Transcript Reduced Confusion B. Cummings

Reducing Confusion Avoiding and managing
perioperative delirium
Beth Cummings, MD FRCPC
Perioperative Medicine Rounds
GIM Fellowship Program, McGill University
November 3, 2009
Learning Objectives
1.
2.
3.
4.
Understand the impact of delirium in the
perioperative period
Identify modifiable and non-modifiable
risk-factors for perioperative delirium
Develop an approach to reducing the
incidence of perioperative delirium
Develop an approach to the management
of perioperative delirium
1. The scope of the
problem
(or Why should we care?)
How common is delirium?
Francis & Kapoor. Journal of General Internal Medicine 5 (1990) 65-79.
How frequently now?
► All
hospitalized patients (medical + surgical)
 22-31% overall
 14% - 56% of elderly
Inouye SK et al. Annals of Internal Medicine 1993; 474-481.
Ganai S et al. Arch Surg 2007; 1072-1078.
► Postoperative
 47% overall
patients
Noimark D. Age and Ageing 2009; 1-6.
 37-74% of geriatric patients
Ganai S et al. Arch Surg 2007; 1072-1078.
 10-15% of general surgery patients
 50% of hip fractur patients
Francis & Kapoor. Journal of General Internal Medicine 1990; 5: 65-79.
Rubino FA. Neurol Clin N Am 2004; 261-276.
The scope of the problem
Postoperative delirium associated with higher
mortality1, 2, 4, 5
►

Mortality ratios 1.6 – 19.71
►

10% - 65% of patients died1
►
1.
2.
3.
4.
5.
2.0 in controls matched for age, sex, and diagnosis
In hospital, at 3 mos, at 6 mos, at 12 mos, at 2 yrs
Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79
Rubino, FA. Neurol Clin N Am 2004; 22: 261-276.
Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821.
Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73.
Inouye SK et al. Ann Int Med 1993; 119:474-481.
Increased Mortality
Increased Morbidity
►
Post-operative delirium associated with
higher morbidity2, 3, 4




1.
2.
3.
4.
5.
More
More
More
More
falls & fractures
disruptive behaviour
incontinence  Foley  UTI
physical & chemical restraints
Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79
Rubino, FA. Neurol Clin N Am 2004; 22: 261-276.
Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821.
Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73.
Inouye SK et al. Ann Int Med 1993; 119:474-481.
Poor functional recovery
►
Poor functional recovery2


