Transcript Delirium: What It Looks Like Why Frail Patients Succumb

Delirium:
The Confusion Conundrum
February 4, 2011
Mitchell T. Heflin, MD
Barbara Kamholz MD
Juliessa Pavon, MD
Yvette West, RN
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Case Presentation
Mr. A
– 82 year old white male post-op day #18 from AAA
repair
– Consult for agitation and altered mental status
HPI:
– Pulsatile mass found by PCP on routine exam
– Confirmed as 8.2 cm infrarenal AAA on CT
– Referred for elective surgical repair
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Case: History
• Past Medical History:
– Hypertension
– Hyperlipidemia
– Smoked 1ppd until quit 1995
– s/p finger amputation on left hand from work accident
• Home Medications:
– Simvastatin 40 mg daily
– Bisoprolol 5 mg bid
– ASA 81 mg daily
• ROS:
– Denied abd pain, back pain, chest pain, sob, claudication
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Case: History
• Family History:
– Alzheimer’s disease in both parents
• Social History:
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Lives at home alone, widower for 5 years
Independent in ADLs and IADLs
Physically active, playing golf daily
Son and daughter do not live locally
Duke GEC
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Case: Hospital Course
• Elective AAA repair on 12/15/10
• Returned to OR on POD #0 for bleeding from
aneurysm
• Following surgery:
– Mental status did not return to baseline despite weaning
off sedation
– Failed trial of extubation due to AMS
• POD #3: atrial fibrillation and tachycardia
– Amiodarone started
• POD #7: Trach and PEG
Duke GEC
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Case: Hospital Course
• POD #7-14: Restless and agitated
– Pulling at trach and PEG
– Attempts to treat with haldol, risperidone and ativan
• POD # 16: Adynamic ileus and aspiration
– Vancomycin and ciprofloxacin
• POD # 18: Geriatrics consulted
– Assist with management of agitation and altered mental
status
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Case: Medications
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Aspirin
Amiodarone
Metoprolol
Vancomycin
Ciprofloxacin
Ativan 1 mg IV q6hrs
Risperidone 0.5 mg VT qhs
Haldol 0.5 – 1.5 mg IV PRN (5 mg in last 24 hrs)
Dilaudid 0.5 mg IV q6hrs PRN (0 mg in last 24 hrs)
Duke GEC
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Case: Exam
T 36.4 HR 100s BP 90s/60s Pulse ox 97% on 40 % FiO2
Gen: Somnolent but easily arousable and anxious
Grimacing and tachypneic during exam
Trach in place on ventilation
CV: Tachycardic, irregular
Pulm: Coarse breath sounds
Abd: Mildly tender, + BS, healing midline wound and PEG
Ext: Restraints on hands, edema in LE
Neuro:
Opens eyes to loud voice and tracks but does not follow simple
commands, moves all extremities, no Babinski or clonus
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Case: Diagnostic Testing
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Head CT: No focal lesions
CXR: Small bilateral effusions
KUB: Mildly distended loops of small bowel
WBC 12K, Hct 28%
Creatinine 1.0, Albumin 2.3, LFT’s and TSH normal
UA: 2+ blood, 1+ LE, 6 WBC, > 50 bacteria
EKG: Afib 100, no ischemia or conduction problems
Cardiac enzymes: normal
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Case: Daughter’s input
• Very physically and socially active
• Had problems with forgetfulness, repeating and
perseverations in the prior year
• Very hard of hearing and wears glasses for distance
vision
• Drank at least two glasses of wine each night
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Delirium: Definitions
• Acute disorder of attention and global cognitive
function
• DSM IV:
– Acute and fluctuating
– Change in consciousness and cognition
– Evidence of causation
• Synonyms: organic brain syndrome, acute
confusional state
• Not dementia
Duke GEC
www.interprofessionalgeriatrics.duke.edu
So what’s the conundrum?
• Highly prevalent
• Associated with much suffering and poor
outcomes
• Complex and often multifactorial
• Preventable but….
