Transcript Delirium: What It Looks Like Why Frail Patients Succumb

Delirium Teaching Rounds:
My place…. Or Yours?
December 9, 2011
Eleanor McConnell, PhD, RN, GCNS-BC
& Mitchell Heflin, MD
Duke GEC
www.interprofessionalgeriatrics.duke.edu
A BIG Problem
• Hospitalized patients over 65:
– 10-40% Prevalence
– 25-60% Incidence
•
•
•
•
•
ICU: 70-87%
ER: 10-30%
Post-operative: 15-53%
Post-acute care: 60%
End-of-life: 83%
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Levkoff 1992; Naughton, 2005; Siddiqi 2006;
Deiner 2009.
Costs of Delirium
• In-hospital complications1,3
– UTI, falls, incontinence, LOS
– Death
• Persistent delirium– Discharge and 6 mos.2 1/3
• Long term mortality (22.7mo)4
HR=1.95
• Institutionalization (14.6 mo)4
OR=2.41
– Long term loss of function
• Incident dementia (4.1 yrs)4
• Excess of $2500 per hospitalization
Duke GEC
www.interprofessionalgeriatrics.duke.edu
OR=12.52
1-O’Keeffe 1997; 2-McCusker 2003;
3-Siddiqi 2006; 4-Witlox 2010
Clinical Features of Delirium
•
•
•
•
•
Acute or subacute onset
Fluctuating intensity of symptoms
Inattention
Disorganized thinking
Altered level of consciousness
– Hypoactive v. Hyperactive
• Sleep disturbance
• Emotional and behavioral problems
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Common Risk Factors for Delirium
Predisposing
• Advanced age
• Preexisting dementia
• History of stroke
• Parkinson disease
• Multiple comorbid conditions
• Impaired vision
• Impaired hearing
• Functional impairment
• Male sex
• History of alcohol abuse
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Precipitating
• New acute medical problem
• Exacerbation of chronic medical problem
• Surgery/anesthesia
• New psychoactive medication
• Acute stroke
• Pain
• Environmental change
• Urine retention/fecal impaction
• Electrolyte disturbances
• Dehydration
• Sepsis
Marcantonio, 2011.
Framework for Risk
Baseline Vulnerability
High
Low
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Precipitating Stimulus
Noxious
Mild/None
Objectives
Discuss challenges in evaluation and management after
the recognition of delirium, including:
– Challenges in communication among providers, caregivers
& patients
– Challenges in communication across sites of care
– Opportunities for improvement in communication across
settings and key actors
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Meet Mr. Crevasse
82 year old retired, divorced veteran from Garner, NC
brought to the VA Emergency Department by his
daughters for evaluation of aggression.
• 4 days ago he was discharged from a community
hospital for similar behavioral problems.
Discharge diagnoses:
Disposition:
• Urinary retention with acute renal
failure, indwelling catheter
placement
• Cerbrovascular disease:
Head CT-MRI consistent with prior
infarct
• Home with family &
hospice support –
indwelling catheter
remains
• Placed on Depakote &
Zyprexa for behavior
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Past Medical History
Problem List
Transient Ischemic Attack
Diabetes Mellitus
Hypertension
Mild Cognitive Impairment
h/o of Traumatic Brain
Injury (Remote)
h/o Head and Neck Cancer
Medications
Pravastatin 20 mg. @ HS
Lisinopril 5 mg. daily
Amlodipine 5 mg. daily
Vit D & Calcium
Zyprexa
Depakote
Recently relocated to NC d/t family concerns about
managing at home alone
Duke GEC
www.interprofessionalgeriatrics.duke.edu
You are the emergency room staff
assigned to his care….
Consider the following questions:
1. Could this patient have delirium?
2. What predisposing/precipitating factors are important to
consider in this case?
3. What is the role of standardized cognitive assessment in
helping to clarify the diagnosis or treatment approach?
4. What additional assessment would you recommend?
5. Where is that assessment best conducted?
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Assessment: Part 1
Time/
Event
Key Information
1
• VS: BP 169/68, p = 65/reg, T = 97.5, SpO2 = 99%, Pain = 0
Triage RN • NAD, calm, cooperative initially but became increasingly aggressive
1300 hrs
verbally, insisting upon going home, threatening physical violence.
• Oriented to name only
2
ED Care
RN
3
1430 hrs
MOD
• Rec’d rpt from triage RN, accompanied by family, trying to get out of
room
• Restless, follows commands when instructed to sit down, keeps
refusing blood work.
• Notes episode of pt. locking self in BR while with social worker
Imp: Dementia, urine retention s/p Foley placement,
Ongoing combative behavior that cannot be managed by family.
Plan: 1. CBC/Chem 7; no other localizing s/s to pursue
Duke GEC
2. Request assistance of Psychiatric Emergency Team for
www.interprofessionalgeriatrics.duke.edu
management, possible admission for placement
Assessment Part 2
Time/
Event
Key Information
4
PEC
SW
Assess.
• CC: “I have no communicable diseases – why won’t they let me go?”
• PPH: No h/o inpatient or outpatient treatment
• MSE: Clean, appropriately dressed; Speech: volume low, mumbles;
Mood: Anxious, paranoid, laughs inappropriately,
AH/VH: Denies, but warned SW to be careful as we crossed bridge to
golf course
• Imp: Axis I: Delirium & cognitive problems – further psychiatric screen
5
POD
Assess.
• MMSE: 21/30, Further MSE & behavioral description
• Assessment: AMS -- recent hosp. & rpt. of elev. WBC suggest medical
illness as etiology. Presentation c/w delirium in addition to underlying
dementia. Significantly impaired cognition & capacity – specifically to
refuse blood work or evaluation for medical illnesses
• Recs: 1) Ongoing medical evaluation for AMS
2) Admit to either medicine or psychiatry (if medically cleared).
Duke GEC
6
• Ward noted & Receiving RN report given & references triage note
www.interprofessionalgeriatrics.duke.edu
RN
• Templated info: IVs, MRSA swab & Pt. education
Use to include in text case material
Time/
Event
Key Information
7
• Unable to obtain history, family gone, copied from ED note
Admitting • PE – unremarkable except for disorientation,
MD
• Labs: WBC = 12.6; Glu = 160, BUN = 10, Cr = 1.1;
Urine: + leukocyte esterase, - nitrite, 1+ bacteria
5AM the • Imp: Behavioral changes more c/w dementia.
next day
Pt. refused admission to psychiatry with concerns this is delirium with
underlying medical cause.
However, patient does not appear to have waxing/waning mental
status with marked inattention which would be expected in delirium.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Summary
• Delirium recognition can be challenging in ED
because of limited time with patient
• Even when delirium recognized – challenges
can emerge with respect to decision-making
about follow-up evaluation and management
• Multiple team members should be involved
to optimize management of precipitating
factors and patient safety
Duke GEC
www.interprofessionalgeriatrics.duke.edu