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Delirium Basics
Jason Moss, PharmD, &
Eleanor McConnell, PhD, RN, GCNS-BC
October 24, 2011
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Objectives
• Describe the prevalence of delirium and its impact
on the health of older patients
• Discuss pathophysiology, risk factors and key
presenting features
• Distinguish presenting features of delirium, dementia
and depression
• Use nursing process to organize thinking about key
nursing activities in preventing and managing
delirium
• Find opportunities to improve current practice
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #1 from 3-D quiz
Question: A chronic, progressive loss of brain
cells resulting in decline of day-to-day cognition
and functioning.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #2 from 3-D quiz
Question: At least 6weeks, but can last several
months to years, especially if not treated.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #3 from 3-D quiz
Question: Performance on mental status exam
may vary from poor to good depending of time
of day and fluctuation in cognition.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #4 from 3-D quiz
Question: Often of a frightening or paranoid
nature.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #5 from 3-D quiz
Question: Treatable and reversible especially if
caught early.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Meet Mrs. Florence
• 78 year old resident of Durham admitted to
the hospital after a fall in her home…..
•
•
https://phw-lmsc.duhs.duke.edu/production/DUHS_Common/delirium/videos/hyper_clip1_101711/hyper_clip1_101711.html
https://phw-lmsc.duhs.duke.edu/production/DUHS_Common/delirium/videos/hyper_clip2_101711/hyper_clip2_101711.html
• Have you ever seen anyone like this?
• How would you describe her behavior?
• What do you think is wrong?
Duke GEC
www.interprofessionalgeriatrics.duke.edu
What is Delirium?
1. Acute onset of mental status
changes
or a fluctuating course
and
2. Inattention
3. Disorganized
Thinking
and
or
4. Altered level of
consciousness
= Delirium
Duke GEC
www.interprofessionalgeriatrics.duke.edu
CAM, CAM-ICU
A BIG Problem
• Hospitalized patients over 65:
– 10-40% Prevalence
– 25-60% Incidence
•
•
•
•
•
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.
Rudolph J et al, 2011
Duke GEC
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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
So…If delirium such a big
problem, why don’t we
hear more about it?
1.
2.
3.
4.
5.
6.
7.
Acute or subacute
onset
Fluctuating intensity
of symptoms
Inattention
Disorganized thinking
Altered level of
consciousness
• Hypoactive v.
• Hyperactive
Sleep disturbance
Emotional and
behavioral problems
Duke GEC
www.interprofessionalgeriatrics.duke.edu
https://phwlmsc.duhs.duke.edu/producti
on/DUHS_Common/delirium
/videos/hypo_clip1_101811/
hypo_clip1_101811.html
https://phwlmsc.duhs.duke.edu/producti
on/DUHS_Common/delirium
/videos/hypo_clip2_101811/
hypo_clip2_101811.html
Delirium Pathophysiology
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246
Let’s go back to our case!
Duke GEC
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Mrs. Florence: Background
• 78 year old female who fell climbing into attic
• PMH significant for Knee Osteoarthritis
Hypertension, Restless legs, Stroke
• Married, lives with husband of 52 years
• 4 beers a day
On admission to the hospital:
• BAL=80
• Na=128
• Pain score 9/10
Duke GEC
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Medications
Outpatient
– clonazepam
– ropinirole
– lisinopril
– aspirin
– furosemide
– amlodipine
– oxycodone
– oxybutynin
– OTC benadryl as needed
for allergies
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Inpatient
– ropinirole
– lisinopril
– aspirin
– furosemide
– amlodipine
– oxycodone prn
– oxybutynin
– sliding scale insulin
– ranitidine
Risk Factors
• Baseline Vulnerability (Predisposing)
-Risk factors r/t person’s baseline
- Often we cannot modify these
• Precipitating
– These are things that happen to the
patient
– Insults
– Often Iatrogenic
• Baseline + Precipitating = Delirium
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Risk Factors- General
• Baseline Vulnerability
– Underlying Brain Disease
(Dementia, Stroke,
Parkinson’s Disease)
– Increased Age
– Institutionalization
– Chronic disease
(HIV, ETOH dependency,
diabetes, etc)
– Visual/Hearing deficits
Duke GEC
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• Precipitating
–
–
–
–
–
–
–
–
–
Medications
Infection
Dehydration
Immobility/restraints
Malnutrition
Tubes/catheters
Medications
Electrolyte imbalance
Sleep Deprivation
Framework for Risk
Baseline Vulnerability
High
Low
Duke GEC
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Precipitating Stimulus
Noxious
Mild/None
Medication Side Effects
• Anticholinergic
• CNS sedation
• Constipation
• Abrupt withdrawal of chronic psychotropic
medications
Duke GEC
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Concerning Medications
Anticholinergic
Oxybutynin
Amitriptyline
(**furosemide, ranitidine)
Antihistamines
Diphenhydramine (Benadryl)
Chlorpheniramine
Anticonvulsants
Primidone
Phenobarbital
Antiparkinsonian
Levodopa-carbidopa
Dopamine agonists
Antipsychotics
Clozapine and other atypicals
Benzodiazepines
Diazepam, clonazepam
Hypnotics
Zolpidem (Ambien)
Opioid analgesics
Meperidine, morphine, oxycodone
Duke GEC
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Medications
Outpatient
– clonazepam
– ropinirole
– lisinopril
– aspirin
– furosemide
– amlodipine
– oxycodone
– oxybutynin
– OTC benadryl as needed
for allergies
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Inpatient
– ropinirole
– lisinopril
– aspirin
– furosemide
– amlodipine
– oxycodone prn
– oxybutynin
– sliding scale insulin
– ranitidine
What Predisposing Factors Did She Have?