Better care requires a shift in paradigm
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Objectives
• Describe the prevalence of delirium and its impact
on the health of older patients
• Identify pathophysiology, risk factors and key
presenting features
• Describe strategies for prevention and management
• Find opportunities to improve current practice
Duke GEC
www.interprofessionalgeriatrics.duke.edu
A BIG Problem
• Hospitalized Patients over 65:
– 10-40% Prevalence
– 25-60% Incidence
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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
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OR=12.52
1-O’Keeffe 1997; 2-McCusker 2003;
3-Siddiqi 2006; 4-Witlox 2010
The experience…
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Grade for Recognition: D• 33-95% of in hospital cases are missed or
misdiagnosed as depression, psychosis or
dementia
• ER: 15-40% discharge rate of delirious patients
– 90% of delirium missed in ED is then also
missed in hospital!
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Inouye, J Ger Psy and Neurol., 11(3) 1998 ;Bair,
Psy Clin N Amer 21(4)1998
Clinical Features of Delirium
• Acute or subacute onset
• Fluctuating intensity of symptoms
– ALL SYMPTOMS FLUCTUATE…not just level of
consciousness
– Clinical presentation can vary within seconds to
minutes
• Inattention – aka “human hard drive crash”
Duke GEC
www.interprofessionalgeriatrics.duke.edu
In-attention
• Cognitive state DOES NOT meet
environmental requirements
• Result= global disconnect
– Inability to fix, focus, or sustain attention to most
salient concern
• Hypoattentiveness or hyperattentiveness
• Bedside tests
– Days of week backward
– Immediate recall
Duke GEC
www.interprofessionalgeriatrics.duke.edu
This Can Look Very Much Like…
….depression
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60% dysphoric
52% thoughts of death or suicide
68% feel “worthless”
Up to 42% of cases referred for psychiatry consult
services for depression are delirious
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Farrell Arch Intern Med. 1995 155:22
Improving The Odds of Recognition
• Clinical examination
– CAM
• Team observations
– Nursing notes
• Prediction by risk
– Predisposing and precipitating factors
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Diagnosis: Confusion Assessment
Method
• Geropsychiatry assessment gold standard
• Recent systematic review2
– Sensitivity 86% (74-93)
– Specificity 93% (87-96)
– LR + 9.4 (5.8-16)
– LR – 0.16 (0.09-0.29)
Duke GEC
www.interprofessionalgeriatrics.duke.edu
1 Inouye 1996; 2 Wong 2010.
CAM
1.
2.
3.
4.
Acute onset and fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Or
Inouye 1994
Nursing Input
• Chart Screening Checklist
• Nurses’ commonly charted behavioral signs
(Sensitivity= 93.33%, Specificity =90.82% vs CAM)
• Pulling at tubes, verbal abuse, odd behavior,
“confusion”, etc
• 97.3% of diagnoses of delirium can be made by
nurses’ notes alone using CSC
• 42.1% of diagnoses made by physicians’ notes alone
using CSC
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Kamholz, AAGP 1999
Risk Factors
Predisposing factors:
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Vision impairment
Severe illness (>APACHE 2)
Cognitive impairment (MMSE<24)
BUN/Cr >18
Precipitating factors:
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Physical restraints
Malnutrition (wt loss, alb)
>3 meds added
Bladder catheter
Any iatrogenic event
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Adjusted RR
3.5
3.5
2.8
2.0
Adjusted RR
4.4
4.0
2.9
2.4
1.9
Inouye SK 1998
Putting it all together...
