june 18, 2013

Brain Failure: Prevention, Assessment, and Management of Delirium in Older Hospitalized Individuals

Matthew J. Beelen, MDGeriatric SpecialistsLancaster General Health

June 18, 2013

Case 79 year old man, baseline mild cognitive

impairment (MCI) CABG in July 2012 Post-operative delirium

“mild bouts of confusion” post op “confusion, delusions, and hallucinations” “impulsive”

To rehab facility Confusion gradually improved

Case, continued Returned home – since then:

No longer able to manage finances No longer able to manage medications Confusing dates and appointments Failed driving test (wife does not drive) Unable to continue working part time Depressed Wife distressed about his decline, his

repeating, his depression

Almost 1/3 of hospitalized elderly will develop delirium

Learner Objectives Articulate the significance of delirium Recognize and identify delirium

promptly as it occurs Describe approaches to delirium

prevention and incorporate these into Compare approaches to delirium

management and incorporate these into practice.

What is Delirium? A disturbance in consciousness that:

Has acute onset (hours to days) and fluctuates over the course of the day

Involves reduced ability to focus, sustain, or shift attention

Involves a change in cognition (memory, orientation, language, etc) or perception (hallucinations)

Is associated with an underlying medical etiology

APA; DSM-IV, 1994

Inflammatory Model of Delirium

Marcantonio ER, JAMA . 2012;308:73-81.

Delirium Subtypes Hyperactive

Agitation Increased

vigilance Hallucinations

Hypoactive Somnolent,

lethargic, stupor, coma, decreased psychomotor activity

Often unrecognized 75% of cases in

the elderly Associated with

higher mortality

Delirium or Dementia?Delirium Dementia

Time Pattern Acute changes and fluctuation during the day

Chronic and gradual, possible changes in response to environment, fatigue (“sundowning”)

Level of Consciousness

Often altered Alert

Attention Impaired Usually intact unless severe dementia

Speech Incoherent, disorganized

Ordered, anomic/aphasic

Dementia and delirium often coexist What is the patient’s baseline?

Identification: Confusion Assessment Method

Feature 1: Acute change andfluctuating course of mental

statusAnd

Feature 2: Inattention

And

Feature 3: Altered level of consciousness

Feature 4: Disorganized thinking

Or

Inouye, et. al. Ann Intern Med 1990; 113:941-948.1

Confusion Assessment Method (CAM) 86-94% sensitive, 89-93% specific Validated in over 1000 patients Used in over 250 original published

studies 28 page training manual…

Improved accuracy with formal training Improved accuracy when using a standard

cognitive screen as part of the CAM (Modified Mini-Cog)

Takes about 5 minutes to performhttp://hospitalelderlifeprogram.org

Modified Mini-Cog Assessment Orientation

1. Time: Day, Year, day/night, last meal, how long in hospital.

2. Place: City/State, Hospital, Floor Registration

3. Name 3 objects: (apple, watch, penny) Ask the patient all 3 after you have said them. Repeat until

all 3 are learned Clock-drawing

4. Draw a circle, draw numbers, and place hands at “ten past eleven”

Recall 5. Ask for 3 objects in question 3

http://hospitalelderlifeprogram.org

Identification in the ICU: CAM-ICU Assesses same domains as CAM

Different questions/methods of assessment used

Ideal for non-verbal patients

Incorporates the Richmond Agitation and Sedation Scale (RASS) To decide if patient can be assessed for

delirium To assess level of consciousness

www.icudelirium.org; Ely EW et al, JAMA. 2001;286:2703-2710.

CAM-ICU: RASS

www.icudelirium.org

Identification Using CAM-ICU 93-100% sensitive, 89-100% specific Validated for ventilated and non-

ventilated critically ill patients 28 page training manual… Takes about 5 minutes to perform Recommended to be done every shift

Evidence of benefit?

www.icudelirium.org; Ely EW et al, JAMA. 2001;286:2703-2710.

