoxication or medication side effect)
Pathophysiology
N t fully
Not
f ll understood,
nd
t d lik
likely
l to
t b
be complex
mpl x
o
o
o
o
Neurotransmitter imbalance
cholinergic
g deficiency
y
elevated brain dopaminergic fucntion
relative imbalance between the dopaminergic and cholinergic system
glutamate, beta-aminobutyric acid, serotonin, norepinephrine
Different mechanisms may occur in different acute illnesses
Metabolic or ischemic insult (hypoxemia,hypoglycemia) : impaired
th i and
d release
l
f neurotransmitters
t
itt
synthesis
of
Trauma/infection/surgery : release of proinflammatory cytokines -> activate
microglia in brain -> affect neurotransmitter synthesis/release
High level of cortisol : elderly has impairment in feedback regulation of cortisol,
predispose to delirium
Risk factor model
Multifactorial
: complex
interaction between predisposing and
precipitating factors
o
o
Relation between
y and degree
g
of
vulnerability
insult
patient with high vulnerability develop
delirium even with mild degree of insult
P ti t with
ith llow vulnerability
l
bilit resistant
i t t
Patient
to delirium even with noxious insult
Elderly
y patient
p
:
vulnerability
high
g
Risk factors associated
with delirium
o
o
o
• Old age
• Possible underlying cognitive impairment
• Hypoglycemia/Hyperglycemia
Predisposing
• Anemia
“Key” for
successful
• Low albumin
Age > 65
• Acute liver failure
management
Male sex
• Infection ( ?urinary tract infection )
addressing and manage all the risk
Dementia or other cognitive
• Immobilization device : foley insertion,
impairment physical
factors restrains
or Visual impairment
• Environmental factors : change Hearing
of ward/staff
“Individualized”
Individualized
What are the possible risk
factors for our patient?
Infection
Electrolyte disturbance
Metabolic disturbance :
base,
glucose disturbance,
thyroid function
acid-
adrenal or
Functional dependence
Organ failure
- acute renal or liver failure
- respiratory
i
or cardiac
di failure
f il
Acute stroke
History of falls or fracture hip
Anemia
Alcohol abuse
Malnutrition or low albumin
P h ti drugs
d
Psychoactive
D
ithd
l or intoxication
i t i ti
Drug
withdrawal
Polypharmacy
High number of hospital procedure
Multiple physical illness
Immobilization device
Chronic renal or liver failure
Environmental factors
History of stroke or neurological
disease
Psyc
Psychological factors
Terminal
T
i l illness
ill
Prolong
sleep
deprivation
P l
l
d i i
Definitely
our patient is at high risk………
different
patients
/clinical
setting -> different risk factors
search carefully with clinical
sensibility in each case
Precipitating
Development of delirium
Risk factor
model
- vulnerability ( predisposing factors)
- degree of insults (major causes and
precipitating factors of delirium )
Pathophysiology ( different
diff r nt m
mechanisms
ch nisms
in different acute illnesses )
Diagnosis according
To DSM-IV criteria
Why delirium is important?
•Commonness
C
•Under-recognition
•Adverse outcomes
•Persistent
P i
delirium
d li i
•Delirium progress to dementia?
Commonness
“Prevalent” delirium : on admission (14-24%)
* no consensus on definition of time interval : definition of within 36/48/72 hours
“Incidence” delirium : develop during hospital stay (6-56%)
* high incidence delirium due to poor screening of prevalence delirium on admission
o
o
o
o
o
o
o
o
o
Common in different clinical settings
Community 1-2%
Hospital elderly 14-56%
General medical 15-50%
Postoperative patient 15-53%
Hip fracture 43-61%
ICU 70
70-87%
87%
Palliative care 83%
Nursing Home or Post acute care setting 50%
Emergency department 30%
U d
Under-recognition
i i
Under detection rate 32-67%
o
o
o
o
o
o
Reasons for under-recognition
under recognition
non-specific presentation, daily fluctuating -> lucid period pitfall for diagnosis
a low-status medical presentation, not require extra resources
not a medical problem, consider it as psychiatry problem
multiple etiology different from the classic “myth” of “one man one disease ”
hypoactive delirium
Common in patients with previous cognitive impairment -> masking effect
Screening tools to improve detection rate? Still not commonly
used in most health care setting…..