Precipitating Factors
Predisposing Factors
0 RF 1-2 RF 3-4 RF
0 RF
0
0
0
1-2 RF 0
3.2
13.6
3-4 RF 1.4
4.9
26.3
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Inouye SK 1998
Oxidative Stress
Model: ARDS
• ANY source of ischemia
– Low cardiac output
– Impaired pulmonary function/oxygenation
– Low Hgb/Hct
• Mechanisms:
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Dysfunction of CAC
Rapid depletion of ATP
Depolarization of cell membrane
Ca++ influx, imbalance of neurotransmitters
Remodeling at all neuronal levels, including decreased
synaptic transmission, cell death
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Inflammatory Process
Model: Sepsis
• Peripheral interleukins (IL6,TNFa, IL1B) induce
symptoms of delirium
– Direct neural pathways (primary autonomic afferents)
– Transport across BBB
– Circumventricular region/BBB non-continuous
• TNFa can persist for months in CNS
• Gradient from dementia to delirium of TNFa
(amount, rate of cognitive decline)
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Neurotransmitter Dysfunction
• Dopamine
– Hypoxiamitochondrial dysfunctioncellular
instabilityCa++influx:
– Increases in production of DOPA due to upregulated
tyrosine hydroxylase
– Decreased activity of COMT
• Acetylcholine
– Synthesis very sensitive to hypoxia
– Transmission is very sensitive to metabolic abnormalities,
especially of O2 and glucose
– Suppresses immune dysregulation via vagal nerve pathway
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Summary: Feet of Sand
• Delirium in frail patients often associated with
disturbances of most basic substrates and
cellular functions:
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Impaired oxygenation (blood loss, pulmonary disease)
Metabolic disturbances, commonly Na, Calcium
Infection/inflammation (UTI, Pneumonia)
Medications, especially those that affect vital, basic
pathways
• Helps with prediction
• Primary CNS causes are in the distinct minority
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Multicomponent Intervention to
Prevent Delirium
• 852 patients over 70 on Gen Med
– IM risk (1-2 RF’s) or High risk (3-4 RF’s)
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Randomized by units with prospective matching
Standardized protocols for 6 risk factors
ID Team: Nurse specialist, PT, RT, MD and volunteers
Outcomes assessed daily by CAM
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Inouye 1999.
Elder Life Program
Risk factor
Protocol
Outcome
Cognitive
impairment
Orientation and therapeutic activities
Orientation
score
Sleep
deprivation
Non-Rx sleep protocol
Quiet nights
Use of sleep
meds
Immobility
Early mobilization
Removal of tethers
ADL score
Vision
problems
Visual aids and adaptive equipment
Early vision
correction
Hearing loss
Wax disimpaction, amplifying devices,
other comm. techniques
Whisper test
Dehydration
Early recognition and volume repletion BUN/Cr < 18
Results of Multicomponent
Intervention Trial *
Control
Delirium
incidence
Days of delirium
Intervention
15.0%
9.9%
161
105
* p< 0.02 for both outcomes
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Inouye 1999.
Results
• Most effective for IM risk group
• No change in severity of delirium
• Cost
– $327/pt
– $6341/case prevented
• No lasting beneficial effect on functional
status or resource utilization
• Benefit replicated
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Inouye 1999; Rizzo 2001; Bogardus 2003
Reducing Delirium After Hip Fracture
Geriatrics Consultation
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CNS oxygen delivery
Fluid and electrolytes
Treatment of pain
Unnecessary
medications
• Bowel/bladder
• Early mobilization
Duke GEC
www.interprofessionalgeriatrics.duke.edu
• Prevention, early
detection and
treatment of
complications
• Nutrition
• Environmental stimuli
• Agitated delirium
Marcantonio 2001.
Results
Control
(n=64)
Any
delirium
Severe
delirium
Intervention
(n=62)
RR
50%
32%
0.64 (0.37-0.98)
29%
12%
0.40 (0.18-0.89)
• No change in length of stay
• Most effective in patients without
– Pre-existing dementia
– ADL impairment
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Marcantonio 2001.
Pharmacotherapy
• Dopamine blockade1
– Haldol (1.5 mg daily) prophylaxis in high risk hip fracture
patients
– No change in incidence
– Decrease in severity and duration
• Acetylcholinesterase inhibitor2
– Donepezil did not decrease incidence or severity of
delirium
Duke GEC
www.interprofessionalgeriatrics.duke.edu
1 Kalisvaart 2005, 2 Liptzin 2005.
Treating pain
• Prospective cohort study >500 hip fracture patients
with and without delirium
• Patients receiving <10 mg IV Morphine/day were 5x
more likely to become delirious
• Patients reporting severe pain 10x more likely to
develop delirium
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Morrison 2003.
Delirium Management: Key Points
• Early recognition of high risk patients and situations
is key to effective management
• Prevention is more effective than treatment
• Address:
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Physiologic
Environmental
Pharmacologic
Psychosocial
• Enlist a team
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Sendelbach and Guthrie, 2009.