Predisposing
• Advanced age
• Preexisting dementia
• History of stroke
• Parkinson disease
• Multiple comorbid conditions
• Impaired vision
• Impaired hearing
• Functional impairment
• Male sex
• History of alcohol abuse
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Baseline
Vulnerability
High
Low
Precipitating
Stimulus
Noxious
Mild/None
Marcantonio, 2011.
Common Risk Factors for Delirium
Predisposing
• Advanced age
• Preexisting dementia
• History of stroke
• Parkinson disease
• Multiple comorbid conditions
• Impaired vision
• Impaired hearing
• Functional impairment
• Male sex
• History of alcohol abuse
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Precipitating
• New acute medical problem
• Exacerbation of chronic medical problem
• Surgery/anesthesia
• New psychoactive medication
• Acute stroke
• Pain
• Environmental change
• Urine retention/fecal impaction
• Electrolyte disturbances
• Dehydration
• Sepsis
Marcantonio, 2011.
What Predisposing Factors Did She Have?
Precipitating
• New acute medical problem
• Exacerbation of chronic medical
problem
• Surgery/anesthesia
• New psychoactive medication
• Acute stroke
• Pain
• Environmental change
• Urine retention/fecal impaction
• Electrolyte disturbances
• Dehydration
• Sepsis
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Baseline
Vulnerability
High
Low
Precipitating
Stimulus
Noxious
Mild/None
Marcantonio, 2011.
What is Delirium?
1. Acute onset of mental status
changes
or a fluctuating course
and
2. Inattention
3. Disorganized
Thinking
and
or
4. Altered level of
consciousness
= Delirium
Duke GEC
www.interprofessionalgeriatrics.duke.edu
CAM, CAM-ICU
Improving The Odds of Recognition
Prediction by risk
– Predisposing and precipitating factors
Team observations
– Nursing notes
Clinical examination
– CAM
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Team Input
• Nursing recognition of high risk medications
for delirium
– Ask
– Observe
– Be suspicious
– Communicate
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Kamholz, AAGP 1999
1 month before adm
PCP Note
Episode of confusion following her knee surgery. She does not feel confused presently.
Presents to ED
20:20 ED
Verbally converses and oriented 5
Day Admitted
01:25 Adm Data
She can’t tell me how many stairs she fell down. She is a little disoriented…reports ~2 beers per day which puts
her at risk for withdrawal...monitor closely for signs/symptoms of withdrawal.
Day Admitted
03:05 PRM
10:40 AM BSN Findings: Independent prior to admission: Newly dependent
Hospital Day 1
03:10 Nursing
Patient is very drowsy.
Hospital Day 1
10:14 OT
Cognition: Alert, changed to lethargic once medication had taken affect.
Hospital Day 1
11:40 PT
Cognition: Impaired…Oriented to self, place, time, situation, with significant prompting.
Hospital Day 1
17:25 Post Anesthesia
Reports mild post-operative confusion, but per husband significantly better anesthesia recovery than the
previous surgery 1 year prior.
Hospital Day 1
18:55 Nursing
Pt a/o x 3, unaware of correct date/time…pulling at soft cast on left hand but reorients well.
