1 / 49

Delirium: The Confusion Conundrum

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

peers
Download Presentation

Delirium: The Confusion Conundrum

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


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

  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 • 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

  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 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

  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: 2+ blood, 1+ LE, 6 WBC, > 50 bacteria EKG: Afib 100, no ischemia or conduction problems 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 glasses of wine each night

  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, J Ger Psy and Neurol., 11(3) 1998 ;Bair, Psy Clin N Amer 21(4)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 • ALL SYMPTOMS FLUCTUATE…not just level of consciousness • Clinical presentation can vary within seconds to minutes • Inattention – aka “human hard drive crash”

  19. 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

  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 Arch Intern Med. 1995 155:22

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

  22. 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) 1 Inouye 1996; 2 Wong 2010.

  23. CAM • Acute onset and fluctuating course • Inattention • Disorganized thinking • Altered level of consciousness Or Inouye 1994

  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 SK 1998

  26. Putting it all together... Precipitating Factors Predisposing Factors Inouye SK 1998

  27. Oxidative StressModel: 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

  28. Inflammatory ProcessModel: Sepsis • Peripheral interleukins (IL6,TNFa, IL1B) induce symptoms of delirium • Direct neural pathways (primary autonomic afferents) • Transport across BBB • Circumventricular region/BBB non-continuous • TNFa can persist for months in CNS • Gradient from dementia to delirium of TNFa (amount, rate of cognitive decline)

  29. Neurotransmitter Dysfunction • Dopamine • Hypoxiamitochondrial dysfunctioncellular instabilityCa++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

  30. 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

  31. 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.

  32. Elder Life Program

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

  34. 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

  35. 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.

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

  37. 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.

  38. 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.

  39. 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.

  40. 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 • AMBULATE!

  41. 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 • Increase trach size • Treat UTI and aspiration • Bowel regimen • Schedule oxycodone and acetaminophen • 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

  42. 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

  43. 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

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

  45. 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

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

  47. 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

  48. 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

  49. 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

More Related