delirium in the hospitalized patient - weebly
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Delirium in the hospitalized patient
Jennifer A. Tarin, M.D. Department of Hospital Medicine
Geriatric Health Safety Chair Colorado Permanente Medical Group
UCLA Reynolds Scholar
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Delirium Preventing delirium or recognizing it early has the potential to dramatically improve safety, decrease morbidity and mortality for our patients, as well as reduce costs.
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Learning Goals
S Why should you care about Delirium
S Recognizing Delirium
S Four risk factors for Delirium
S What physicians are thinking/doing…
S The Delirium Order set/bundle changes
S What can you do…
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So why should you care if your patient has delirium?
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Prevalence of delirium is 14-24% at time of
admission.
Incidence in hospital (new cases) 6-56%
Inouye, SK NEJM 2006; 354: 1157-1165 Maldonado,
JR Crit Care Clin 2008; 24: 657-722
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Prevalence of delirium in the ICU is 70-87%.
Inouye, SK NEJM 2006; 354: 1157-1165
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Of the 13 million patients 65 and older hospitalized in 2002,
10% to 52% had delirium at some point during their
hospital stay.
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For 80% of patients some symptoms persist at > 6
months.
McCusker. J. J Gen Int Med. 2003; 18:696-704
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One year mortality is 35-40%
Inouye, SK NEJM 2006; 354: 1157-1165
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2 year survival may be as low as 33%
McCusker. J. J Gen Int Med. 2003; 18:696-704
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Adjusted average annual costs were 2.5 times higher
for patients w/ delirium.
Leslie DL, et al. Arch Intern Med 2008; 168:27-32
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Total annual costs attributed to delirium were $16,000-
$64,000 per patient.
Leslie DL, et al. Arch Intern Med 2008; 168:27-32
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We cannot diagnose delirium or manage and decrease its complications if we do not
look for it.
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Nurses play a crucial role in the recognition of
delirium.
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Nurses’ Recognition of Delirium
S Study compared nurses’ recognition of delirium with trained interviewer ratings
S Nurses’ recognized delirium in only 31% of patients (or 40 of the 131 patients with delirium)
Inouye, SK, Arch Intern Med. 2001; 161: 2467-2473
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Nurses’ Recognition of Delirium
S However the specificity of nurses’ rating delirium was high compared with the researchers (95.8%).
S This indicates the nurses did not over identify delirium.
Inouye, SK, Arch Intern Med. 2001; 161: 2467-2473
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Nurses’ Recognition of Delirium
Nearly all disagreements in ratings were due to under-recognition by nurses.
Pts with 3 or 4 risk factors had a 20 fold risk for unrecognized delirium.
Risk factors: S Age over 80 S Hypoactive Delirium S Vision impairment S Dementia
Inouye, SK, Arch Intern Med. 2001; 161: 2467-2473
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Nurses’ Recognition of Delirium
S Nurses’ are at the front line in the process of delirium recognition.
S Education and training are essential for detection of the key features of delirium by nursing staff.
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Who is at risk for developing delirium?
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Patients’ at risk for developing delirium
S Age 65 or older
S Cognitive impairment (past or present) or dementia
S Current hip fracture
S Serious illness
(NICE clinical guideline 103, July 2010)
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Risk factors
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Current screening outside of the ICU.
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The Intensive Care Delirium Screening
Checklist The ICDSC consists of 8 items based off the DSM-IV criteria
for diagnosing delirium.
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8 items RN’s assess for
S Drowsiness or hypervigilance
S Inattention
S Disorientation
S Hallucinations
S Agitation
S Inappropriate speech
S Sleep/wake issues
S Symptom fluctuations
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ICDSC
S The ICDSC has a 99% sensitivity and 84% specificity
S A score of ≥ 4 is suggestive of delirium and needs further physician assessment.
S Score will now show up on as a “vital sign” for providers.
