Transcript Delirium - UNC Lineberger Comprehensive Cancer Center

Delirium
Lindsay Wilson, MD
Jan Busby-Whitehead, MD
Ellen Roberts, PhD, MPH
The University of North Carolina at Chapel Hill
With Support from The Donald W. Reynolds Foundation
©The University of North Carolina at Chapel Hill, Center for Aging and Health.
All Rights Reserved.
Self-Test:
1. Delirium is associated with a _________-fold increase in
mortality in the hospital.
2. _________ is the most common complication of hospital
admission for older people.
3. Patients with delirium have an average increase of
_________ days in the length of hospital stay.
4. If an appropriately trained person uses a brief cognitive
assessment, they can diagnose delirium ________% of
the time.
5. Up to ______% of cases in the hospital are unrecognized.
2
How Did You Do?
1. Delirium is associated with a 10-fold increase in
mortality in the hospital.
2. Delirium is the most common complication of hospital
admission for older people.
3. Patients with delirium have an average increase of 8
days in the length of hospital stay.
4. If an appropriately trained person uses a brief cognitive
assessment, they can diagnose delirium approx 90% of the
time.
5. Up to 70% of hospital cases are unrecognized.
3
Goals
1. Define delirium and describe its cardinal
features and underlying pathophysiology
2. Recognize that delirium is common, underdiagnosed, and associated with significant
morbidity and mortality
3.
•
•
•
•
Regarding delirium, know ways to:
prevent
diagnose
evaluate
manage
4. Feel comfortable with teaching key concepts in
< 1 minute
4
Goals
1. Define delirium and describe its cardinal
features and underlying pathophysiology.
5
Delirium Definition
Medical condition characterized by acute
onset of:
•
•
•
•
•
Fluctuating course
Altered level of awareness
Inattention
Disorganized thinking
Increased or decreased psychomotor
activity
• Disturbance of sleep-wake cycle
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Pathophysiology
Image of black box or another image showing the multiple inputs to the
brain that cause delirium
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Predisposing factors
•
•
•
•
•
•
•
Dementia
Age
Male sex
Frailty
Malnutrition
Depression
Terminal
illness
•
•
•
•
•
Functional impairment
Immobility
Alcohol abuse
Sensory impairment
High medical
comorbidity
• Polypharmacy
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Precipitating factors
• Medications
•
• Neurologic
•
disease
•
• Surgery
•
• Uncontrolled pain
•
• Hypoxia
•
• Metabolic
•
derangements
Severe illness
Low Hct
Bed rest
Indwelling devices
Restraints
Sleep deprivation
Dehydration
9
Tipping the scale...
The greater the predisposing factors, the fewer
precipitating factors required to initiate the
delirium. Delirium is usually
MULTIFACTORIAL.
Picture of scales
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Prediction models:
Example by Inouye et al:
Assign 1 point for each of four risk factors:
1) Vision impairment
2) Severe illness
3) Cognitive impairment
4) BUN:Cr > 18 (signifying dehydration)
Those with 3-4 points have risk of delirium 32-83%.
Other predictive models specific for certain subsets of
geriatric patients (ex. surgical patients).
Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on
admission characteristics. Ann Intern Med 1993: 119 (6); 474-481.
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Goals
2. Recognize that delirium is common, underdiagnosed, and associated with significant morbidity
and mortality
12
How many geriatric patients have
delirium?
At presentation to the ED: 7-33%.
At hospital admission: 14-25%.
Postoperatively: 15-53%.
In the ICU: 70-87%.
In the community, ages 65-85: 1-10%, those
>85: 14% .
At the end of life: Up to 83%.
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Why under-diagnosed???
70% of cases go unrecognized!
#1 cause is neglecting to determine the
acuity of change in mental status and
dismissing presentation as dementia.
We ALL miss more of the hypoactive cases.
Diagnosis is delirium unless otherwise
proven! Don’t be tempted to attribute the
presentation to dementia or depression.
14
Prognosis
May persist weeks, months- 44% at 1 month, 33% at 3
months.
Has a waxing and waning course.