1.
2.
3.
4.
5.
Greater need for LTC or assisted living on
discharge from hospital1, 4, 5
Worse functional outcome 6 months after
surgery3
Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79
Rubino, FA. Neurol Clin N Am 2004; 22: 261-276.
Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821.
Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73.
Inouye SK et al. Ann Int Med 1993; 119:474-481.
Increased length of stay
► Longer
length of stay1, 2, 5
 Length of stay ≥ 14 days4
1.
2.
3.
4.
5.
Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79
Rubino, FA. Neurol Clin N Am 2004; 22: 261-276.
Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821.
Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73.
Inouye SK et al. Ann Int Med 1993; 119:474-481.
► Retrospective Chart
► Inclusion criteria
Review
 ≥70 y/o
 2-3 of visual impairment, cognitive impairment,
dehydration (BUN: Crt ≥18)
 Severe illness requiring “major abdominal surgical
procedures” – eg. open exploration for bowel
perforation, obstruction, bleeding, ischemia, infection,
and cancer
► Excluded
“less serious diseases” eg. uncomplicated
hernia repair or cholecystectomy
Arch Surg. 2007;142(11):1072-1078
Ganai et al. – Indications for Surgery
Ganai et al. - Findings
► Results
 Delirium 60%
 Mortality 20%
 Prolonged length of stay (≥14 days) 32%
Table 5. Univariate Analyses of Association of Clinical Factors With Adverse Outcomes
Increased costs ($)
► Franco,
Litaker, Locala, Bronson (2001)
 Economic analysis
►Preop
assessment by internal medicine for elective,
inpatient, non-cardiac procedures
►Patients ≥ 50 y/o
►Expected length of stay > 2 days
 11.4% had post-op delirium
 LOS 6.0 days vs. 4.6 days (p<0.001)
Costs
2. Recognizing delirium
http://www.cartoonstock.com/lowres/rni0036l.jpg
Often not diagnosed
► May
be missed in up to 50% of cases
Franco, Litaker, Locala, Bronson (2001)
 More often noted by nursing than by MDs
DSM IV criteria
► Delirium
 Disturbance of consciousness with reduced
ability to focus, sustain, or shift attention
 A change in cognition or the development of a
perceptual disturbance that is not accounted for
by dementia
 Develops over hours to days and fluctuates
 Direct physiological consequence of underlying
general medical condition, substance use,
substance withdrawal, medication side-effect…
Clinical manifestations
► Wandering
attention
► Easily distracted
► Hyperactive
 Especially night-time agitation
► Hypoactive
 Daytime lethargy
► Confusion
► “He’s
just not himself, Doctor”
3. Risk factors for
delirium
A Case…
► Mrs.
A.
 72 year-old admitted for elective right
hemicolectomy for colon Ca
 PMH & Baseline
►Hypertension
– well controlled on HCTZ
►Plays golf regularly in spring & summer; crosscountry skiing in winter
►Retired accountant; now “does the books” for a local
not-for-profit organization
► What’s
her delirium risk?
A different case…
► Mrs.
K.
 72 year-old admitted for elective right
hemicolectomy for colon Ca
 PMH & Baseline
►CRF
due to DM2 – creatinine 198, on insulin 4x/d
►Lives by herself but has help from her children to pay
bills
► What’s
her delirium risk?
What we know…
► Millar
(1981)
 Consecutive series of 100 patients, ≥65 y/o
 48 bed general surgical unit (3 surgeons)
 “psychiatrically assessed before and in the first
week after elective surgery”
►Standardized
►Cognitive
interview
test
►Nurses recorded “any psychiatric abnormality in the
‘cardex’”
Millar’s findings
► Post-operative




psychiatric illness
Age over 80
Major operations
Biliary tract or malignant disease
Prescription of at least 5 drugs
Millar’s findings cont’d
► Post-operative







intellectual impairment
Abnormal electrolytes/urea
Cardiovascular problems
Respiratory disease
Wound infection
Morphine or diamorphine analgesia
IV infusions
Foley catheters
** … mental status changes were an early sign of
complications **
► Independent
risk factors for the
development of delirium
 Vision impairment
 Severe illness
►APACHE
II > 16 or nurse rating of severe
 Cognitive impairment
►MMSE
ARR 2.82 (1.19 - 6.65)
<24
 High BUN:Crt
►Ratio
ARR 3.51 (1.15 - 10.72)
ARR 3.49 (1.48 - 8.23)
≥18
ARR 2.02 (0.89 - 4.60)
Inouye et al. - Validation
Delirium Risk
► Low risk patients = 0 points
 RR 1.0
► Intermediate
risk patients = 1-2 points
 RR 2.5 in development cohort
 RR 4.7 in validation cohort
► High
risk patients = 3-4 points
 RR 9.2 in development cohort
 RR 9.5 in validation cohort
Inouye et al. - Outcomes
Death or nursing home placement
► Low risk (0 points)
 9% development cohort / 3% validation cohort
► Intermediate
risk (1-2 points)
 16% development cohort / 14% validation
cohort
► High
risk (3-4 points)
 42% development cohort / 26% validation
cohort
Non-modifiable risk factors
► Risks
inherent to the patient
 Neurological disease
Myasthenia gravis, Parkinson’s, previous CVA
 Psychiatric disease
Depression, BAD, anxiety, psychosis
 Mild cognitive impairment or dementia
 Severe chronic systemic illness
Chronic renal failure, chronic liver disease
HTN, DM, MI, CVA, A-fib, PAD, CHF, ASA ≥3
Potentially modifiable risk factors
► Anaesthesia
 General anaesthesia increases risk for 24-48hrs
Rubino FA. Neurol Clin N Am 2004; 261-276
► Presence
of delirium preoperatively
► Pre-operative