Adverse outcomes
Independent risk factors for poor outcomes
* Occurrence and outcome of delirium in medical in-patients : a systematic literature review.
Age and ageing 2006, 35:350-364. Siddiqi N, House AO, Holmes JD.
- Results of outcomes in 19 study cohorts
- delirium associated with increase mortality at 12 months, increase length of hospital stay and
institutionalizations
o
o
o
o
o
o
o
Hospital complications
(aspiration, pressure sore, incontinence, acute retention of urine, decrease oral intake pulmonary embolism)
Functional and cognitive decline, loss of independence
Prolong length of hospital stay
Psychological impact to families
Increase post discharge health care support
Institutionalization
One year mortality rate 35-40%
35 40%
Persistent delirium
Traditional belief : reversible and transient
Recent studies : delirium persist much longer than believed
o
o
o
* Persistent delirium in older hospital patients : a systematic review of frequency and prognosis. Age and Ageing
2009, 38:19-26. Cole MG, Ciampi A, Belzile E, et al.
18 studies reviewed
combined proportions with persistent delirium at discharge, 1,3 and 6 months were
44.7%, 32.8%, 25.6% and 21%
outcomes ( mortality, nursing home placement, function, cognition ) are poorer in
patients with persistent delirium
Risk factors associated with persistent delirium identified
* Risk factors for delirium at discharge : Development and Validation of a predicitive model.
o
o
o
o
o
o
Arch Intern Med, 2007, Vol 167(No.13):1406-1413. Ionuye SK, Zhang Y, Jones RN, et al.
Five independent
p
risk factors identified :
dementia (OR 2.3)
vision impairment (OR2.1)
functional impairment (OR1.7)
high comorbidity (OR1
(OR1.7)
7)
use of physical restrain(OR3.2)
Delirium progress to dementia?
Relationship remains unclear
: a spectrum of cognitive disorder? ( both
associated with cholinergic deficiency, inflammatiion )
Dementia : strongest risk factor associated with delirium
Permanent cognitive and functional decline after an episode of
delirium reported in some cases
Delirium commoner in patients with incipient dementia?
* Delirium episode
as a sign
: a 2 year
follow up
p
g of undetected dementia among
g community
y dwelling
g elderly
y subjects
j
y
p
study. J. Neurol. Neurosurg. Psychiatry, 2000, 69, 519-521. Rahkonen T, Paanila S, Sivenius J.
Poor outcome for patients with delirium superimposed on
dementia : accelerate rate of progression of dementia and poorer outcome than
those without delirium
* Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals. J. Gerontol.
Nurs, 2000, 26, 30-40. Fick D, Foreman M
Whatt is
Wh
i the
th clinical
li i l feature
f t
of delirium
• Core
C
features
f t
• Subtypes
• Subsyndromal delirium
• Severity
S
i
Core features
o
o
o
o
o
o
o
o
Acute onset with daily fluctuating course
Disturbance in attention
Disorganized thinking
Altered level of consciousness e
e.g.
g viligant
viligant, lethargy
Disorientation
Memory impairment
Perceptual disturbance
Psychomotor agitation and retardation
Sleep-wake cycle disturbance
A
h :
Approach
o
o
establish Baseline cognitive function, any recent change
Severity of delirium : relationships with outcome?
many tools for assess severity : Memorial
M
i lD
Delirium
li i Assessment
A
S
Scale
l (MDAS)
(MDAS), D
Delirium
li i I
Index(DI),
d (DI) D
Delirium
li i
Assessment Scale (DAS), Delirium Rating Scales-revised version (DRS-R-98)
largely used in clinic research, may have role in clinical practice
Subtypes
first described by Lipowski (1990) : refer to psychomotor
activity or level of arousal
o
o
o
Three subtypes
Hyperactive : hallucination, delusion, agitation, restlessness, hypervigilance
Hypoactive : lethargy,
lethargy sedation
sedation, respond slowly to questioning
Mixed : fluctuate between hyperactive and hypoactive form
Hypoactive
delirium :
yp
significant higher rate at people age over 65
Lack of consensus on classification of subtype of delirium :
barrier to research
Different pathophysiology, causes, prognosis and responses to
treatment?
