Concept Mapping

Caroline Harada, MD

Concept Map

• A concept map is a diagram showing the relationships among concepts. It is a graphical tool for organizing and representing knowledge.

• We plan to use them here to:– Provide an initial conceptual frame for

subsequent information and learning– Increase meaningful learning– Enhancing metacognition (thinking about what

you know and what you need to learn) Wikipedia, “Concept map” Accessed Sept 4, 2009

Becomes a geriatrician

Example of a Concept MapApplies to geriatrics fellowship

Accepted to geriatrics fellowship

Spends a year learning geriatrics

Example Concept Map

Tired person Skips exercise

Eats muffins

Drinks lots of coffee

Gains weight

Doesn’t sleep well at night

Patient: Mrs. T• 75 year old woman with a history of hemorrhoids and

depression admitted for blood in stools on Monday evening

• She is very weak and there is concern she will fall, so she is put on bedrest and a foley is placed

• She is made NPO, IVF are started, she gets prepped for colonoscopy by drinking a gallon of GoLytely

• She has a colonoscopy on Tuesday afternoon• Tuesday evening she becomes very agitated, she

starts fighting caregivers, pulling out her IV and foley• She is placed in restraints• She is now extremely confused. How did this happen?

Is this confusion delirium?

Delirium & the Hospitalized Older Patient

Learning Objectives

• Recognize delirium in hospitalized older adults

• Describe hospitalized older adults who are at risk for delirium

• Identify common causes of delirium in the hospitalized older adult

• Develop strategies to prevent or manage delirium

What is Delirium?

What is Delirium?

• Acute confusional state• Acute decline in attention and cognition• Usually there is evidence of an underlying

physiologic or medical condition

Inouye SK, NEJM 2006

A. Disturbance in level of awareness and reduced attention

B. A change in cognitionC. There is evidence from the history, physical

examination, or laboratory findings that the disturbance is caused by the direct physiologic consequences of a general medical condition

D. The disturbance develops over a short period of time (usually hours to a few days) and tends to fluctuate in severity

DSM V criteria

http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=32

Common Symptoms

• Thinking is slow and muddled but content can be complex

• Hallucinations/delusions (30%)• Sleep wake reversal• Labile affect• Psychomotor disturbances: 2 characteristic

forms– Hyperactive- agitation, picking behaviors– Hypoactive- lethargy

Inouye SK. NEJM 2006

Confusion Assessment Method (CAM)

Does your patient have: 1. Acute change in mental status with fluctuating

course2. Inattention

PLUS, either3. Disorganized thinking4. Altered level of consciousness

Inouye SK et al. Ann Int Med 1990

Do you hear the term “DELIRIUM” used often?

• Delirium is often called something else:– Altered mental status– Dementia– Confusion– Agitation– Sundowning– Loopy

Delirium recognition is particularly poor in patients

with dementia• If person has dementia it is assumed they are

“at baseline”• Delirium gets confused with dementia

– Dementia patients are at HIGH risk for delirium when in the hospital

– Anyone can get delirious (even if they don’t have dementia)

Fick, DM et al JAGS 2002

Delirium OR Dementia?• Confused, inattentive• New, acute onset

• Fluctuating course• Reversible• Caused by MANY triggers

• Altered level of consciousness (sleepy, hyperalert)

• Sometimes preventable

• Confused but attentive• No different from baseline

• Minimal fluctuations• Irreversible• Caused by one disease

• Normal level of consciousness (alert)

• Not preventable

Epidemiology

How common is it?

• One fifth of hospitalized patients over 65• One third of hospitalized patients over 70 • One third of older ER patients• 70-87% of older ICU patients

Geriatrics Review Syllabus 6th Ed; Inouye SK. NEJM 2006

Impact of Delirium

Cost

• Adds $2,500 to the hospital cost per patient

• $6.9 billion of Medicare expenditures due to delirium

Inouye SK. NEJM 2006

Patient Outcomes

• Patients with it die often and quickly– Mortality for hospitalized patients with delirium

is 22-76% (similar to AMI or sepsis)– One year mortality 35-40%

• Deconditioning• Longer hospital stays• 3-5 times risk for nosocomial complications• Increased risk of nursing home placement

after dischargeInouye SK. NEJM 2006; Geriatrics Review Syllabus 6th Ed

What causes delirium?

Vulnerable patient: a house of cards

• Old age• Male• Dementia• Functional dependence• Visual/Hearing

impairment• Dehydration• Multiple drugs or

coexisting conditions• Depression, alcoholism Inouye SK. NEJM 2006

A trigger: the fan gets turned on your house of cards…

• Drugs • Neurologic disorders• Illness• Surgery• Environmental triggers

(hospitalization, ICU, restraints, Foley, sleep deprivation)

• Pain, malnutrition/dehydration

• Constipation, urinary retention

Inouye SK. NEJM 2006

What can we do to prevent delirium?

Prevention

Yale Delirium Prevention Trial• Targeted common risk factors:

– Cognitive impairment– Immobilization– Psychoactive drugs– Sleep deprivation– Vision/hearing impairment– Dehydration

Inouye SK, NEJM 1999

Yale Delirium Prevention Trial: Interventions

– Cognitive impairment

– Immobilization

– Psychoactive drugs

Inouye SK, NEJM 1999

Frequent reorientation- white boards, volunteers

Out of bed early- chair is better than bed

Nonpharmacologic approaches to agitation

– Sleep deprivation

– Dehydration

– Vision/hearing impairment

Inouye SK, NEJM 1999

Herbal tea, massage, music

Hearing aids, magnifying glasses

Feeding volunteers, early IV fluids

Yale Delirium Prevention Trial: Interventions

Results

• Delirium developed in: – 9.9% of patients in the intervention group– 15% in the normal care group

• Delirious episodes were shorter in the intervention group

• But… the intervention did not affect severity of delirium or recurrence rates

Inouye SK, NEJM 1999

Case

• Ms. Z is 87 years old with mild stage Alzheimer’s disease

• She is in the hospital after a fall down the stairs with C-2 and humerus fracture

• She is mildly confused, but alert and pleasant. She is able to pay attention to you when you ask her questions, but her answers usually don’t make sense.