Hospital Day 1
22:22 Nursing
Pt is alert and orientedx4, with mild anxiety present…pulling wrap to arm…told numerous times to leave it
alone…order for a hand mitt restraint…is aware if tugging again will be restrained.
Hospital Day 2
03:03 Nursing
alert and orientedx2-3, with mild anxiety and occasional hallucinations… pulled out foley catheter...pulled at
cast… Bilat hand mitts and wrist restraints were applied.
Hospital Day 2
14:04 Nursing
Pt. AOx1-2, very agitated and restless at times... Pt. resting quietly at this time. Family at bedside.
Hospital Day 4
15:00 PT
The patient reports "Take this off of me (referring to restraints and mits) so I can run an errand."
Hospital Day 4
18:52 Nursing
Pt s/p right radial fracture, right hip fracture, now with delirium r/t possible alcohol w/d.
Hospital Day 5
05:08 Nursing
Has been agitated…Sitter at bedside. Restraints. Pt not agitated at the time the BP taken.
Hospital Day 5
18:32 Nursing
A&ox4 today with some stm deficits noted.
Hospital Day 5
15:01 Nursing
PATIENT CAN BE IMPULSIVE AT TIMES…EMOTINOAL SUPPORT GIVEN
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Assessment: Standardized Tool
• Confusion Assessment Method (CAM-ICU)
Puts definition into action!
1.Change in cognitive status in past 24 hours?
2.Inattention?
3.Altered Consciousness?
4.Content of consciousness
http://www.mc.vanderbilt.edu/icudelirium/
Duke GEC
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• http://www.mc.vanderbilt.edu/icudelirium/
Duke GEC
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Richmond Agitation-Sedation Score (RAAS)
Duke GEC
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Intervention
• Prevention 1st!
• Management 2nd
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Nursing Interventions & Evaluation
Yale Delirium Prevention Program : multi-component
interventions





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 2004
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
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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
Duke NICHE: 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
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?
Altered
Mental
Status
Other Management
• Medications
– Low doses of certain antipsychotics
– Short-acting benzodiazepines
– Older adults may require lower doses
• Symptom triggered therapy
– Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-A)
• Supportive therapy
– Comorbidities
– Hydration and nutrition
• Team care
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Back to Mrs. Florence
Hospital Course and beyond:
•Pain management
•Sitters and family
•Activity
•Clonazepam
•Geriatrics consultation
Duke GEC
www.interprofessionalgeriatrics.duke.edu
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
Summary
•
•
•
•
Maintain a high level of suspicion
Document findings in the chart
Discuss with other members of the team
Inform/educate patients and families
Duke GEC
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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
Supplemental Resources
• GRECC 5-D Card
• Delirium brochure for direct caregivers
• – Vanderbilt University www.icudelirium.org
– RASS pocket cards
– Videos for CAM administration (2 minutes!)
• Vancouver Health Authority
– http://www.viha.ca/mhas/resources/delirium/too
ls.htm
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Delirium Teaching Rounds
“Itching for a Fight!”
November 4, 2011
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 , CNE
• Katja Elbert-Avila, MD
• Mitch Heflin, MD
Duke GEC
www.interprofessionalgeriatrics.duke.edu
•
•
•
•
•
•
•
•
•
•
•
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
Acknowledgements
• Mitchell Heflin, MD & Cornelia Poer, MSW
Duke University Geriatrics Division for case material & slides
adapted from Medicine Grand Rounds February, 2011
• Brenda Pun, RN, MSN, ACNP – slides adapted from Delirium
II Module prepared for Duke University School of Nursing
Geriatric Innovations in Nursing Education (GNIE) Project
• Duke-NICHE Geriatric Resource Nurses:
–
–
–
–
Kristin Nomides, RN
Grace Kwon RN
Samantha Badgley, RN
Yvette West, RN, C MSN, Director, Duke-NICHE
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #1 from 3-D quiz
Question: A chronic, progressive loss of brain
cells resulting in decline of day-to-day cognition
and functioning.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #2 from 3-D quiz
Question: At least 6weeks, but can last several
months to years, especially if not treated.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #3 from 3-D quiz
Question: Performance on mental status exam
may vary from poor to good depending of time
of day and fluctuation in cognition.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #4 from 3-D quiz
Question: Often of a frightening or paranoid
nature.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Item #5 from 3-D quiz
Question: Treatable and reversible especially if
caught early.
A. Depression
B. Delirium
C. Dementia
D. I don’t know.
Duke GEC
www.interprofessionalgeriatrics.duke.edu