Transcript Part I - Curriculum for the Hospitalized Aging Medical Patient (CHAMP)

CHAMP
Incident Delirium in the
Hospitalized Senior
Andrea Bial, MD
Don Scott, MD, MHS
University of Chicago
Goals
1. Facilitate learning and teaching around
the topic: “Incident Delirium in
Hospitalized Seniors”
2. Reduce the Incidence of Delirium in
Hospitalized Seniors
3. Improve the Care of Hospitalized
Seniors who develop Delirium
Objectives
Section 1 (Don)
1.
Learn More & Teach More About Assessing Risk for
Delirium
•
2.
Learn More & Teach More About Delirium Prevention
Strategies
•
•
3.
Predicting Older Patients Probability of Developing
Delirium
Avoiding Precipitants
Prevention Interventions
Learn More & Teach More About Diagnosing
Delirium: Using the Confusion Assessment Method
(CAM)
•
•
To Diagnose Delirium
To Help Distinguish from Dementia
Objectives
Section 2 (Andrea)
5. Learn More and Teach More about the Systematic
Approach to the Evaluation of the Hospitalized
Senior with Delirium
6. Learn More and Teach More about the Systematic
Approach for the Treatment of the Hospitalized
Senior with Agitated Delirium
HPI: Mrs. G., 87 y.o. woman from home; 4-5 days c
fever,
cough, malaise, appetite, po; 1 day 
DOE
PHx: DM c neuropathy, HTN, A-Fib, OA, Glaucoma, COPD
Meds: glipizide, amitriptyline qhs, lisinopril, Digoxin,
Vioxx, T#3’s prn, Warfarin, Ditropan
Soc / Fx Hx: Lives with husband, retired teacher, Ind. in
ADLs and IADL’s
PEx
• Vitals 381; 155/90,HR 105, RR 20; O2 94% RA, Non-Toxic
–
–
–
–
–
–
HEENT: edentulous, dry OP
Chest:  BS and Exp Wheezes
CV: Syst. M c/w SEM
Abd: Benign; gExt’s: Trace Pedal Edema
Neuro: A&O X 3, Non-Lateralizing, follows commands
Labs:
145 105
4.6 22
43 298
1.7
185
10.5
32.0
16.7
(MCV=85)
Dig = 1.4 Albumin 4.0 (LFT’s WNL)
U/A: >20 WBC, +LE / N, Many Bacteria
U & Bld Cx’s P
CXR: + COPD Changes / ?RLL Infiltrate
ECG: A-Fib @ 105
70% N
10% Bds
10% L
Teaching about Delirium in
Hospitalized Seniors
• Teaching Opportunities for:
– Evidence-Based:
• Risk Factors for Delirium at Admission?
•Prediction of Delirium at Admission?
•Delirium-Producing Insults?
•Validated Prediction Tool for Delirium?
– Differentiating Delirium from Dementia?
•Prevention Strategies?
Teaching Moment Alert!
• Why Thinking about Delirium in
Vulnerable Older Adults is as Important
Delirium in Hospitalized
Seniors: Significance
1. The Prototypical Geriatric Symptom
– Medical Emergency  THE Cardinal Symptom
• “Brain Failure”  Congestive Heart Failure
2. Independent Risk Factor for:
• Mortality
• Functional Decline
• Length of Stay
–
• Nursing Home Placement
(? cognitive decline)
3. Common: Gen Med Wards
--Incidence = 14-25% (>70)
Delirium in Hospitalized
Seniors: Significance
4. Potential Iatrogenic Complication of
Hospitalization (X 2)
5. Costly
6. Preventable
Learn More & Teach More About
Assessing Baseline Risk for Delirium
Sharon Inouye’s Work
Develop a Useable Diagnostic Tool and Validate

Identify Baseline Risk Factors & Develop
Predictive Model for Incident Delirium

Identify Precipitating Insults Causing Incident
Delirium and Develop Predictive Model

