delirium literature update 10/2011 n.j. o’dorisio

Delirium

Literature Update10/2011N.J. O’Dorisio

Clinical case

Mrs. Johnson is 76 yo female with diabetes, heart failure and urosepsis.

Her exam reveals HR 96, BP 100/62, rr 20 and 94% on 2l nc

Labs-include wbc 14000, UA-+LE, + bacteria, +nitrites

You admit her to the step down unit

Clinical case

Hosp day # 2 your partner is called at 0100 to evaluate Mrs. Johnson

She is pulling at her IV, pulls off her telemetry leads and is talking about her deceased husband

You evaluate her that morning and she is oriented to name and answers questions

Is this Delirium?

What do you do?

A. Formal testing?B. Psychiatry consult?C. Family History/input?D. “I know it when I see it”?

Review of Literature

Wong, C.L, Holroyd-Leduc, J. Does this Patient have Delirium. JAMA 2011; 304 (779-786)

O’Mahony, R, Murthy, L, et.al. Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of delirium. Annals of Internal Medicine 2011; 154 (746-752)

Witlox, J, Eurlings, L, et al. Delirium in Elderly Patients and the Risk of Postdischarge Martality, Institutionalization, and Dementia. JAMA 2010. 304; (443-451)

Wald, H, Galsheen, J, et al. Evaluation of a Hospitalist-Run Acute Care for the Elderly Service. Journal of Hospital Medicine 2011. 6; (313-321)

Is this Delirium

Wong, C.L, Holroyd-Leduc, J. Does this Patient have Delirium. JAMA 2011; 304 (779-786)

What is the appropriate test?

Background

Delirium is often mistaken for dementia, mental illness, withdrawl

There is no pathognemonic sign or lab to indicate the onset

Delirium adds to the M/M and cost of a Hospital stay

Clinical scenario

Diagnosed by sudden onset (v. dementia)

Careful observationInattentionAltered consciousnessSleep disturbance

Who to test?

Age greater than 65Oncology/Palliative care unitICUMultiple co-morbiditiesSurgical intervention

How to test?

Multiple different bedside testsMMSEGlobal Attentiveness Rating (GAR)Memorial Delirium Assesment Scale

(MDAS)Clinical assesment of Confusion (CAC)Delirium Observation Screening Scale

(DOSS)Based on DSM-IV criterion

Which is best?

CAM has been widely adoptedtranslated in 10 languagesrequires training and 5 min

GARBased on 2 min of conversationBased on analog scale

CAM

GAR

Clinical scenerio

Mrs. Johnson improvesShe’s on cipro for sens E.coliPT/OT are on boardNo further Hospitlization neededIs widowed, lives alone and dghtr

lives “down the road”What should we do and can we do?

Now what? How do you d/c?

A. D/C to home and ask her to call the PCP?B. Social work consult for placement?C. Arrange home health and nursing?D. Schedule appt for PCP within 1 week?E. Combination of discharge strategies?

What happens?

Witlox, J, Eurlings, L, et al. Delirium in Elderly Patients and the Risk of Postdischarge Martality, Institutionalization, and Dementia. JAMA 2010. 304; (443-451)

Assoc. with prolonged hosp. stayPoor-outcomesIncreased costMortality

Delirium sequelae

Pts. (esp. older) have high rates of post discharge complications

May lead to long term cognitive deficit

Higher rate of institutionalzationHarbinger of dementia?

What to do?

O’Mahony, R, Murthy, L, et.al. Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of delirium. Annals of Internal Medicine 2011; 154 (746-752)

Get ‘em mobile (PT/OT)Treat pain (trade off)Reconcile meds Max. nutrition

What to do?

Coordinated care team-min. hand offsScreen at admissionMax. circadian rhythm/familiarityAssure hydrationFix hypoxiaDon’t forget infection!

Question # 1

What do you do?

A. Formal testing?B. Psychiatry consult?C. Family History/input?D. “I know it when I see it”?

Question # 2

How do you discharge Mrs. Johnson?

A. D/C to home and ask her to call the PCP?

B. Social work consult for placement?C. Arrange home health and nursing?D. Schedule appt for PCP within 1 week?E. Combination of discharge strategies?

Take home points

Delirium is a clinical diagnosisMultifactorial-but predisposing factorsHas patient centered and health

system costsIs important to identify and treatDon’t forget longitudinal care