Subsyndromal delirium
o
o
No consensus of definition
not meet DSM-IV criteria but exhibit few core features of delirium
some exhibit
hibit prodromal
d
l symptoms
t
: restlessness,
tl
anxiety,
i t iirritability,
it bilit di
distractibility,
t
tibilit
sleep disturbance
may
y progress
p g
to full-blown delirium over 1-3 days
y
Some report similar worse outcomes to those with mild delirium
*The prognostic significance of subsyndromal delirium in elderly medical inpatients. J Am Geriatr
Soc, 2003 June, 51(6) :754-60. Cole M, McCUsker J, Dendukuri N, Han L
Need close monitoring in this group of patient?
Confusion Assessment Method (CAM)
Most commonly used
perform with formal cognitive testing
Reliable when used by trained interviewer : sensitivity 94-100%,
specificity 90-95%, high inter-rater reliability
CAM Algorithm ( presence of 1+2 and either 4 )
11.
2.
3.
4.
Acute onset + fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
* Clarifying confusion : the confusion assessment method : A new method for detection of delirium
Annals of Internal Medicine. 1990 Dec 15;113(12):941-8. Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI
Routine screening needed? Mode of screening? Which screening
test? Who should be screened?
Table 2 Tools for the assessment of delirium
Fong TG et al. (2009) Delirium in elderly adults: diagnosis, prevention and treatment
Nat Rev Neurol doi:10.1038/nrneurol.2009.24
Is there any
y effective
treatment for delirium?
• Non-pharmacological
N
h
l i l
• Pharmacological treatment
• Prevention
G
General
l principals
i i l
Multi-disciplinary approach
Identification and treatment of the etiological causes
Addressing all the precipitating and modifiable risk factors
Treating the behavior symptoms
Preventing complications
Maintaining function and independence
Counseling to their care-giver
care giver and relative
Non-pharmacological treatment
“ First-line” treatment, Nursing care based………
sensory
n
imp
impairment
i m nt (spectacles,
(
l
h
hearing aids)
d )
nutrition, hydration and electrolytes disturbance
avoid faecal impaction, watch out for acute retention of urine
orientation
i t ti programme (reorientation, clear instructions, frequent eye contact, clock, calendars)
avoid Physical retrain (decrease mobility, increased agitation/injury, prolongation of delirium)
early mobilization
d noise at night
h time
quiet patient-care setting, avoid
low-level lighting at night, bright light at daytime
avoid sleep deprivation
limiting room and staff changes
environment modification to minimize risk of injury
Evidence to support a multi-disciplinary
approach?
Three systematic reviews performed and only two randomized
control trial identified
* Systematic
S t
ti detection
d t ti and
d multidisciplinary
ltidi i li
care of
f d
delirium
li i
iin older
ld medical
di l iinpatients:
ti t a randomized
d i d ttrial.
i l Cole
C l
MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, and Laplante J. Canadian Medical Association
Journal, 2002. 167(7): p. 753-759.ole et al (2002) [100]
* Systematic intervention for elderly inpatients with delirium: a randomized trial. Cole MG, Primeau FJ, Bailey RF,
Bonnycastle MJ, Masciarelli F, Engelsmann F, Pepin MJ, and Ducic D,. Canadian Medical Association Journal, 1994. 151(7):
p 965
p.