Develop and Test a Prevention Strategy
Delirium:Multifactorial Model
Predisposing Factors/
Vulnerability
Precipitating Factors/
Insults
High Vulnerability
Noxious Insult
Low Vulnerability
Less Noxious
Insult
Inouye, S, et. al. JAMA. 1996; 275:852- 857.
Predicting Delirium:
PreDisposing Risk Factors
• Purpose: Develop and Validate a Predictive
Model for Occurrence of Incident Delirium in
persons > 70 years
• Design: Prospective Cohort Study
– Development Cohort
• Validation
Cohort
• Setting: Univ-Based Teaching Hospital; Gen.
Med. Service
• 10 Outcome: Incident Delirium via CAM
– Assessed within 24 of Admission & Daily
• Analysis: ID Risk Potential Ind Risk Factors c
Bivariate  Stepwise Prop. Hazards Model to ID
Ind Risk Factors  Predictive Model
Inouye SK , et al. Ann Intern Med. 1993;119:474-481
Predicting Delirium:
PreDisposing Risk Factors
DEVELOPMENT COHORT
N=107
RR
1.  Vision
3.5 (1.2-10.7)
2. Severe Illness 3.5 (1.5-8.2)
3.  Cognition
2.8 (1.2-6.7)
4. BUN/Cr > 18 2.0 (1.1-4.6)
ROC = 0.74 (0.63, 0.85)
-NOTE: COG. IMPAIRMENT (MMSE < 24); VISION
IMPAIRMENT > 20/70; BUN/CR > 18/1; SEVERE ILLNESS=
APACHE II > 16 OR CHARLSON ORDINAL CLINICAL =
RATED AS SEVERE
ROC= 0.74 (0.63-0.85)
Inouye SK , et al. Ann Intern Med. 1993;119:474-481
VALIDATION COHORT
N=174
RR
1. Low Risk (0)
1.0
2. Int. Risk (1-2)
2.5
3. High Risk (3-4) 9.2
ROC = 0.66 (0.55-0.77)
(SEE Pocket Card)
Teachable Moment ALERT !
Teachable Moment 1: Risk Stratification
• Predicting Older Patients Probability of
Developing Delirium
Triggers: The Long-Call or Short Call
Presentation
Standing at the Bedside with an AtRisk Patient
Teachable Moment ALERT !
• Teachable Moment 1 (Cont’d)
– Risk Stratification  Targeting  Efficiency
– What do you think this patient’s risk is of
developing delirium?
• Was Vision Checked? Glasses?
• Was a MMSE or other Cognitive Screen Performed ?
• Does Patient appear Severely Ill?
• BUN/Cr and Volume Status ?
– ? Risky Meds ? PRN’s?
– Delirium Risk Score = 2 (Vision &
Azotemia)
(SEE 3X5 Card)
Learn More & Teach More About
Diagnosing Delirium: Using the
Confusion Assessment Method (CAM)
• To Diagnose Delirium
• To Help Distinguish from Dementia
Delirium: Diagnosis--CAM
1. Acute Onset &
Fluctuating Course
AND
2. Inattention
plus either
3. Disorganized
Thinking
4. Altered LOC
DELIRIUM
Inouye SK et al. Ann Intern Med 1990;113:941-948.
CAM (Confusion Assessment Method)
• Feature 1: Acute Onset & Fluctuating Course
– This feature is usually obtained from a family
member or nurse and is shown by positive
responses to the following questions:
•Evidence of sudden change in mental status
from baseline?
•Did the abnormal behavior fluctuate during
the day, that is, tend to come and go, or
increase or decrease in severity?
Inouye SK et al. Ann Intern Med 1990;113:941-948
Validity of CAM

Inouye S, et. al. Clarifying confusion: The confusion assessment method. Ann
Intern Med. 1990; 113: 941- 948
 Comparison = DSM III-R Interview
 Sens 94 & 100% Spec 90 & 95% PPV 91 & 91% NPV 90 & 100%