Hypoalbuminemia
Abnormal sodium, potassium, glucose
Hypermagnesemia
High BUN: Crt
Leukocytosis
Precipitants
► Systemic
disease
 Infection, organ failure
► Toxins
and drugs
 Withdrawal of EtOH, benzos, sedatives
► Primary
cerebral disease
 Acute CVA, seizure
► Psychophysiologic
states
 Anxiety, sensory deprivation, overstimulation,
unfamiliar environment
Iatrogenic causes
► Dehydration
► Disorientation
► Drugs
► Immobilization
► Sleep
deprivation
Dr Sharon Marr’s approach
►D
►E
►L
►I
►R
►I
►U
►M
rugs
lectrolyte abnormalities
ack of drugs (eg. Benzo withdrawal)
nfection
educed sensory input
ntracranial process (CVA, seizure, bleed)
rinary retention / fecal impaction
yocardial (MI, CHF)
Approach to prevention
► Minimize
potential precipitants in patients at
high risk of delirium






Use lower dose narcotics
Avoid benzodiazepines
Avoid anticholinergics (including Gravol)
Enable normal sleep-wake patterns
Promote early mobilization
Allow access to H2O unless contraindicated
Can we prevent delirium?
► Inouye
et al. (1999)
 Controlled clinical trial – general medical service
 Patients matched for age, sex, baseline delirium risk
 Interventions aimed at addressing 6 risk factors
Cognitive impairment (orientation, therapeutic activities)
Sleep deprivation (warm drink, quiet ward, less done overnight)
Immobility (early mobilization)
Visual impairment (visual aids)
Hearing impairment (amplifiers, communication techniques)
Dehydration (encouraged po fluids)
Inouye (1999) - Results
► Decreased
rate of delirium
 9.9% vs. 15%, p=0.02 (42 vs. 64 cases)
► Fewer
total number of days of delirium
 105 vs. 161 days, p=0.02
► Fewer
total number of episodes of delirium
 62 vs. 90 episodes, p=0.03
► Average
cost $6341 per case of delirium
prevented
Holroyd-Leduc, CMAJ 2009.
Table 2. Examples of
strategies that targeted
risk factors in
multicomponent
intervention for the
prevention of delirium
4. Managing delirium
http://www.acphospitalist.org/weekly/archives/2008/04/30/cartoon.jpg
Approach to management
► Identify
precipitant and reverse/treat it
 Infection
CBC, U/A, UCx, +/- CXR, +/- wound Cx, +/- blood Cx
 Hypoxemia, hypercarbic resp failure,
hypoglycemia
ABG, O2 sat, CBGM
 Dehydration, electrolyte disturbance
SMA-10 (Na, Ca, Crt, BUN), volume status
 Pain
Poorly controlled pain or side-effects from medications
Consider the less common
► Consider
other causes of delirium not
directly related to the OR
 EtOH/benzo withdrawal
 Acute CVA or seizure
►Good
history and exam – Most patients do not need
CT head or EEG
 Intracranial bleed
►Any
patient on full-dose anticoagulation or with hx of
head trauma due to fall from bed
Avoid making things worse…
► Judicious
use of medications
 Reduce doses of narcotics
 Eliminate benzos and anticholinergics
 Consider Imovane (zopiclone) if qhs sleep
medication is still needed
►Non
benzodiazepine
►May still worsen confusion or agitation
►Start with 3.75 mg po qhs prn
Rx
► Treat
with antipsychotics – Haldol (haloperidol)
 Risperdal, Zyprexa, Seroquel, Clozaril  1.6x death rate
in dementia, not approved for delirium
 Unlikely to cause EPS in short term
 Can start with low doses (0.5 mg) but can increase
doses as needed
 Can Rx po or IM
 Avoid IV (arrhythmia and sudden cardiac death)
 Watch for NMS
Fever, muscle rigidity, AMS, high CK
Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.
O’Keefe ST. Age and Ageing 1999; 28-S2: 5-8.
Other Rx
► Use
benzodiazepines only for EtOH/sedative
withdrawal
 Otherwise, may worsen confusion & agitation
Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.
O’Keefe ST. Age and Ageing 1999; 28-S2: 5-8.
Additional management
► Family
members / sitters at bedside
► Eyeglasses / hearing aids
► Provide calendars / clocks
► Avoid multiple room switches
Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.
Rubino FA. Neurol Clin N Am 2004; 22: 261-276.