Physiologic
Psychosocial
Assess substance use
Address stress and distress
Educate patient and family
Assess decision making
Consider function and safety
Pharmaceutical
Reduce/avoid certain meds
- Benadryl, Benzo’s
Monitor for S.E.’s of pain meds
Low dose neuroleptic
Benzo’s for withdrawal
Duke GEC
www.interprofessionalgeriatrics.duke.edu
O2 and BP
Food and fluids
Sleep/wake cycle
Activity and mobility
Bowel and bladder
Pain
Infections
Environmental
Reorientation
Continuity in care
Family or sitters
Hearing aids, glasses
QUIET at night
No restraints
AMBULATE!
What about Mr. A?
Psychosocial
Watch for w/d symptoms off Ativan
Educate patient and family
Provide reassurance and means
of communication
Pharmaceutical
Taper Ativan
Monitor for S.E.’s of Oxycodone
Risperidone 0.5 mg bid
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Physiologic
Control HR, BP improved
Increase trach size
Treat UTI and aspiration
Bowel regimen
Schedule oxycodone and acetaminophen
Advance tube feeds
Environmental
Light, activity, orientation during day
QUIET at night—avoid VS, meds, etc.
Remove restraints
Glasses on, loud voice and lip reading
Geriatrics
• Inpatient consult service
• Assistance with older adults with:
– Delirium and other cognitive disorders
– Multiple, complex medical problems
– Medications, medications, medications
– Goals of care
• Pager 970-0370
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Old way….
D = Dehydration
E = Electrolytes (including glucose, Ca)
L= Low oxygen
I = Infection
R = Retention of urine/stool
I = In pain
U = Under-diagnosed withdrawal
M = Medications
Duke GEC
www.interprofessionalgeriatrics.duke.edu
A better way….
PA’s
Social work
Psychosocial
Medicine
Physiologic
Nursing
Patients
and
Caregivers
Environmental
Pharmacologic
Pharmacy
Nutrition
Administrators
Duke GEC
www.interprofessionalgeriatrics.duke.edu
PT/OT
• 5 year, $1.2 million project funded by HRSA
• Goal: Create Geriatrics Education Hub
- Staffed by interprofessional faculty
- Focused on improving the care of older adults with
or at risk for delirium
- Learning resources, clinical experiences and
practice improvement projects
- Part of six school consortium addressing this issue
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Delirium: Nursing Strategies
Duke NICHE
Geriatric Resource Nurse Initiative
Kristin Nomides RN
Grace Kwon RN
Samantha Badgley RN
Duke Hospital 2100
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Supporting Literature: Nursing Interventions
Yale Delirium Prevention Program : multi-component interventions
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Cognitive impairment with Reality Orientation
Sleep enhancement protocol
Sensory impairment with therapeutic activities protocol
Sensory deprivation
Dehydration
Reduction in delirium 9.95% (c) vs. 15% (i);
LOS & # episodes
Inouye, s. 2004
Delirium education for team (MD and RN)
 Provided post program support and learning reinforcement
 250 acute admit patients > 70 recruited on 2 units
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Delirium 12/122 intervention unit vs. 25/128 control unit
Tabet N,, et al, 2005
Post op multi-factorial intervention educational program
 Teamwork and care planning on prevention and treatment of delirium
 Targeted delirium risk factors

Post op delirium compared to controls (56/102 and 73/97)
Lundrtrom, et al. 2007
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Nursing Interventions:
• Delirium & Risk Factors Staff Education
• Activity Cart / Busy Apron
– Stimulate cognitive and motor skills
• All About Me Poster
– Orientation Information
• Me File
– Orientation information provided by patient /
family for high risk patients
• Question Mark
– Identification of patients with AMS
Duke GEC
www.interprofessionalgeriatrics.duke.edu
?
Altered
Mental
Status
Summary
• Delirium is common and caustic for older
adults
• It can be diagnosed using validated tools (e.g.
CAM)
• Predisposing and precipitating factors are well
established
• Prevention is more effective than treatment
• Management requires a team approach
Duke GEC
www.interprofessionalgeriatrics.duke.edu