Ely EW., et al. Delirium in mechanically ventilated patients: validity and
reliability of the confusion assessment method for the intensive care unit (CAMICU). JAMA. 2001;286(21):2703-10.
 Comparison DSM IV Interview
 Sens 93 & 100% Spec 98 & 100%
inter-rater reliability  = 0.96
• Monette J., et al. Evaluation of the confusion assessment method (CAM) as a
screening tool for delirium in the emergency room. Gen. Hosp. Psychiatry.
2001;23(1):20-5.
– Comparison: “Geriatrician Interviewer”
– Sens 86% Spec 100%
Distinguishing Delirium from Dementia
(See Pocket Card)
Teaching Points
Feature
Delirium
Dementia
ONSET
SUDDEN
INSIDIOUS
NEED TO KNOW THE
PATIENT’S BASELINE
ATTENTION &
CONSCIOUSNESS
DISORDERED
NORMAL
EXCEPT IN ADVANCED
DEMENTIA
REQUIRES KNOLEDGE OF
BASELINE AND ATTENTION
TO MENTAL STATUS
EVALUATION
REQUIRES ATTENTION TO
MENTAL STATUS
EVALUATION
COURSE
FLUCTUATES
STABLE
HALLUCINATIONS
USUALLY
VISUAL
OFTEN
ABSENT
INVOL.
MOVEMENTS
TREMOR
PICKING
ASTERIXIS
USUALLY
ABSENT
ATTENTIVE OBSERVATION
REQUIRED
Teachable Moment 2: Using the Confusion
Assessment Method (CAM)
• To Diagnose Delirium
• As a Springboard To Help Distinguish Delirium
from Dementia
(see Pocket Card)
BEDSIDE TEACHING TRIGGERS
–
Suspected Delirious Patient, Dementia Patient
–
DEMONSTRATE USE OF CAM TO DIAGNOSE HYPOACTIVE
DELIRIUM
OR
–
USE OF CAM TO DIAGNOSE AND DISTINGUISH
HYPOACTIVE DELIRIUM VS. DEMENTIA
(see Pocket Card)
Video Clip & Practice Using CAM
Learn More & Teach More About
Delirium Prevention Strategies
• Precipitating Factors
• A Successful Prevention Strategy
Predicting Delirium:
Precipitating Risk Factors
• Purpose: To prospectively Develop and Validate a
Model for Incident Delirium based on
Precipitating Factors During
Hospitalization
• Design: Prospective Cohort Study
• Setting: Univ-Based Teaching Hospital; Gen. Med.
Patients
• 10 Outcome: Incident Delirium via CAM
(precipitating factor must proceed > 240)
• Analysis: Group Risk Factors on 4 Axes (a priori
assumption)  Reduce variables on each axis using
Multivariable Binomial Regression Models (ID’s Ind
Inouye
SK , etFactors
al. Ann Intern
Med.each
1993;119:474-481
Risk
from
Axis)  Predictive Model
Predicting Delirium
Precipitating Risk Factors
DEVELOPMENT COHORT
N=196
RR
1 Phys. Restraints 4.4 (2.5-7.9)
2 Malnutrition
4.0 (2.2-7.4)
3  3 meds added 2.9 (1.2-4.7)
4 Bladder Catheter 2.4 (1.2-4.7)
5 Iatrogenic Event 1.9 (1.1-3.2)
(SEE Pocket Card)
Inouye SK, et. al. JAMA 1996: 275; 852- 857
VALIDATION COHORT
N=312
(RR)
1. Low Risk (0 Points) 1.0
2. Intermed Risk (1-2) 7.1
(3.2-15.7)
3. High Risk (3-5)
17.5
(8.1-27.4)
Learn More & Teach More About
Delirium Prevention Strategies
• Precipitating Factors
• A Successful Prevention Strategy
A Multicomponent Intervention to Prevent
Delirium in Hospitalized Older Adult
Patients. NEJM. 1999.
– Design: Prospective, Matched, 852 patients,
Medicine Service
– Inclusion: Age > 70, Not delirious at admit,
Intermed. or High Risk
 Intervention --Focused on 6 risk factors for delirium:
Cognitive Impairment, Sleep Deprivation, Immobility,
Visual impairment, Hearing impairment, Dehydration
 1o End Point = Incident Delirium  Assessed daily
until discharge
Inouye SK, et al. NEJM. 1999;340:669-676
Targeted Interventions
Cognitive
Impairment
Orientation/
Activities
Sleep Deprivation
Non-drug; sleep
enhancement
Immobility
Early
Mobilization
Targeted Interventions
Visual
Impairment
Visual Aids,
Devices
Hearing Impairment
Hearing devices,
Remove earwax
Dehydration
Early recognition
& po repletion
Prevention Protocols
Inouye SK, et al. NEJM. 1999;340:669-676
SEE CHALK
Results






USUAL CARE = 15.0%
PREVENTION GROUP =
9.9%
OR 0.60 (CI 0.39- 0.92)
RRR= 40% ARR= 5.1%
NNT = 20
NO BENEFIT ONCE
DELIRIUM OCCURED
Inouye SK, et al. NEJM. 1999;340:669-676.
Back to Case
HPI: Mrs. S., 87 y.o. woman from home; 4-5 days c
lethargy, appetite, po; 1 day n/v, no po
DX: Cystitis and Possible Pyelonephritis
A/P
– IV Abx and NS; Clear Liquid, ADA Diet; Foley to
Gravity; Bed Rest
– Continue Out-Patient Medicines
– SSI & FS qac & qhs
– PRN’s: MOM, Compazine, Prosom, T#3’s
– DVT Prophylaxis
– AM lABS
– Abd/Renal U/S & AM Labs
Teachable Moment ALERT !
• Teachable Moment 3: “Preventing” Delirium
• Potential Triggers
– Post-Call or Short Call Presentation
– Bedside
• Room Dark, TV Blaring, Tethered to Bed, No Glasses, No
Hearing Aids, Dry Board with Wrong Day and Other Info
– Ask re Out of Bed, Diet (and ?eating / drinking),
BM’s?
• Why is the Patient in Bed
• Where’s the Geri-/Cardiac Chair ?
– What is Happening Overnight ?
– MAR Review
Teachable Moment 3: Preventing Delirium
Avoiding Precipitants & Prevention Interventions
•
•
•
•
•
•
•
•
? Pt’s Baseline Risk ?
What Meds have we Added? What psychoactive medications are on
the MAR? (Time for MAR Review?) (SEE 3X5 Card)
?Any “regular Meds” that could have been temp. D/C’s?
? Vision and Hearing ?  Are Glasses and Hearing Aids Present; Is
a “Pocket Talker” Needed (?Available)
Is a Foley Present and if so what is the indication?
What are the plans for getting the Patient out of Bed? Can we find a
Cardiac / Geri Chair? Has PT been Ordered? Family and Pt
encouraged? Are IV Fluids Really Needed
Does the patient really need to be awakened for am labs and vitals ?
Really need FS qac and qhs?
Is the patient eating? Has the Diet been Advanced? Is the patient
pooping?
Break Time