Transcript Hospital Acquired Delirium

Hospital Acquired Delirium
Computer Tutorial and Presentation
Amy Gajkowski RN
Instructions
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Expected Outcomes
 Understand the causes of hospital
acquired delirium.
 Recognize appropriate nursing
interventions to prevent hospital acquired
delirium
 Understand that prevention is the best
treatment for this medical condition.
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Table of Contents
Objectives
Stress/Inflammation
Response (POD)
Pre Test
Quiz Three
Delirium Defined
Role of Genetics
Hospital acquired
delirium
Preventing Delirium
Quiz One
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Managing Delirium
Pathophysiology
Post Test
Quiz Two
References
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Pre Test
Delirium has a slow onset in patients
True
No. It has an abrupt onset
False
Yes! This is one way delirium
differs from dementia and Alzheimer’s
Pre Test
Unlike dementia, delirium is reversible
True
Yes! Unlike Dementia
and Alzheimer’s, it is reversible
False
No. You will learn through this tutorial
ways you can treat and prevent delirium!
Delirium Case Study
A 75 year old male was admitted to a medical unit around 2100. He
presented with the police who brought him in after finding him
wandering the streets around his home. When trying to take him
home the man became abusive, confused, and frightened. The
officers had stated that he “looked pale, ill, and agitated,” and they
could find no identification. Upon the nurses’ assessment, it was
very difficult to gain the man’s attention, and for him to focus on
answering questions. Once he was able to answer, he rambled on in
an incoherent, disorganized manner. The patient had intervals of
agitation and was diaphoretic, and then would become very
withdrawn. At times the man appeared to be falling asleep during
the assessment, and could not describe where he was. His pulse
was 94 and regular, BP 145/88. There was no evidence of injury or
trauma.
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Delirium Case Study
Think about this…
What interventions or investigations should be done?
If a family member is contacted, what questions would
you want to ask?
The physician said the patient probably has Alzheimer’s;
The nurse has five other patients, one needs to be
discharged home, is this new patient urgent?
Yes
Yes! This tutorial will explain
why this is a medical emergency!
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No
Assume this is an emergency,
until proven otherwise
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Delirium Case Study
 Delirium is often due to an acute illness or
physiological change in the body.
 It can be a presentation of many underlying
diseases
 It is often neglected as a medical emergency.
 It is best to assume the onset of confusion is
acute if there is no medical history available.
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Delirium Case Study
 What should be done?
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CBC, electrolytes, renal/hepatic function, blood
alcohol, chest x-ray, CT head.
Results: UTI and dehydration.
The patient improved, but was still confused.
His son stated that he was fully functional at
home with no memory impairments/confusion.
The absence of history made it crucial to regard
this patient as an emergency, and to observe
him closely.
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Delirium defined
 “Delirium is an acute
decline of cognition and
attention that represents a
common and serious
problem for older persons,
particularly in times of
acute illness and
hospitalization” (Inouye,
2006 ).
Permission to use image granted from Nature Reviews Neurology.
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Delirium defined
Clinical features of delirium…
 Acute onset- occurs abruptly, over a period of hours or

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
days.
Fluctuating course- increase/decrease in severity,
symptoms may come or go. Lucid intervals are common
in post op patients.
Inattention- shifting attention, difficulty focusing
Disorganized thinking- illogical flow of ideas, rambling
Altered level of consciousness- reduced clarity of
environment, lethargy (Inouye, 2006).
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Symptoms of delirium come on gradually
over time.
True
No! It is an
abrupt onset
False
Yes! It usually comes
on quickly; sometimes as
fast as over a
couple of hours.
Delirium defined
Clinical features of
delirium…
Cognitive deficits
 Memory impairment
 Disorientation
Perceptual disturbances
 Hallucinations/illusions (Inyoue,
Psychomotor variants
 Hyperactivevigilance/agitation
 Hypoactive- decreased motor
ability/lethargy (Inyoue, 2006).
2006).
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Delirium defined
Clinical features of delirium…
Altered sleep cycle Insomnia/Sleep cycle reversal/Daytime sleeping /Fragmented
patterns
Emotional disturbances Fear/Anxiety/Depression/Apathy/Anger/Euphoria/Paranoia/Irritability
(Inyoue, 2006).
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Hospital acquired delirium
 Delirium can be associated with substantial
morbidity, functional decline, loss of
independence, nursing home placement, and
death (Jones, Metzger, Yang, Marcantonio, Gottlieb, 2009).
