Transcript Revisions to Delirium Module A

Week 1 Module A: Instructions
 Please view video 1 and review charts
prior to starting this module.
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Week 1 Module A: Instructions
 For each question, please choose one
answer that best addresses the question and
then hit “click here.”
 For those slides where there are "click
here" instructions, please do so or else you
might skip over slides.
Week 1 Module A: Question 1
 What is the ICD-9 diagnosis of Mrs.
Rivera’s cognitive state?
 A. Acute mental status change click here
 B. Subacute befuddlement click here
 C. Δ MS click here
 D. Delirium click here
Why should we care about
delirium in the elderly?
Incidence Among Elderly
Patients is HIGH
 1/3 of patients presenting to ER
 1/3 of inpatients aged 70+ on general med
units
 Occurs in 10-15% after elective noncardiac
surgery
 May exceed 50% after emergent hip
fracture repair
Delirium: Increased Mortality
 Delirium is an independent predictor of
higher mortality up to 1 year after
occurrence:
 Hazard ratio = 2-3 (people with delirium
compared to people without it)
– Even after adjustment for covariates such as age, illness severity,
comorbid conditions, dementia, use of sedatives or analgesic
meds
– (McCusker J et al. Arch Intern Med. 2002; 162:457-463; Ely EW et al. JAMA.
2004; 291:1753-62)
Delirium: Increased Risk of…
 Functional decline
 New nursing home placement
 Persistent cognitive decline:
– Only 18-22% of hospitalized elders had complete
resolution of delirium 6-12 mo after discharge
– However: Many subjects in these studies had
preexisting cognitive impairment
– (Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al.
J Gen Intern Med. 2003; 18:696-704)
Week 1 Module A: Question 2
 What features of Mrs. Rivera’s
presentation are more consistent with
delirium than with dementia?
 A. Disorientation to place click here
 B. Acute change in mental status click here
 C. Inattention click here
 D. Lethargy click here
How to Distinguish
Delirium from Dementia
 Features seen in both:
– Disorientation
 Key features of
delirium:
– Memory impairment
– Acute onset
– Paranoia
– Impaired attention
– Hallucinations
– Altered level of
– Emotional lability
– Sleep-wake cycle
reversal
consciousness
Assume it is Delirium until
Proven Otherwise!!!
Delirium may be the only
manifestation of life-threatening
illness in the elderly patient
There is a simple and quick way
to diagnosis delirium…
CONFUSION ASSESSMENT
METHOD
Inouye et al Ann of Intern Med 1990; 113: 941-948
 (1) Acute change in
mental status with a
fluctuating course,
with
 (2) Inattention
AND
 (3) Disorganized
thinking
OR
 (4) Altered level of
consciousness
Inouye et al Ann Intern Med 1990; 113 (12): 941-948
Sensitivity: 94-100%, Specificity: 90-95%
Week 1 Module A: Question 3
 Factors that may be contributing to Mrs.
Rivera’s delirium include:
 A. Underlying cognitive impairment click
here
 B. Over-the counter medications click here
 C. Pleuritic chest pain click here
 D. Hypoxia click here
 E. All of the above click here
A Model of Delirium
A multifactorial syndrome that arises from an
interrelationship between:
 Predisposing factors a patient’s underlying
vulnerability
AND
 Precipitating factors noxious insults
Delirium arises when noxious insults act in
combination with a patient’s predisposing
factors.
Predisposing Factors
i.e. baseline underlying vulnerability
 Baseline cognitive
impairment
– Dementia patients have a
2.5-fold increased risk of
delirium
– 25-31% of delirious
patients have underlying
dementia
 Medical
comorbidities:
– Any medical illness
 Visual impairment
 Hearing impairment
 Functional
impairment
 Advanced age
 History of ETOH
abuse
 Male gender
“A Predictive Model for Delirium in
Hospitalized Patients based on Admission
Characteristics”
Inouye SK et al Ann Intern Med 1993; 119: 474-481
 Two prospective cohort studies done in
tandem
 Age 70 and over
 Patients without delirium on admission
 Question: what characteristics were most
strongly associated with occurrence of
delirium?
Independent Predisposing Risk Factors
Inouye et al Ann Intern Med 1993;119:474-481
Risk Factor
Adjusted RR
95% CI
Vision
3.51
impairment
Severe illness 3.49
1.15 to 10.71
Cognitive
2.82
impairment
High BUN/Cr 2.02
ratio
1.19 to 6.65
1.48 to 8.23
0.89 to 4.60
“A Predictive Model for Delirium in Hospitalized Patients
based on Admission Characteristics”: Performance of the
Predictive Model Inouye et al Ann Intern Med 1993;119:474-481
preceding slide for factors)
Development
Cohort
% delirium
Validation
Cohort
% delirium
Low
0
9%
3%
Intermediate
1-2
23%
16%
High
3-4
83%
32%
Risk group
# of Risk
Factors (see
P<0.0001
P<0.002
The more predisposing risk
factors present…
 The more likely delirium becomes.