965-70
70 (1994) [53]
o
o
o
o
received consultations by a geriatrician/geriatric psychiatrist and treatment
recommendations
daily visits by a liaison nurse to ensure adherence to intervention
unable to demonstrate a significant difference between the two group
a cross contamination effect, general standard of care (control group) was high, study
was underpowered
Ph
Pharmacological
l i l treatment
o
o
o
o
o
Indications
severe behavioral or emotional disturbance e.g. interfering with sleep-wake cycle,
anxiety, fear and hallucinations
threatens own or others safety
interfere with essential medical or nursing care
ensure medical causes for agitation treated e.g. pain, constipation, urinary retension,
hypoxia
other non-pharmacological measures failed to ease the symptoms
Aim
o
o
o
o
: alert and manageable patients
When start treatment
commence at lowest dose, shortest duration, titrate against level of agitation
clear documentation : dose,, frequency,
q
y, route,, side effects
close monitoring of vital signs, mental state by nursing staff
review regularly by physicians : drug use to treat delirium can increase confusion or
lead to over-sedation
o
o
o
o
o
o
o
Treatment Choice based on expert guidelines
few high-quality, randomized, controlled trials
A
American
i
P
Psychiatric
hi t i A
Association
i ti (APA) guidelines,
id li
llastt updated
d t d 2004
mainly for use in hyperactive delirium, role in hypoactive delirium : controversial
H l
Haloperidol
id l : most widely
id l used
d
0.25mg oral (tablet/drop), 0.5-1mg Intramuscular route : peak effect ~ 20-40mins
efficacy shown in randomized, controlled trials : reduce symptoms severity/duration
Ad
R
ti
ff
l
h the
h QT interval,
l antiAdverse
Reactions
: extrapyramidall side effects,
acute dystonias, lengthen
cholinergic effecs (AROU, dry mouth, constipation, increased confusion), sedation
Avoid in patients with withdrawal syndrome, hepatic insufficiency, neuroleptic
malignant syndrome
o
o
o
o
o
o
o
o
o
o
Atypical antipsychotics
risperidone 0.25mg daily -> 0.5mg bd, olanzapine 2.5mg daily -> 5mg daily, quetiapine 12.5mg daily
comparable efficacy to haloperidol demonstrated in small randomized control trial
more favorable motor side-effect profile than haloperidol : Prkinson’s disease, Lewy body
dementia, prefer in elderly
risk of prolong QT interval, increased risk of stroke in older patients with dementia
Benzodiazepine
not recommended as first-line agents treatment due to effect limited by adverse
effect :paradoxical excitation, over-sedation, exacerbation of confusion, respiratory depression
withdrawal delirium related to seizures,
seizures diffuse
use in particular situations : alcohol or sedative-hypnotic drug withdrawal,
Lewy body disease, parkinson’s disease, neuroleptic malignant syndrome
second-line treatment following failure of antipsychotics
lorazepam : preferred agent in geriatric patients, shorter half-life, lack of active
metabolites,, availability
y in parenteral
p
form
Cholinesterase inhibitors
donepezil 5mg daily
efficacy reported by case report
Is there any prevention for
d li ium?
delirium?
P
Prevention
i possible?
ibl
30-40% preventable
Incidence delirium :
an iindicator
di t of
ff
failure
il
of
f hospital
h
it l care?
?
Intervention program : HELP
Proactive Geriatric consultation :
Education program to staff
Pharmacological Prophylaxis
post fracture hip, decrease delirium 40%
Preventive measures
Risk factors associated with development of incidence delirium,
delirium
five independent risk factors identified
o
o
o
o
o

* Precipitating factors for delirium in hospitalized elderly persrons : prevdictive model and interrelationship with baseline
vulnerability. JAMA 1996, 275(11):852-7. Inouye SK, Charpentier PA
use of physical restraints ( RR4.4 )
malnutrition ( RR4.0 )
more than three medications added ( RR2.9 )
use of bladder catheter ( RR2.4 )
any iatrogenic event ( RR1
RR1.9
9)
factors targeted on to prevent incident delirium during hospitalization?