 “Hospital costs are estimated to be greater than
$8 billion annually, and post hospital costs are
greater than $100 billion annually” (Jones, Metzger, Yang,
Marcantonio, Gottlieb, 2009).
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Hospital acquired delirium
 Prevalence increases with age.
 “The mortality rate among hospitalized patients
with delirium range from 22-76%” (Bryant, 2009 ).
 The one year mortality rate associated with
cases of delirium is 35-40%
(Jones, Metzger, Yang, Marcantonio, Gottlieb, 2009).
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Hospital acquired delirium
 Delirium is often
unrecognized due to
 fluctuating nature
 overlap with dementia
 lack cognitive
assessment
 lack of knowledge of
the consequences
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The best treatment for
delirium is prevention!
Risk Factors include:
Age >65
Neurodegenerative disease
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Quiz one
What is the best
treatment for
delirium?
Medications
No, it is suggested to
avoid medications
Prevention
Yes, prevention!
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Pathophysiology of delirium
Theories of the
causes of
delirium
 Acetylcholine
deficiency
 Alterations in
pro-inflammatory
markers
Permission to use image granted by Nature Reviews
Neurology
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Pathophysiology of delirium
The exact pathophysiology is unknown
Theories: 1. Acetylcholine deficiency
2.Increase in pro-inflammatory markers circulating
(Both are related to stress/inflammation and aging.)
• Acetylcholine (ACH)- regulation of mood, attention, memory, motor
activity
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Age dependent decrease of ACH neurotransmission. (Reduced
cholinergic reserve)
Inflammation/Stress induced ACH-neurotransmission impairment
(explains post-op delirium)
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Pathophysiology- Aging
(Click to proceed)
-Age-associated decline
in acetylcholine
- Loss of cholinergic cell bodies
-Efficiency of proteins for the production
of acetylcholine decreases
-Number of acetylcholine receptors
decreases
-Reduced cholinergic reserve
-Acetylcholine deficiency is
linked to cognitive decline and
delirium.
Pathophysiology of delirium
With aging…
 Blood brain barrier has structural/ functional changes
-Increases strength of the inflammation response
-“If the brain is inflamed due to a neurodegenerative
disease, the CNS response is more severe” (Maclullich et.al, 2008).
 Microglial cells are constantly activated by persistent
neurodegeneration
-“Microglial cells produce low levels of proinflammatory cytokines” (Maclullich et. al, 2008).
-Ready to respond intensely to
stimulation/inflammation
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Pathophysiology of delirium
With the stress/inflammation response…
• Increased amount of cytokines circulating which can lead
to neurotransmission impairment.
-“Sickness behavior” (bodies’ way of trying to protect
energy and reduce further injury)
- Trauma, surgery, infection/illness
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Pathophysiology of delirium
Sickness behavior
 Adaptive behavioral/metabolic changes during infections/ immune
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stimulations.
CNS synthesis of cytokines/prostaglandins
Transduced without compromising the blood brain barrier (BBB)
Inflammatory mediators interact with neurons which do not have a
BBB.
Activates endothelial cells of the brain
Releases prostaglandins into the parenchyma
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Pathophysiology-Stress/inflammation
(Click to proceed)
Stress Response
(Illness/infection)
Microglia is activated.
(Pro inflammatory markers)
Which leads to an increased
level of cytokines circulating
Imbalance of neurotransmitters/
neurotransmission
Delirium
Quiz Two
Which of the reasons below, or both, can cause an
increased level of cytokines seen in delirious patients?
Inflammation due to neuro-degeneration
with aging can cause an
increased level of cytokines.
Yes!
Patients with an inflammatory
Disease (Alzheimer’s) are
at an even greater risk!
An inflammatory response to an
illness or infection to further prevent any
further injury can cause an increase in
cytokines
Yes! This can be termed
“Sickness behavior” and it is seen
in many delirious patients
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Stress/Inflammation Response in
Post-op patients
 Surgery can cause a
stress/inflammation
response that increase
inflammatory markers.
 Patients undergoing
major surgery are at a
great risk for developing
post-op delirium (POD).
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 There is an
inflammation cascade
response to the
traumatized tissue
that can lead to a
delirious state.
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How does the stress/inflammation cause delirium?
(Click to proceed)
Leukocytes adhere to
endothelial cells and activate
Free radicals are released after
degranulation
Endothelial cell
swelling/destruction
Capillary density due to narrowing
of the vessel walls/ edema
Longer distance for
O2 synthesis/ neurons cannot
keep up
No release of
neurospecific enzyme
Perfusion due to the
longer diffusion distance for O2
“Acetylcholine synthesis is sensitive to low O2 tension,
symptoms of deficiency will develop” = DELIRIUM (Hala, 2007).