The Role of CAM and CAM-ICU Evidence of

benefit of screening is lacking

“We cannot manage delirium or decrease its complications unless we recognize it”

Useful as a means to monitor for delirium as part of QI process

Delirium is Common

ED

Admission

Gen M

ed

Post O

pICU

DC to EC

F0%

10%20%30%40%50%60%70%80%90%

100%

MaximumMinimum

Prevalence of Delirium at Various Points of Hospitalization

Delirium Has Significant Impacts For patients while in the hospital

For patients after they leave the hospital

For society Population management

Impact in the Hospital physical function nutrition post-op

complications (2-5x risk)

self-extubation or removal of lines

death: 22-76% mortality rate (10-fold risk)

pneumonia falls pressure ulcers exposure to

physical and chemical restraints

family distress burden on

nurses and patient care staffInouye SK. N Engl J Med 2006;354:1157-65

Marcantonio ER. JAMA 2012;308:73-81

Impact Post-Hospitalization 3-fold increased risk of institutional

placement at discharge 2-fold risk of 30-day readmission

from ECF Death

3 fold risk of death at 6 months Every day an ICU patient spends in delirium

increases risk of death at 6 months by 10% 1 year mortality rate is 35-40% Risk of higher mortality persists for up to 2

years Ely EW et al. JAMA 2004;291:1753-1762Marcantonio ER et al. J Am Geriatri Soc 2005;53:963-969

Inouye SK. N Engl J Med 2006;354:1157-65Marcantonio ER. JAMA 2012;308:73-81

Impact Post-Hospitalization Worsening cognition in those with pre-

existing cognitive impairment

Patients with Alzheimer’s who develop delirium: Rate of cognitive decline is doubled in

the year after delirium compared to those without delirium More rapid rate of decline persists for 5 years

Gross AL et al. Arch Int Med 2012;172:1324-1331Fong TG et al. Ann Int Med 2012;156:848-856Fong TG et al. Neurology 2009;72:1570-1575

Delirium and Cognitive Decline

Saczynski JS et al. N Engl J Med 2012;367:30-39

Impact Post-hospitalization New cognitive impairment:

Greater then 10-fold increase risk in new development of dementia over the next 4 years

Cognitive reserve theory

Witlox J et al. JAMA 2010;304:443-451.

Cognitive Reserve and Delirium

delirium

Impact on Society Increased length of stay

2-5 days longer than those without delirium Increased ICU and ventilator days

Increased costs of care $60,000 incremental costs over the

following year $6.9 billion annual cost to Medicare to treat

delirium Impact on caregiver burden

Assistance with activities of daily living Emotional impact

Marcantonio ER. JAMA 2012;308:73-81.O’Mahony R et al. Ann Intern Med 2011;154:746-751.

Delirium - Cost to Society

Monthly Health Care Costs After Discharge from Hospital

Leslie DL. Arch Int Med 2008;168:27-32

Approach to Delirium Prevention

Recognize Risk

Reduce Risk

Prevention of Delirium “At least 30-40% of cases may be

preventable. Prevention is the most effective strategy for reducing delirium frequency and complications.” (Inouye, 2006)

“We should not wait for delirium to happen but must work to implement proven interventions that prevent delirium” (Ely, 2012)

“Effective strategies that prevent delirium should be a high priority for health care systems.” (O’Mahony, 2011)

Risk Factors for Delirium

Inouye SK. J Geriatr Psychiatry Neurol 1998;11:118-125.

Predisposing Factors Baseline

cognitive impairment***

Vision Impairment

Hearing Impairment

Older age Low educational

level ADL impairment

From ECF

Depression Alcohol abuse Multiple

significant chronic conditions

High numbers of home medications

Use of opioids or benzodiazepines prior to admission

Predisposing Factors Dehydration

Bun/Cr > 18 Severe Illness

on Admission Sepsis/SIRS/

infection Acute organ

failure Electrolyte/

metabolic Acute cardiac

event Stroke/seizures

Malnutrition Surgical patient

Hip fracture Fracture/trauma Prior stroke Parkinson’s Prior delirium*

Predictive Value of Risk Factors 4 predisposing risk factors (low vision,

cognitive impairment, dehydration, severe illness)Initial Initia

lValidation

Validation

# of RFs

Risk Group

Rate (%)

RR Rate (%) RR

0 Low 9 1.0 3 1.0

1-2 Intermediate

23 2.5 16 4.7

3-4 High 83 9.2 32 9.5“Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.”