Has been associated with a
•
•
•
•
10-fold increased risk of death in the hospital
3-5 increased risk of nosocomial complications
prolonged length of stay
impaired physical and cognitive recovery at 6 and
12 months
• need for post-acute nursing home placement
Has an associated one-year mortality rate of 35-40%!
15
Goals
3. Regarding delirium, know ways to:
•
•
•
•
prevent
diagnose
evaluate
manage
16
Prevention
Preventing delirium is the most effective
strategy for reducing its frequency and
complications.
At least 30-40% of cases may be
preventable.
How do we prevent delirium???
17
Picture of person sleeping
Picture of hearing aids
Picture of a walker
Picture of a calendar
Picture of eye glasses
Picture of a beside toilet
Picture of a glass of water
Picture of earwax in ear
Picture of a clock
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Prevention: Yale Delirium
Prevention Trial
Demonstrated the effectiveness of intervention protocol that
included:
1.
2.
3.
4.
5.
6.
Orientation and therapeutic activities
Early mobilization
Nonpharmacologic approaches
Adaptive equipment
Early intervention for volume depletion
Sleep-enhancement protocol
Development of delirium reduced from 15% to 9.9%
Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older
patients. NEJM 1999; 340(9): 669-676.
19
Diagnosis
Picture of a patient or someone at the bedside
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Diagnosis
*****CAM: Confusion Assessment Method*****
Based on the 4 cardinal elements of the DSM-3 criteria for
delirium:
1.
2.
3.
4.
Acute onset and fluctuating cource
Inattention
Disorganized thinking
Altered level of consciousness
Must have have 1 and 2 and either 3 or 4
Sensitivity 94%-100%
Positive LR 9.6
Specificity 90-95%
Negative LR 0.16
Inouye SK et al. Clarifying confusion: The confusion assessment method. A new method for
detection of delirium. Ann Intern Med 1990: 113 (13): 941-948.
21
Feature 1. Acute Onset or
Fluctuating Course:
Must have this one!
This feature is usually obtained from a family member or
nurse and is shown by positive responses to the following
questions:
Is there evidence of an acute change in mental status from
the patient’s baseline? Did the (abnormal)
behavior fluctuate during the day, that is, tend to come and
go, or increase and decrease in severity?
22
Feature 2. Inattention:
Must have this one!
This feature is shown by a positive response to the
following question:
Did the patient have difficulty focusing
attention, for example, being easily distractible, or
having difficulty keeping track of what was being
said?
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Feature 3. Disorganized thinking—
May have this OR Feature 4
This feature is shown by a positive response to the
folllowing question:
Was the patient's thinking disorganized or
incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject?
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Feature 4. Altered Level of
Consciousness—May have this
OR Feature 3
This feature is shown by any answer other
than “alert” to the following question:
Overall, how would you rate this patient’s
level of consciousness?
-alert
-vigilant
-lethargic
-stupor
-coma
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Practice
Ms. G is a 73 year-old with mild Alzheimer's dementia. She
is a new admit to rehab after surgery for a hip fracture. On
morning rounds, she continuously sits up, then lies back in
bed, picking at the bed sheets. Her family states that she did
not sleep at all last night. This morning, she complained
about "all the small children on her bed." Her family says she
is not herself. You try to talk to the patient--she startles
easily, then seems distracted and unable to pay attention to
the conversation.
What risk factors does this patient have for
delirium? Is she CAM positive?
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Diagnosis
*****GAR: Global Attentiveness Rating*****
Rate how easily patient can be engaged in a 2-minute
conversation
"How well did the patient keep his mind on interacting with
you during the interview?"
Supported by 1 study with geriatricians
Sensitivity 94%
Positive LR 65
Specificity 99%
Negative LR 0.06
O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997;
45(4): 470-473.
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Diagnosis: Differentiating delirium from
dementia and psychiatric conditions
Talk with family/caregivers to establish baseline
Observe the patient:
An acute change in mental status is NOT dementia
Rapidly fluctuating course is NOT typical for dementia
Abnormal level of consciousness is NOT typical for
dementia
But, the lines are blurry and the diagnosis becomes
more difficult in patients with dementia.
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Evaluation: D.E.L.I.R.I.U.M
Drugs!!