Is this delirium or just her underlying dementia?

Delirium OR Dementia?• Confused, inattentive• New, acute onset

• Fluctuating course• Reversible• Caused by MANY triggers

• Altered level of consciousness (sleepy, hyperalert)

• Sometimes preventable

• Confused but attentive• No different from baseline

• Minimal fluctuations• Irreversible• Caused by one disease

• Normal level of consciousness (Alert, awake)

• Not preventable

What do you need to know to help prevent delirium in this patient? • Geriatric assessment is the first step

– Assess hearing, vision, cognition, mobility/fall risk, pressure ulcer risk

• Look for hospital hazards– Foley, restraints, O2, Telemetry

What was done for Ms. Z?

Nursing interventions– Cognitive impairment

– Immobilization

Family encouraged to stay, educated on reorientation

OOB to chair daily, Foley out, O2 off

– Vision/hearing impairment

– Dehydration

– Sleep deprivation

Put on her glasses

D/c low cholesterol diet, RN educated on signs of dehydration

See next slide

Avoiding Sleep Deprivation

• Nursing interventions for daytime– Keep lights on, curtains open

• Nursing interventions for nighttime– Keep lights in hallway low– Keep lights low and TV off in patient rooms– Keep hallway noise down at night

• Stop waking the patient up– Check labs BEFORE bedtime– No vital sign checks between 11pm and 6am– No nebs at night

List 3 things that increase the risk of delirium where you work

THAT COULD REALISTICALLY CHANGE RIGHT NOW

Create an Action Plan

List 3 things you would like to make available to your patients to reduce delirium where

you work

Create a Wish List

Practice Audits

Summary: Delirium Prevention• Frequent reorientation• Out of bed as much as possible• Keep the environment calm and non-stressful• Minimize sensory impairments• Avoid dehydration• Promote nighttime sleep• PAIN control• Avoid irritants- TAKE OUT THE FOLEY, unneeded

IVs, Tele, O2, braces & cervical collars• Avoid constipation, look for urinary retention

The case continues…

• Mrs. Z does NOT develop delirium for the first 5 days of hospitalization.

• On hospital day #5, she develops a small bowel obstruction and requires surgical repair.

• Postoperatively, she is initially very somnolent, but then develops agitation and confusion, (much worse than her baseline).

• What do you think was the trigger for her delirium?

• The doctor orders lorazepam and restraints. • The patient becomes even more agitated, and

she pulls out her Foley catheter.

Why did the delirium get worse?

• Restraints and benzodiazepines tend to cause or worsen delirium and agitation.

• What works better?

Management: What can we do once delirium occurs?

Management: 3 Components

Eliminate Triggers

Avoid Complications

Manage Symptoms

Management

• Look for and eliminate all possible triggers– Infection, Ischemia– Metabolic disturbances– Medications– Restraints

• Avoid complications– Avoid DVT– Protect airway– Avoid pressure ulcers– Avoid dehydration– Avoid falls- low bed?

Eliminate Triggers

Avoid Complications

Management

• Manage symptoms– Nonpharmacologic

• Continue delirium prevention• Use sitters, NOT restraints• Encourage sleep at night• Use music, massage, relaxation techniques for agitation

Inouye SK, NEJM 2006

Manage Symptoms

• Unclear if these modify the natural course of disease

• One placebo controlled RCT in the elderly showed no benefit to quetiapine

• Haloperidol- po if possible• Atypical antipsychotics

– Lowest possible doses, as infrequently as possible (0.5 mg risperidone BID, 2.5mg olanzapine QD, 25mg quetiapine qhs)

• Use standing doses for 2-3 days at most

Pharmacologic Symptom Management

Manage Symptoms

Flaherty JH, et al. JAGS 2011

Mrs. Z• You notice that although the patient just had

surgery, she hasn’t asked for any pain meds. The only pain med ordered is acetaminophen prn.

• Haloperidol prn agitation• You order scheduled acetaminophen, oxycodone

prn• Restraints are removed• Foley is NOT replaced • Mrs. Z becomes calm and comfortable (and

pleasantly forgetful) the rest of her hospitalization.

Back to Concept Maps

Patient: Mrs. T• 75 year old woman with a history of hemorrhoids and

depression admitted for blood in stools on Monday evening

• She is very weak and there is concern she will fall, so she is put on bedrest and a foley is placed

• She is made NPO, IVF are started, she gets prepped for colonoscopy by drinking a gallon of GoLytely

• She has a colonoscopy on Tuesday afternoon• Tuesday evening she becomes very agitated, she

starts fighting caregivers, pulling out her IV and foley• She is placed in restraints• She is now extremely confused

Draw a Concept Map

• How did Mrs. T get so confused?

Blood in stools

Delirium

Summary

• Delirium is an acute state of confusion• Delirium is different from dementia (because it’s

fixable), but dementia is a risk factor for getting delirious

• Delirium can sometimes be prevented• All health care providers can play a role in

protecting patients from getting delirious while in the hospital

Useful References

• Inouye SK. Delirium in Older Persons. NEJM 2006; 354:1157-65

• Inouye SK et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM 1999; 340:669-76

• Flaherty JH et al. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. Journal of the American Geriatrics Society 2011; 59:S269-276