Inouye SK. J Geriatr Psychiatry Neurol 1998;11:118-125

Precipitating FactorsDerangements in

Normal Functions: Fluid intake

Bladder emptying Nutrition intake

Bowel movements Oxygen intake

CO2 release Sleep/wake cycle Mobility

New Acute Conditions:

Metabolic Acid/base Electrolyte Glucose

Anemia Infection/fever CNS

event/condition Cardiac

event/condition Hypotension/shock

Precipitating FactorsExtrinsic Factors Procedures /

Surgery Ventilators / ICU Tubes, lines,

catheters, restraints, devices

Environment change

Other Symptoms Pain Emotional

Distress

Medications >3 added the

previous day “polypharmacy” Benzodiazepine

s Anticholinergics ETOH or drug

withdrawal Opioids (+/-)

Prevention Strategies Prevention should focus on those at

intermediate to high risk

Effective prevention must address the complex array of precipitating risk factors Limited evidence of benefit for isolated

interventions

Prevention requires cooperative interdisciplinary effort

Multi-Component Interventions Methods and specific interventions vary

widely

Reston JT and Schoelles KM. Ann Intern Med. 2013;158:375-380.

Hospital Elder Life Program (HELP) Age ≥ 70 on a general medicine unit, ≥1

risk factor (impaired cognition, elevated BUN/Cr ratio, vision impairment, severe illness) = medium to high risk

Additional risks assessed in the first 48 hours: Sleep deprivation: interview and nurse

input Immobility: ADL assessment scale Hearing impairment: Whisper test

Initial and daily assessment for delirium: CAM

Inouye SK et al. N Engl J Med 1999;340:669-676

The HELP Team Elder Life Nurse Specialist – Masters

level with geriatric training and experience

Elder Life Specialist/Volunteer Coordinator Performs screening, develops care plans,

oversees and coordinates volunteers, training, data collection

Masters level with experience with human services or healthcare, geriatrics, supervisory experience

Geriatrician Program Director (may be one of the

above) Volunteers (3-4 hours, 1-2 times per

week)

Inouye SK et al. N Engl J Med 1999;340:669-676

HELP - Intervention What did the HELP Team do?

Performed initial and ongoing assessments Administered a set of care protocols for at-

risk patients Targeted 6 risk factors for delirium

Provided ongoing staff education Led interdisciplinary meetings and rounds Led ongoing CQI process

HELP Interventions for 6 Risk Factors

Targeted Risk Factor Standardized Intervention

Cognitive impairmentOrientation & therapeutic activity protocol(discuss current events, word games, reorient, etc)

Sleep deprivationSleep enhancement & nonpharm sleep protocol(noise reduction, back massages, schedule adjustment)

ImmobilityEarly mobilization protocol(active ROM, reduce restraint use, ambulation, remove catheters)

Visual impairment*Vision protocol(glasses, adaptive equipment, reinforce use)

Hearing impairment*Hearing protocol(amplification devices, hearing aids, earwax disimpaction)

Dehydration*Dehydration protocol(early recognition of dehydration & volume repletion)

HELP Outcomes – Original Study

852 patients Delirium

incidence 9.9%

intervention 15% controls

Decrease in total number of days of deliriumInouye SK et al. N Engl J Med 1999;340:669-676

Subsequent HELP Outcomes Disseminated to sites worldwide Less functional and cognitive decline,

falls, and pressure ulcers during hospitalization

Little impact on delirium severity once it occurred*

Cost effectiveness has been demonstrated

Cost savings to hospitals has been demonstrated

Improves geriatric education within the hospital

Volunteer use benefits the community Implementation support is available

Inouye SK et al. J Am Geriatr Soc 2000;48Rubin FH et al. J Am Geriatr Soc 2011;59:359-365.

General Prevention Recommendations

Early risk assessment and develop plan to address risk factors

Plan carried out by competent inter-disciplinary team

Minimize staff and location changes

Orienting interventions

Familiar visitors

Treat pain Minimize infection

risk Optimize:

hydration and nutrition

bowel/bladder function

oxygenation activity and

mobility medications sensory input sleep

O’Mahony R et al. Ann Intern Med 2011;154:746-751.