Electrolyte/endocrine disturbances (dehydration, sodium
imbalance, uremia, hypercalcemia, hypoglycemia,
thyrotoxicosis)
Lack of drugs (withdrawal from ETOH, benzos or poor pain
control, B12 deficiency)
Infection (sepsis, meningitis, encephalitis)
Reduced sensory input (can't see or can't hear)
Intracranial (infection, hemorrhage, stroke, tumor)
Urinary, fecal (urinary retention, fecal impaction--can be a
cause!)
Major organ system issues-- infarction, arrhythmia, shock,
COPD, hypoxia, hypercapnia, renal failure, liver failure,
hypertensive encephalopathy
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Evaluation
Picture of pills
Basics:
History
Physical exam
Targeted labs
Careful medication history
Alcohol, illicit drug use
Vital signs
Multiple factors likely involved rather than a single
"cause" but delirium can be the sole manifestation
of serious underlying disease.
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If still looking...
LP
Blood cultures
UA/Urine culture
Urine toxicology
Cardiac enzymes and EKG
Arterial blood gas
Blood alcohol
Head CT
EEG
31
Practice: Our 73-year old
You are concerned that Ms. G has delirium. What do
you do to evaluate her delirium?
32
Additional history
Ms. G does not drink any alcohol. She does have
hearing loss and vision loss and usually wears
hearing aids and glasses. She has not had either
since being in the hospital. She has had trouble
making it to the bathroom to urinate. A couple of
times she has been incontinent. Also per hospital
records, she has not had a bowel movement
since being admitted (5 days ago). She has not
reported any pain over the last 24 hours.
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Physical exam
Vitals
T 98.9
Heart rate 83
BP 110/70
RR 14
Physical exam
CTA bil, nl wob
RRR, no MRGs
No LE swelling
Abd full, decreased bowel sounds, no tenderness to
palpation
Surgical wound appears CDI, no erythema/drainage
Neuro exam unremarkable
CAM +
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Ms. G's medication list
Lisinopril 5 mg q day
Percocet 5/325 mg q 6 hours as needed for pain
Benadryl 25 mg qhs as needed for insomnia
Aricept 10 mg q day
Aspirin 81 mg q day
Calcium + D two tablets twice daily
HCTZ 25 mg q day
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Ms. G's tests
Na 129 (baseline 135)
K 4.9
Cr 1.3 (baseline 1.2)
WBC 10 (baseline 5)
Hgb 10 (baseline 11)
UA 2+ LE, + nitrites, WBC clumps
CXR clear
Postvoid bladder scan <10
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Management of delirium
First, try to remove/treat precipitants of delirium.
Provide frequent orientation and therapeutic activities.
Provide glasses and hearing aids.
Avoid constipation/urinary retention/dehydration/electrolyte
imbalances.
Avoid complete bed rest.
Educate family and nursing support staff of ways to comfort
patient.
Try scheduled tylenol, ice/heat packs, warm milk in place of meds.
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Medications to reduce or eliminate...
Anticholinergics
Diuretics
Antidepressants
Benzos
Opioids
Anticonvulsants
Antiparkinsonian agents
Nonbenzodiazepine
hypnotics
(zolpidem)
Fluroquinolones
(levaquin)
Muscle relaxants
Antiemetics
Steroids
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What is your plan for Ms. G?
39
Your management plan for Ms. G...
1) Stop benadryl!!
2) Have family bring in glasses and hearing aids...
and have patient wear them!!
3) Start patient on an aggressive bowel regimen.
4) Stop her HCTZ and monitor her sodium
closely.
5) Obtain urine culture.
6) Start antibiotic to cover UTI.
7) Stop percocet. Start patient on tylenol 1000
mg TID and oxycodone 2.5 mg-5 mg q 6 prn pain
depending on how concerned you are that she
may have pain.
8) Get patient out of bed to the chair by the
window. Have the family provide frequent
orientation.
9) Try other measures for insomnia.
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About restraints...
We DO NOT recommend restraints as they can cause
bad outcomes (even death!).
Always, evaluate the patient first.