Post-Op Delirium
 After leukocyte-endothelial cell interaction, the inflammation process
may lead to perfusion impairment.
 Blood flow in the capillaries can become disrupted.
 “This may hinder the organisms’ ability to heal. “No-reflow”
phenomenon which can explain why some patients suffer from
permanent cognitive impairments once they recover from a delirious
state” (Barbosa, 2008).
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Pathophysiology of delirium
 Direct brain insults
(Hypotension, hypoxia,
infarcts, hemorrhage etc.)
 compromise brain
function
 energy depletion
 changes in
neurotransmitter levels
 metabolic abnormalities
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Permission to use image granted from
Nature Reviews Neurology
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Quiz Three
What is one of the theories of the cause of delirium?
A. Reduction of
inflammatory response
B. Acetylcholine
deficiency
C. Decrease in cytokines
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No. There is an extreme increase
in the severity of
the inflammation response
Yes! It has been shown in
delirious pts that ACH deficiency causes
delirious behaviors
No. There is a marked increase
in the levels of cytokines in a delirious
Patient, due to the stress/inflammation response
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Post-Op Delirium
 Sometimes there can be
a lucid interval for a postop patient.
 Watch for
 During the lucid interval,
there may be no
psychiatric symptoms.
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symptoms on the
second or third day!
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Role of genetics in delirium
 Studies link apolipoprotein E4 allele (APOE) and
delirium in elderly.
 “linked to cognitive impairment in people with dementia.
role in neural plasticity, repairs damaged neurons, and aids in
neural transmission” (Van Munster, 2009)

“APOE E4 genotype- increased inflammation, reduced cholinergic
activity in the brain, increased cytokines and reduced
acetylcholinergic pathways” (Van Munster, 2009).
 According to the articles, more research is to come our way!
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Recognizing/Preventing Delirium
 When a patient presents with confusion:
 “Determining the acuity of the change in mental status
is the essential first step” (Inouye, 2006).
 Every older hospitalized patient should undergo
formal cognitive testing. (Ex. CAM).
 “Older adults should be aroused during rounds and
evaluated if the hypoactive form of delirium is
suspected” (Inouye, 2006).
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Recognizing/Preventing Delirium
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Address risk factors
Provide orienting communication
Encourage mobilization
Use visual/ hearing aids
Prevent dehydration
Provide un-interrupted sleep time
Avoid psychoactive drugs
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Recognizing/preventing delirium
If there is a mental change that is acute…
 “Perform a cognitive assessment and evaluation for
delirium.
Rule out depression, mania, and acute psychosis” (Inouye,
2006).
In the case study, the nurse would have done a screening for delirium, such as
a CAM score. The RN would have re-oriented the patient, and monitored
his mental status closely.
If delirium is confirmed…
 “Provide supportive care/ prevent complications”
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(Inouye, 2006).
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Managing delirium nonpharmacologically
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Non-pharmacologic treatment strategies
Continue delirium prevention
Reorient patient, encourage family involvement
Use sitters/avoid physical restraints/foley catheters
Use music/massage/relaxation techniques for agitation
Use of hearing/ visual aids /interpreters
Maintain patient’s mobility
Normalize sleep/wake cycle
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What in this picture can lead to, or help prevent
delirium? (Use your mouse, there are 7)
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Images from clip art and Google Image
Managing delirium nonpharmacologically
Supportive care includes…
 Protecting airway/preventing aspiration
 Provide nutritional support
 Provide skin care/prevent pressure sores
 Mobilization/ prevent DVT, and PE
With the man from the case study, the RN would have
checked a chest X-ray, EKG, other lab work, etc. to see
if the patient had an infection or any other deficits that
may be causing his delirium.
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CAM/CAM ICU
 CAM- Confusion Assessment Method
-Screens for overall cognitive impairment
-Screens for acute onset, inattention, disorganized thinking,
altered level of consciousness
 CAM ICU
The CAM ICU excludes verbal indicators because it’s intended for
intubated/ventilated patients, or any patient who cannot speak or
participate.
Click on the link below for a website on ICU delirium.
On the right, click on the video clip on CAM ICU in a clinical setting
http://www.icudelirium.org/assessment.html
Copyright ©2009 by Vanderbilt University Medical Center
Post Test
1.What is the best treatment for delirium?
Medications
No, this is not
the recommended
treatment.
