Delirium: What It Looks Like Why Frail Patients Succumb

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 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 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 Case: History Family History:

Alzheimers 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 Duke GEC 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 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 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) Duke GEC 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 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, LFTs 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 Case: Daughters 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

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 So whats 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 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 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 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 OR=12.52 1-OKeeffe 1997; 2-McCusker 2003; 3Siddiqi 2006; 4-Witlox 2010 Duke GEC

The experience Duke GEC 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 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 FLUCTUATEnot just level of consciousness Clinical presentation can vary within seconds to minutes Inattention aka human hard drive crash Duke GEC 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 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 Duke GEC 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 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 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 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

Kamholz, AAGP 1999 Risk Factors Predisposing factors: Vision impairment 3.5 Severe illness (>APACHE 2) 3.5 Cognitive impairment (MMSE<24) BUN/Cr >18 2.0 Precipitating factors:

Adjusted RR Adjusted RR Physical restraints 4.4 Malnutrition (wt loss, alb) >3 meds added 2.9 Bladder catheter 2.4 Any iatrogenic event 1.9 Duke GEC

2.8 4.0 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 Inouye SK 1998 Oxidative Stress Model: ARDS ANY source of ischemia

Low cardiac output Impaired pulmonary function/oxygenation Low Hgb/Hct Mechanisms: 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 Inflammatory Process Model: Sepsis Peripheral interleukins (IL6,TNF IL1B) induce symptoms of delirium Direct neural pathways (primary autonomic afferents) Transport across BBB Circumventricular region/BBB non-continuous TNF can persist for months in CNS Gradient from dementia to delirium of TNF(amount, rate of cognitive decline) Duke GEC Neurotransmitter Dysfunction Dopamine Hypoxiamitochondrial dysfunctioncellular

instabilityCa++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 Summary: Feet of Sand Delirium in frail patients often associated with disturbances of most basic substrates and cellular functions:

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 Multicomponent Intervention to Prevent Delirium 852 patients over 70 on Gen Med IM risk (1-2 RFs) or High risk (3-4 RFs)

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 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 Intervention Delirium incidence 15.0% 9.9% Days of delirium 161

105 * p< 0.02 for both outcomes Duke GEC 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 Inouye 1999; Rizzo 2001; Bogardus 2003 Reducing Delirium After Hip Fracture Geriatrics Consultation CNS oxygen delivery Fluid and electrolytes Treatment of pain Unnecessary medications Bowel/bladder Early mobilization Duke GEC Prevention, early detection and treatment of complications Nutrition Environmental stimuli Agitated delirium Marcantonio 2001. Results Control (n=64) Intervention (n=62) RR

Any delirium 50% 32% 0.64 (0.37-0.98) Severe delirium 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 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

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 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:

Physiologic Environmental Pharmacologic Psychosocial Enlist a team Duke GEC Sendelbach and Guthrie, 2009. 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, Benzos Monitor for S.E.s of pain meds Low dose neuroleptic Benzos for withdrawal Duke GEC Physiologic 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 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 nightavoid 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 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 A better way. PAs Social work Psychosocial Medicine Physiologic Nursing Patients and Caregivers

Environmental Pharmacologic Pharmacy Nutrition Administrators Duke GEC 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 Delirium: Nursing Strategies Duke NICHE Geriatric Resource Nurse Initiative Kristin Nomides RN Grace Kwon RN Samantha Badgley RN Duke Hospital 2100 Duke GEC 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) Duke GEC

Lundrtrom, et al. 2007 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

? 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

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