Caution with physical restraints
► Bedrails
and restraints often used
 No evidence of efficacy
 Vest restraints can cause death from
strangulation and contribute to pneumonia &
decubitus ulcers
 Falls more likely to result in injury
55% of falls result in injury (vs. 29%)
Injuries were more severe (p<0.0001)
Francis & Kapoor. Journal of General Internal Medicine 1990; 65-79
Tan KM et al. Irish Journal of Medical Science 2005; 174(3): 28-31
Rubino FA. Neurol Clin N Am 2004; 22: 261-276
Back to our cases
► Mrs.
A.
 72 year-old admitted for elective right
hemicolectomy for colon Ca
 PMH & Baseline
►Hypertension
– well controlled on HCTZ
►Plays golf regularly in spring & summer; crosscountry skiing in winter
►Retired accountant; now “does the books” for a local
not-for-profit organization
► What’s
her delirium risk?
Mrs. A.’s risk
► Using
Inouye et al.’s risk factor model, 0 of
vision impairment, severe illness, cognitive
impairment, High BUN:Crt
► Using other known risk factors, has good
functional capacity and good cognitive
function at baseline. Only has wellcontrolled hypertension.
► LOW delirium risk. No specific intervention
needed
A different case…
► Mrs.
K.
 72 year-old admitted for elective right
hemicolectomy for colon Ca
 PMH & Baseline
►CRF
due to DM2 – creatinine 198, on insulin 4x/d
►Lives by herself but has help from her children to pay
bills
► What’s
her delirium risk?
Mrs. K.’s risk
► Using
Inouye et al.’s risk factor model, 2 of
vision impairment, severe illness, cognitive
impairment, High BUN:Crt
► INTERMEDIATE delirium risk
► Will need to use caution with Rx of
analgesia, anticholinergics, sedatives
► Should be assessed daily for development of
delirium so investigation/management is not
delayed.
Take Home Messages
► Delirium
occurs in 10-15% of general surgery
patients & is associated with increased mortality,
morbidity, length of stay, and costs
► Delirium may be preventable in intermediate/high
risk patients
► Management of delirium involves identifying and
treating the precipitant, judicious use of
medications, improving the patient environment,
and haloperidol when needed
Thank you.
Questions?
References
Francis J & Kapoor WN. Delirium in Hospitalized Elderly. Journal of General Internal Medicine 1990; 5: 65-79.
Franco K, Litaker D, Locala J, Bronson D. The Cost of Delirium in the Surgical Patient. Psychosomatics 2001; 42: 68-73.
Ganai S, Lee KF, Merrill A, Lee MH, Bellantonio S, Brennan M, Lindenauer, P. Adverse Outcomes of Geriatric Patients Undergoing Abdominal Surgery
Who Are at High Risk for Delirium. Archives of Surgery 2007; 142(11): 1072-1078.
Inouye SK, Viscoli CM, Horwitz, RI, Hurst LD, Tinetti ME. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Baed on Admission
Characteristics. Annals of Internal Medicine 1993; 119: 474-481.
Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. NEJM 1999; 340(9): 669-676.
Laine C & Williams SV (Eds). In the clinic: Preoperative Evaluation. Annals of Internal Medicine 2009; ITC1: 1-16.
Litaker D, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for post-operative delirium. General Hospital Psychiatry 2001; 23:
84-89.
Millar HR. Psychiatric Morbidity in Elderly Surgical Patients. British Journal of Psychiatry 1981; 138: 17-20.
Noimark D. Predicting the onset of delirium in the post-operative patient. Age and Ageing 2009; 1-6.
O’Keeffe ST. Delirium in the elderly. Age and Ageing 1999; 28-S2: 5-8.
Rubino FA. Perioperative management of patients with neurologic disease. Neurologic Clinics of North America 2004; 22: 261-276.
Tan KM, Austin B, Shaughnassy M, Higgins C, McDonald M, Mulkerrin EC, O’Keefe ST. Irish Journal of Medical Science 2005; 174(3): 28-31.
Thomas DR & Ritchie CS. Preoperative Assessment of Older Adults. Journal of the American Geriatrics Society 1995; 43(7): 811-821.