Hospital
Elder
Life
p
E
L f Program
g m (HELP)
( EL ) : innovative strategy
gy of
f
hospital care for elderly patients
o
o
o
* A Multicomponent intervention to prevent delirium in hospitalized older patients. NEJM, 1999 Mar 4;340(9):66976. Inouye SK, Bogardus ST Jr, Charpentier JA, Leo-Summers L, Acampora D, Holford TR, et al.
delirium
m incidence ( intervention g
group
p 9.9%
9.9 vs usual care g
group
p 14%,, matched
m
OR 0.6,
. ,
CI 0.39-0.92)
reduce days of delirium
measures include : maintain orientation to surroundings, meeting needs for nutrition,
fluid,, sleep
f
p hygiene,
yg
, promote
p
mobility,
y, visual and hearing
g adaptations
p
Ph
Pharmacological
l i l prophylaxis
h l i
o
o
Haldoperidol as prophylaxis?
Need more study to confirm its role
U iin surgical
Use
i l case may reduce
d
delirium
d li i
* Prophylactic consecutive administration of haloperidol can reduce the occurrence of postoperative delirium in
gastrointestinal surgery. Yonago Acta. Med 42, 1790184 (1999) Kaneko T et al. .
o
Cholinesterase inhibitors
(Donepezil 5mg daily)
as prophylaxis?
Prevention studies not demonstrate efficacy
* Donepezil in the prevention and treatment of post-surgical delirium. American Journal of Geriatric Psychiatry, 2005.
p 1100
1106 Liptzin B
13(12): p.
1100-1106.
B, Laki A
A, Garb JL
JL, Fingeroth R
R, and Krushell R
R,
* A randomized, double-blinded, placebo-controlled trial of donepezil hydrochloride for reducing the incidence of
postoperative delirium after elective total hip replaccement. Int. J. Geriatr. Psychiatry. 22, 343-349 (2007). Sampson
EL et al.
How about our patient……
patient
o
o
o
o
o
o
o
o
Good rehab progress in convalesence hospital
walk with stick with supervision, exercise tolerance > 50 meters
ADL supervision
i i level
l
l
MMSE increase to 14
Discharge home
Follow in our GI clinic
HBsAg –ve, anti-HBs –ve
Anti
HCV –ve
ve
Anti-HCV
Anti-HAV –ve ( IgM )
IgM normal, anti-mitochondrial antibodies(AMA) –ve, Antinuclear antibodies(ANA) -ve,
Anti-smooth muscle antibodies(SMA) +ve
Before
admission
(27 Oct 09)
On admission to
surgical ward
( 20 Jan 2010 )
After
confusion
(23 Jan 10 )
25 Jan 10
27 Jan 10
Convalesence
hospital
( 1 Feb 2010 )
Before
discharge
( 10 Feb 10 )
Follow up in
GI clinic
( 25 Mar 10 )
Bil
8
190
244
250
196
131
59
14
ALT/AST
11/--
840/1079
844/713
553/--
197/--
118/--
60/--
13/22
ALP/GGT
59
220/155
194/--
181/--
219/--
239/--
216/--
78/--
INR
--
1.4
1.4
1.3
3
1.0
0
--
1.04
0
--
Albumin
43
31
27
28
28
30
32
41
Hb
11.7
9.8
10.0
10.1
10.4
9.4
8.9
11.3
Platelet
340
209
313
373
420
380
254
316
WCC
8.3
7.6
8.2
12.1
10.5
5.8
5.3
6.3
Ur/Cr
4.4/76
11/150
5.2/124
5.8/116
--
5.0/75
4.8/80
4.6/89
Na
145
135
135
138
--
141
139
146
K
4.3
4.2
4.2
4.2
--
3.7
3.9
4.3
So what’s
S
h t’ th
the cause of
f acute
t
hepatitis in our patient?
Why did our patient’s skin turn yellow……..
Anti-HEV IgM +ve…………
Acute hepatitis E !!
