Transcript Delirium_2-4-11_MH - Geriatric Education Center

Delirium:
The Confusion Conundrum
February 4, 2011
Mitchell T. Heflin, MD
Barbara Kamholz MD
Juliessa Pavon, MD
Yvette West, RN, MSN, CNS
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
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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
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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
• POD #0 returned to OR 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
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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
• Ext: Restraints on hands, edema
in LE
• Gen:
– Somnolent but easily
arousable and anxious
– Grimacing and
tachypneic
– Trach in place on
ventilation
• Neuro:
– Opens eyes to loud voice and
tracks but does not follow
simple commands
– moves all extremities
– no Babinski or clonus
Duke GEC
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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: + hematuria
EKG: Afib 100, Cardiac enzymes: normal
Duke GEC
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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-three glasses of wine each week
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
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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
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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
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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
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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 1998 ;Bair 1998.
Clinical Features of Delirium
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Acute or subacute onset
Fluctuating intensity of symptoms
Inattention – aka “human hard drive crash”
Disorganized thinking
Altered level of consciousness
– Hypoactive v. Hyperactive
• Sleep disturbance
• Emotional and behavioral problems
Duke GEC
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In-attention
• Cognitive state DOES NOT meet
environmental demands
• 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
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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 1995
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
Confusion Assessment Method (CAM)
1.
2.
3.
4.
Acute onset and fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Duke GEC
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Or
Inouye 1994
CAM
• Geropsychiatry assessment standard
• Recent systematic review2
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Sensitivity 86% (74-93)
Specificity 93% (87-96)
LR + 9.4 (5.8-16)
LR – 0.16 (0.09-0.29)
• Other tools:
– CAM-ICU
– Delirium Rating Scale
Duke GEC
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1 Inouye 1996; 2 Wong 2010.
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
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Adjusted RR
3.5
3.5
2.8
2.0
Adjusted RR
4.4
4.0
2.9
2.4
1.9
Inouye 1996
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
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Inouye 1996
Oxidative Stress
Model: ARDS
• ANY source of ischemia
– Low cardiac output
– Impaired pulmonary function/oxygenation
– Low Hgb/Hct
• Mechanisms:
– Ca++ influx, imbalance of neurotransmitters
– Neuronal damage, including decreased synaptic
transmission & cell death
Duke GEC
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Duke GEC
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Inflammatory Process
Model: Sepsis
• Peripheral interleukins (IL6,TNFa, IL1B) induce
symptoms of delirium
– Increase permeability of BBB
– Alter neurotransmission
• TNFa can persist for months in CNS
• May share inflammatory mechanisms with dementia
Duke GEC
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Pathophysiology of delirium
• 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 (Na, Calcium)
Infection/inflammation (UTI, Pneumonia)
Medications
• Primary CNS causes are in the distinct minority
Duke GEC
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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
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• 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
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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
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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
What about Mr. A?
Psychosocial
Watch for w/d symptoms off Ativan
Educate patient and family
Provide reassurance and means
of communication
Physiologic
Control HR, BP improved
Treat aspiration
Bowel regimen
Schedule oxycodone and acetaminophen
Increase trach size
Advance tube feeds
Pharmaceutical
Taper Ativan
Monitor for S.E.’s of Oxycodone
Risperidone 0.5 mg bid
Duke GEC
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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….
NP’s
PA’s
Medicine
Psychosocial
Physiologic
Social work
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
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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
• RESPECT delirium. Its common and caustic.
• PREDICT delirium. Assess for common
predisposing and precipitating factors.
• RECOGNIZE delirium. It can be diagnosed with
simple tools (e.g. CAM).
• PREVENT delirium. It can be averted with
multicomponent strategies.
• RECRUIT team members to improve care.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
GEC crew
• Eleanor McConnell, RN, MSN,
PhD
• Anthony Galanos, MD
• Jason Moss, PharmD
• Julie Pruitt, RD
• Cornelia Poer, MSW
• Gwendolen Buhr, MD
• Mamata Yanamadala, MD
• S. Nicole Hastings, MD
• Jennie De Gagné, PhD, MSN, MS,
RN-BC
• Katja Elbert-Avila, MD
Duke GEC
www.interprofessionalgeriatrics.duke.edu
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Sandro Pinheiro, PhD
Robert Konrad, PhD
Emily Egerton, PhD
Heidi White, MD
Kathy Shipp, PT, PhD
Deirdre Thornlow, RN, PhD
Lisa Shock, MHS, PA-C
Michelle Mitchell, LMBT
Michele Burgess, MCRP
Joan Pelletier, MPH
Sujaya Devarayasamudram, RN,
MSN
• Loretta Matters, RN, MSN