 Perhaps you can target elderly patients at
the start of their hospitalization for
interventions that would decrease their risk
of developing delirium…
 More to follow later
Precipitating Factors
i.e. noxious insults
 Medications
 Bedrest
 Indwelling bladder
catheters
 Physical restraints
 Iatrogenic events
 Uncontrolled pain
 Fluid/electrolyte
abnormalities
 Infections
 Medical illnesses
 Urinary retention
and fecal impaction
 ETOH/drug
withdrawal
 Environmental
influences
Some drug classes that are
associated with delirium
 Medications with psychoactive effects:
– 3.9-fold increased risk of delirium
– 2 or more meds: 4.5-fold
 Sedative-hypnotics: 3.0 to 11.7-fold
 Narcotics: 2.5 to 2.7-fold
 Anticholinergic meds: 4.5 to 11.7-fold
 Risk of delirium increases as number of
meds prescribed increases
Always ask about over-thecounter medications
 Remember: many OTC sinus and cold
preparations contain antihistamines with
anticholinergic activity.
References and Resources
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Inouye SK. Delirium in hospitalized older patients. Clinics in Geriatric Medicine 14(4):745-64,
1998.
Ely EW. et al. Delirium as a predictor of mortality in mechanically ventilated patients in the
intensive care unit. JAMA. 291(14): 1753-62, 2004.
Levkoff SE et al. Delirium: The Occurrence and Persistence of Symptoms among Elderly
Hospitalized Patients. Arch Intern Med. 152:334-340, 1992.
Inouye SK et al. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Based
on Admission Characteristics. Ann Intern Med. 119:474-481, 1993.
Inouye SK et al. Clarifying Confusion: The Confusion Assessment Method: A New Method for
Detection of Delirium. Ann Intern Med. 113: 941-948, 1990.
Inouye SK et al. Delirium in Older Persons. NEJM. 354:1157-1165, 2006.
McCusker J. Cole M. Abrahamowicz M. et al. Delirium predicts 12-month mortality. Arch Intern
Med. 162(4): 457-63, 2002 Feb 25.
McCusker J. Cole M. Dendukuri N. et al. The course of delirium in older medical inpatients: a
prospective study. J Gen Intern Med. 18: 696-704, 2003.
Delirium. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Teaching Slides.
Volume 1, Fifth Edition. Blackwell Publishing, copyright American Geriatrics Society, 2003
 Click here to end
This is Delirium
 While the terms acute mental status change,
subacute befuddlement and Δ MS have all been
used in the medical literature to describe this
condition, you cannot bill for these entities.
 Delirium has a few ICD-9 codes.
 ICD-9 code for delirium= 780.09
 ICD-9 code for acute delirium= 293.0
 Click here for next slide
Correct: This is Delirium
 Mrs. Rivera has delirium. This is a billable
diagnosis, whereas the other choices do not
have actual ICD-9 codes.
 ICD-9 code for delirium= 780.09
 ICD-9 code for acute delirium= 293.0
 Click here for the next slide
Delirium and dementia share
common features
 It is very difficult to distinguish delirium
from dementia in patients that you are
evaluating for the first time.
 There are symptoms that are common to
both conditions.
 For example, disorientation to place can
occur in both dementia and delirium.
 click here for the correct answer
Correct answer.
Delirium differs from dementia in the following key
ways:
 Time course: whereas dementia usually
progresses over time, delirium occurs acutely
 Inattention: demented patients have intact
attention span
 Altered level of consciousness: demented
patients are generally alert
 click here for the next slide
Correct answer.
 There are likely many factors contributing to
Mrs. Rivera’s delirium. Her acute illness, with its
concomitant fever, hypoxia, tachycardia, pleuritic
chest pain, is likely playing a large role.
 She may have taken over-the-counter cold
preparations that contain antihistamines with
anticholinergic side effects.
 She also has a few predisposing factors for
developing delirium: cognitive impairment
(MMSE 22/30), visual impairment (cataracts).
 click here for the next slide
Usually, there is more than one
factor contributing to delirium
 In elderly patients, look for more than one
etiology of delirium.
 While Mrs. Rivera’s cognitive impairment,
pleuritic chest pain, OTC medication use,
and hypoxia are all possible etiologies, it is
unlikely that just one of these factors is the
sole source of her delirium.
 click here for the correct answer
End of Week 1 Module A