Antibiotics
Prevention
No, this will not
prevent delirium
Yes! This is the
best treatment
2.What is one theory of the cause of delirium?
Reduced levels
of cytokines
ACH deficiency
ACH surplus
No, it’s an increased
amount of cytokines
Yes!
No, there is an
ACH deficiency
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Post Test
3.Which patient, or both, are at risk for developing
delirium?
An elderly man
having a hip replacement
An elderly man
with pneumonia in the ICU
Yes this person is
a high risk due to POD
This man is a high risk due to his
infection and ICU stay
4.Re-orienting patients is one way of preventing delirium.
True
Yes! You can also
use familiar objects
False
No. Orienting patients to their
surroundings prevents delirium
Post Test
5.When would you watch for a delirium postoperatively?
2-3 days post-operative
Yes! You may not see any
symptoms until then due to the
lucid interval
Immediately after
the procedure
No. The lucid interval is
Sometime seen right after surgery
Congratulations!
You have completed this tutorial.
Further Questions?
Amy Gajkowski RN, BSN
[email protected]
References
Barbosa, F, Martins da Cunha, R, & Pinto, A. (2008). Postoperative delirium in the elderly [vol 58 no.6]. Retrieved from
http://www.scielo.br/scielo.php. doi: 10.1590/S0034
Bryant, C. (2010). Dementia, Delirium, Agitation, and Behavioural Problems. Journal of Psychosomatic Research, 200809. Wiley InterScience.
Retrieved from: Http://www.interscience.wiley.com/cgibin/summary/122300212/doi.org/10.1002/9780470017975.
Byrne, M, & Devine, E. (Ed.). (2009). Knowledge Based nursing initiative- risk for delirium in adults in intensive care . Milwaukee: Aurora Health
Care.
Fong, T, Tulebaev, S, & Inouye, S. (2009). Delirium in elderly adults: diagnosis, prevention, and treatment. Nature Review, 5. Retrieved from
http://www.nature.com/nrneurol doi: 10.1038/nrneurol.2009.24
Hala, M. (2007). Pathophysiology of postoperative delirium: Systemic inflammation as a response to surgical trauma causes diffuse microcirculatory
impairment
Medical Hypotheses, Volume 68, Issue 1, Pages 194-196
Ham, R, & Sloan, P. (2008). Primary care geriatrics. St. Louis, MI: Mosby.
Inouye, S. (2006). Delirium in older persons. The New England Journal of Medicine, 65. Retrieved from www.NEJM.org
Jaafar, A, Heycock, R, & George, J. (2008). Frailty- a clinical overview. Review in Clinical Gerontology, 17. doi: 10.1017/S0959259808002642
Jones, R, Fong, T, Metzger, E, Tulebaev, S, & Yang, F. (2010). Aging, Brain disease, and Reserve: Implications for Delirium. American
association for geriatric psychiatry . Retrieved (2010, March 23)
Leentjens, A, & Van der Mast, R. (2005). Delirium in elderly people: an update. Current Opinion in Psychiatry, 18. Retrieved from
http://www.medscape.com/viewarticle/503089
Lemstra, A, kalisvaaart, K, Vreeswijk, R, Van Gool, W, & Eikelenboom, P. (2008). Pre-operative inflammatory markers and the risk of
postoperative delirium in elderly patients. International Journal of Geriatric Psychiatry, 23. Retrieved from www.interscience.wiley.com
doi: 10.1002/gps.2015
Luetz, A, Heymann, A, Radtke, F, Chenitir, C, & Heinz, A. (2010). Different assessment tools for intensive care unit delirium: which score to
use? . Critical Care Medicine, 38(2), 409-417.
Maclullich, A, Ferguson, K, Miller, T, Roolj, E, & Cunningham, C. (2008). Unravelling the pathophysiology of delirium: a focus on the role of
aberrant stress response. Journal of Psychosomatic Research, 65(3), Retrieved from http://www.sciencedirect.com/science doi:
10.1016/j.jpsychores.2008.05.019
Rooji, S, Van Munster, B, Korevaar, J, & Levi, M. (2007). Cytokines and acute phase response in delirium. Journal of Psychosomatic Research,
62(5), Retrieved from www.sciencedirect.com/science doi: 10.1016/j.jpschores.2006.11.013
Van Munster, B, Rooij, S, & Korevaar, J. (2009). The Role of genetics in delirium in the elderly patient. Dementia and Geriatric Cognitive
Disorders, 28. Retrieved from www.karger.com/dem doi: 10.1159/000235796
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