H
Hepatitis
i i E
First discovered in 1982, labeled as Hepatitis E in 1989
Four genotypes: 1,2,3,4
1 2 3 4 and a single serotype
Small non-enveloped particle consists of a single-strand RNA
highly endemic in Central and South East Asia, North and West
Africa as well as Mexico
Highest rate of symptomatic disease in young to middle-age
adults
S
Seasonal
l peak
k in
i winter
i t and
d spring
i
I f
Infectivity
i i
Fecal-oral route : acquired by ingestion of contaminated food
or water
incubation period ranges from two weeks to two months before
y p
appear
pp
symptoms
Infectivity peaked at 2 weeks before the onset of symptoms
o
o
Virus excretion in stools
up to 14 days after onset of jaundice
approximately 4 weeks after oral ingestion of contaminated food or water
Cli i l features
Clinical
f
Resemble other types of acute viral hepatitis
o
o
o
o
o
o
o
o
o
o
o
Initially presented with non
non-specific
specific symptoms
anorexia
malaise
fever
vomiting
Followed by
jaundice
j
tea colour urine
hepatomegaly
Less common symptoms
arthralgia
diarrhoea
pruritus
urticarial rash
Di
Diagnosis
i and
d prognosis
i
o
o
o
o
o
Diagnosis by serology test
presence of anti-HEV IgM antibodies
d t ti of
detection
f serum HEV RNA by
b polymerase
l
chain
h i reaction
ti (PCR)
Prognosis
Recovered in 3-6 weeks
Chronic infection not occur
Mortality rate report in young adult 0.5-3%, Mortality in third trimester can reach
20%
Change in epidemiology in
recent years
Previously only recognized as a endemic disease in developing
countries
o
o
o
o
o
o
o
In recent years, local acquired hepatitis E infection in
developed country increasingly reported
more common than prev
previous
ous recogn
recognized
zed
may be more common than hepatitis A
Several new observations
mostly due to genotype 3 or 4
many case affected elderly men with other coexisting illness
poor prognosis in patient with pre-existing chronic liver disease
frequently misdiagnosed as drug-induced liver injury
chronic infection with genotype 3 has been reported among immunosuppressed persons
* Hepatitis E : an emerging infection in developed countries.
Lancet Infect Dis. 2008 Nov;8(11):698-709. Dalton HR, Bendall R, Ijaz S, Banks M
* Epidemiology of Hepatitis E : current status.
J Gastroenterol Hepatol 2009 Sept;24(9):1484-93. Aggarwal R, Naik S.
L
Local
l data
d
f
from CHP
Notifiable disease in Hong
Kong
o
o
o
o
o
Rising trend of hepatitis E in
last 10 years ( on the
contrary, hepatitis A showed
d
decreasing
trend
d )
1997 : 4 case
2008 : 90 cases
2009 : 74 cases
till 2010 Feb : 22 cases
Hepatitis A : 595 cases (1997)
decrease to 64 cases (2009)
Seasonal peak at winter and
spring seasons ( Jan to
pr )
April
Characteristics of viral Hepatitis
p
E
patients from 1998 to 2007
More male than female
Higher age
Majority patient required
hospitalization : median duration
of
f stay
t 7d
days
o
o
Higher mortality
3 female and 6 males, age 53-82
Median duration of onset to death was
24 days ( 13 to 77 days )
Most case sporadic,
p
, no
outbreak
Fourteen imported case
Hepatitis A
Hepatitis E
Total
number of
case
2596
276
Male :
Female ratio
1.8 : 1
2.5 : 1
Median age
in years
( range
g )
26 (2-94)
48.5 (2-85)
Proportion
of patients
requiring
hospital
treatment
62%
77%
Number of
deaths
( case
fatality
rate )
4 (0
(0.15%)
15%)
9 (3
(3.26%)
26%)
P
Prevention
i
Good personal, food, environment hygiene
o
o
o
Virus heat-sensitive
food cooked thoroughly before consumption
oyster cooked with shells removed
use separate chopstick for raw and cooked food during hotpot
Vaccination not available currently ( a subunit vaccine
shown to be effective in preventing clinical disease, not
yet commercially available )