Prevention - Interdisciplinary Team

Balas MC et al. Crit Care Nurse 2012;32:35-47

Patient

Nurses

Physicians

Respiratory

Therapist

Physical Therapist

Pharmacist

The Health System

Barriers to Optimal Prevention Culture change is needed – proactive vs.

reactive System change is required

To ensure interdisciplinary team coordination QI processes related to key components of

prevention Initial assessment Development of management plan Completion of individual components of plan Monitoring for delirium for early detection and for

monitoring effectiveness of program Institutional support (“buy-in” and

resources)

Treatment of Delirium

Management of Delirium There is little rigorous evidence of

benefit Non-pharmacologic measures show a

trend toward: Shorter duration of delirium Decreased severity Shortened hospital LOS

Medications: as of 2011 there was only one randomized placebo-controlled trial – it showed no difference in outcomes

So what can we do?Flaherty JH. Med Clin N Am 2011;95:555-577.

Management – Team Approach Communicate the diagnosis

To team members To family In the medical record: “encephalopathy” - $

$ irony Multi-factorial assessment of

precipitating factors Management plan to address these

factors Sound familiar?

Brain Failure: serious problem, possible emergency Immediate attention is crucial

Review Precipitating FactorsDerangements in

Normal Functions: Fluid intake

Bladder emptying Nutrition intake

Bowel movements Oxygen intake

CO2 release Sleep/wake cycle Mobility

Acute Illnesses: Metabolic

Acid/base Electrolyte Glucose

Anemia Infection/fever CNS

event/condition Cardiac

event/condition Hypotension/shock

Review Precipitating FactorsExtrinsic Factors Procedures /

Surgery Ventilators Tubes, lines,

catheters, restraints, devices

Environment change

Other Symptoms Pain Emotional

Distress

Medications >3 added the

previous day “polypharmacy” Benzodiazepine

s Anticholinergics ETOH or drug

withdrawal Opioids (+/-)

Management – Focus on Safety Environment

Optimize orientation, comfort, sleep/wake cycle

1:1 supervision or “sitter” Family or friend presence Is a room or unit change indicated? “Don’t neglect the hypoactive”

For severe distress or risk of harm to self or others Consider medication Consider restraints – the least necessary

Treatment With Medications Limited, small studies

Only 1 with a blinded placebo comparison group

Underlying dementia either not mentioned or was used as exclusion criteria in most studies

Delirium subtypes were not accounted for No clear evidence that medications

decrease severity or shorten duration No clear evidence that newer

antipsychotics are more favorable than haloperidol

People with delirium get better without medications…

Seitz DP et al. J Clin Psychiatry 2007;68:11-21.Campbell N et al. J Gen Intern Med 2009;24:848-853.

Flaherty JH et al. J Am Geriatr Soc 2011;59:S269-S276.

Treatment with Medications No FDA approved medications for

delirium Haloperidol

0.25-0.5mg PO Q4 hours PRN 0.5-1.0mg IM q30-60min IV doses have much shorter duration of

action: q60min Atypical antipsychotics – oral

Risperidone 0.25mg-0.5mg Q12-24 hours Olanzapine 2.5-5.0mg Q12-24 hours Quetiapine 12.5-25mg Q12-24 hours

Treatment With Medications Antipsychotics

Can prolong the QT interval (get baseline EKG)

Can cause parkinson-like symptoms at high doses

Can cause worsening or irreversible decline in Parkinson’s or Lewy Body dementia Quetiapine is thought to be best choice for

these conditions If used – start with low end of dose range

Benzodiazapines 2nd line or last resort (unless alcohol

withdrawal) Can induce, worsen, or prolong delirium

Final Case Nov. 2012: 87-year-old woman admitted to

hospital from nursing home with mental status change, tachycardia, tachypnea, fever. Baseline MCI.

3 day hospital stay E coli UTI New onset Atrial fibrillation, fluid overload /

CHF NSTEMI Confused, lethargic, “encephalopathy”

Discharged to nursing home “comfort care, hospice consult, NPO”

Now – back to baseline!

Summary Delirium has significant impacts,

especially after discharge Watch for the hypoactive subtype We may be able to prevent 1/3 of cases Prevention is the best treatment Effective prevention and treatment

requires a careful assessment for risk factors and a plan to minimize them – culture and system change

Medications: limited role

Questions?