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Delirium: The Confusion Conundrum

Delirium: The Confusion Conundrum. February 4, 2011 Mitchell T. Heflin, MD Barbara Kamholz MD Juliessa Pavon, MD Yvette West, RN, MSN, CNS. Case Presentation. Mr. A 82 year old white male post-op day #18 from AAA repair Consult for agitation and altered mental status HPI:

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Delirium: The Confusion Conundrum

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  1. Delirium:The Confusion Conundrum February 4, 2011 Mitchell T. Heflin, MD Barbara Kamholz MD Juliessa Pavon, MD Yvette West, RN, MSN, CNS

  2. 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

  3. 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

  4. Case: History • Family History: • Alzheimer’s disease in both parents • Social History: • 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

  5. 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

  6. 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

  7. Case: Medications • 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)

  8. 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 • Trach in place on ventilation • 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

  9. Case: Diagnostic Testing 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. A BIG Problem Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009. • 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%

  15. 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 OR=12.52 Excess of $2500 per hospitalization 1-O’Keeffe 1997; 2-McCusker 2003; 3-Siddiqi 2006; 4-Witlox 2010

  16. The experience…

  17. Grade for Recognition: D- Inouye 1998 ;Bair 1998. • 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!

  18. Clinical Features of Delirium • 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

  19. 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

  20. This Can Look Very Much Like… • ….depression • 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 • Farrell 1995

  21. Improving The Odds of Recognition • Clinical examination • CAM • Team observations • Nursing notes • Prediction by risk • Predisposing and precipitating factors

  22. Confusion Assessment Method (CAM) • Acute onset and fluctuating course • Inattention • Disorganized thinking • Altered level of consciousness Or Inouye 1994

  23. CAM • Geropsychiatry assessment 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) • Other tools: • CAM-ICU • Delirium Rating Scale 1 Inouye 1996; 2 Wong 2010.

  24. Nursing Input Kamholz, AAGP 1999 • 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

  25. Risk Factors Predisposing factors: Adjusted RR • Vision impairment 3.5 • Severe illness (>APACHE 2) 3.5 • Cognitive impairment (MMSE<24) 2.8 • BUN/Cr >18 2.0 Precipitating factors: Adjusted RR • Physical restraints 4.4 • Malnutrition (wt loss, alb) 4.0 • >3 meds added 2.9 • Bladder catheter 2.4 • Any iatrogenic event 1.9 Inouye 1996

  26. Putting it all together... Precipitating Factors Predisposing Factors Inouye 1996

  27. Oxidative StressModel: 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

  28. Inflammatory ProcessModel: 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

  29. Pathophysiology of delirium • Delirium in frail patients often associated with disturbances of most basic substrates and cellular functions: • Impaired oxygenation (blood loss, pulmonary disease) • Metabolic disturbances (Na, Calcium) • Infection/inflammation (UTI, Pneumonia) • Medications • Primary CNS causes are in the distinct minority

  30. 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) • 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 Inouye 1999.

  31. Elder Life Program

  32. Results of Multicomponent Intervention Trial * * p< 0.02 for both outcomes Inouye 1999.

  33. 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 Inouye 1999; Rizzo 2001; Bogardus 2003

  34. CNS oxygen delivery Fluid and electrolytes Treatment of pain Unnecessary medications Bowel/bladder Early mobilization Prevention, early detection and treatment of complications Nutrition Environmental stimuli Agitated delirium Reducing Delirium After Hip FractureGeriatrics Consultation Marcantonio 2001.

  35. Results • No change in length of stay • Most effective in patients without • Pre-existing dementia • ADL impairment Marcantonio 2001.

  36. 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 1 Kalisvaart 2005, 2 Liptzin 2005.

  37. 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 Morrison 2003.

  38. Delirium Management: Key Points • Early recognition of high risk patients and situations is key to effective management • Prevention is more effective than treatment • Address: • Physiologic • Environmental • Pharmacologic • Psychosocial • Enlist a team Sendelbach and Guthrie, 2009.

  39. Psychosocial Assess substance use Address stress and distress Educate patient and family Assess decision making Consider function and safety • Physiologic • O2 and BP • Food and fluids • Sleep/wake cycle • Activity and mobility • Bowel and bladder • Pain • Infections Pharmaceutical Reduce/avoid certain meds - Benadryl, Benzo’s Monitor for S.E.’s of pain meds Low dose neuroleptic Benzo’s for withdrawal • Environmental • Reorientation • Continuity in care • Family or sitters • Hearing aids, glasses • QUIET at night • No restraints

  40. 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 • Environmental • Light, activity, orientation during day • QUIET at night—avoid VS, meds, etc. • Remove restraints • Glasses on, loud voice and lip reading

  41. 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

  42. 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

  43. A better way…. NP’s Physiologic PA’s Psychosocial Medicine Nursing Environmental Social work Pharmacologic Patients and Caregivers Pharmacy Nutrition Administrators PT/OT

  44. 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

  45. Delirium: Nursing StrategiesDuke NICHEGeriatric Resource Nurse Initiative Kristin Nomides RN Grace Kwon RN Samantha Badgley RN Duke Hospital 2100

  46. Supporting Literature: Nursing Interventions 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, 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 • 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

  47. Nursing Interventions: ? Altered Mental Status • 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

  48. 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.

  49. 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 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 GEC crew

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