Always, try other interventions first:
--Have family stay with patient
--Use a sitter
--Demonstrate calming the patient to those involved in the
patient care.
If medically necessary to the patient, use restraints for the
least amount of time possible and always inform the family
about why they are needed.
Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4):
405-8.
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Pharmacologic Therapy, ie
chemical restraints
Consider only if safety is in issue or if patient's symptoms are
very distressing to the patient
High-potency antipsychotics (haldol) usually first-line
Use low dose and go slow
ex. 0.25 mg IV haldol or 0.5 mg po haldol
Use for shortest duration possible
Can see akathisia, which can be
mistaken for worsening delirium
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Goals
4. Feel comfortable with teaching key concepts in < 1
minute
43
If you have 30 seconds...Delegate!
Ask the family, RNs, or your trusty medical
students to
1) Turn on the lights or open the blinds during the
daytime
2) Keep the calendar and clock right
3) Re-orient the patient frequently
4) Get the patient out of bed to chair as much as
possible
5) Use eyeglasses, hearing aids
7) Distract, reassure the patient as needed to
avoid restraints
8) Get rid of foley asap
9) Monitor closely for pain (nonverbal clues)
10) Evaluate the patient before ordering restraints
(chemical or physical) and use only as a last resort
11) Monitor closely for constipation
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If you have one minute...
Be a good role model!
*Assess all hospitalized elderly
patient's for delirium on a daily basis
*Use the language (the word "delirium")
*Keep it on everyone's radar
because medical students,
nurses, etc won't think it is a big deal unless you
do
*Minimize use of restraints (including catheters
and chemical restraints)
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If you have 2 to 5 minutes...
1) Have a conversation with the patient
to assess for delirium (GAR)
2) Use CAM to assess for delirium
3) Canned talks, examples:
• Ways to prevent delirium
• Ways to manage delirium
• Definition of delirium
4) Use/review DELIRIUM mneumonic
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Hopefully we met these goals...
1. Define delirium and describe its cardinal features and
underlying pathophysiology
2. Recognize that delirium is common, under-diagnosed,
and associated with significant morbidity and mortality
3. Regarding delirium, know ways to:
•
•
•
•
prevent
diagnose
evaluate
manage
4. Feel comfortable with teaching key concepts in < 5
minutes
47
Take-home points
Delirium is common, under-recognized and serious!!
Cardinal features are acute onset, fluctuating awareness,
impairment of memory and attention, increased or
decreased psychomotor activity, disturbance of sleepwake cycle and disorganized thinking.
Preventing and managing delirium is key to minimizing poor
outcomes for our geriatric patients.
Use CAM to diagnose delirium.
Remember D.E.L.I.R.I.U.M. for differential diagnosis.
Drug treatment should be reserved for patients who pose a
risk to themselves or others or who seem to be very
distressed by their symptoms (ie hallucinations, delusions).
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Works cited
Botts, Angela. Delirium in Hospitalized Older Patients. Clinical Geriatrics 2010: Volume 18 (10): 2833.
Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R.(1990). Clarifying confusion:
the confusion assessment method. Annals of Internal Medicine, 113(12), 941-948..
Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older
patients. NEJM 1999; 340(9): 669-676.
Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission
characteristics. Ann Intern Med 1993: 119 (6); 474-481.
Inouye SK. Delirium in Older Persons. NEJM 2006: 354 (11); 1157-1165.
O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997; 45(4):
470-473.
Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4):
405-8
Wong et al. Does this patient have delirium? Value of bedside instruments. JAMA Aug 18, 2010Vol 304.
49
Questions?
THANK YOU!
Contact information:
Lindsay Wilson
[email protected]
919-966-5945 ext 256
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Acknowledgments and
Disclaimers
This project was supported by funds from The
Donald W. Reynolds Foundation. This information or
content and conclusions are those of the author and
should not be construed as the official position or
policy of, nor should any endorsements be inferred
by The Donald W. Reynolds Foundation.
The UNC Center for Aging and Health and The
Division of Geriatric Medicine also provided support
for this activity. This work was compiled and edited
through the efforts of Carol Julian.
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©The University of North Carolina at Chapel
Hill, Center for Aging and Health. All
Rights Reserved.
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