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Diagnosis of Delirium What providers are doing/
thinkingJ
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Confusion Assessment Method (CAM)
S Developed to provide a quick and accurate way for detecting delirium.
S For non-psychiatrist trained clinicians
S Translated into 12 languages and used in over 250 original publications to date
S 95% sensitivity and specificity Inouye, SK, et al Ann Int Med 1990; 113: 941-948
Wong, et al; JAMA 2010; 304: 779-789
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CAM
1) Acute onset and fluctuating course
AND
2) Inattention
And either 3 or 4
3) Disorganized thinking
OR
4) Altered level of consciousness
Inouye, SK, et al Ann Int Med 1990; 113: 941-948
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Mini-cog test
S Orientation: person, place (city/state, hospital), time
S Registration: name three objects, have them repeat until they know all three
S Clock drawing
S Recall: ask for all three words
S Score: 1 pt for each correct word, 2 pts for correct clock
S Score of 0-2 suggests cognitive dysfunction; score of 3-5 suggests no cognitive dysfunction
Borson et al Geriatric Psychiatry 2000; 15: 1021-1027
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Etiologies for delirium:
S infection (PNA, UTI, CNS),
S metabolic (electrolytes, AKI, dehydration)
S neurological (stroke, subdural)
S cardiac (MI, HF)
S pulmonary (PE, hypoxia)
S adequate pain control
S Medication side effect (antihistamines, TCA’s, benzos, opiates),
S bowel or bladder dysfunction (constipation, retention),
S drug withdrawal (alcohol, benzos, opiates)
S sensory deficit (glasses, hearing aids)
(Royal College of Physicians National Guidelines on Delirium 2006; 1-17)
(NICE clinical guideline 103, July 2010)
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Our updated delirium bundle
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Delirium Team
S Our team is very diverse and consists of physicians from various Exempla hospitals, psychiatry, behavioral health, nurses’, residents, clinical pharmacists, physical therapy and IT support.
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AIM statement
S Through the implementation of a comprehensive delirium bundle we hope to decrease the incidence of delirium throughout our hospitals.
S Secondarily we hope to decrease the average length of stay for our geriatric patients, the incidence of falls and the need for institutional care post discharge.
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Delirium Prevention
S All patients at risk for delirium should receive a multi-component intervention to reduce the likelihood of developing delirium.
S This is aided by the use of the delirium order set.
(NICE clinical guideline 103, July 2010; NEJM 1999; 340(9): 669-676)
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Yale Delirium Prevention Study
Modifiable Risk factor Intervention
Cognitive Impairment Reality Orientation
Sleep Deprivation Sleep enhancement protocol*
Immobilization Early mobilization, physical therapy
Vision Impairment Vision aids, adaptive equipment
Hearing Impairment Amplifying devices
Dehydration Early recognition, volume repletion
Inouye, SK NEJM 1999; 340: 669-679; Viden MT, JAGS 2009; 57: 2029-2036
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The multi-component intervention should address:
S cognitive impairment and/or disorientation
S dehydration and/or constipation
S hypoxia and optimize oxygen saturation if necessary
S infectious issues
S immobility and utilize physical therapy as indicated
S sensory impairment
S poor nutrition
S promote good sleep patterns and sleep hygiene.
S review medications that could elicit or exacerbate delirium
NICE clinical guideline 103, July 2010; NEJM 1999; 340(9): 669-676
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Current Delirium Order set
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Delirium Order set
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Delirium order set changes
S All patients at risk for delirium outside of the ICU should be screened by the nurses for delirium in the hospital on admission and at 12-hour intervals using the ICDSC
S The ICDSC screening should occur toward the end of the nursing shift (~6PM and 6AM).
S This will allow the nurses the majority of their shift to evaluate the patient.
Intensive Care Med 2001; 859-864; NICE clinical guideline 103, July 2010)
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Delirium order set changes
S The ICDSC scores will populate the clinical summary and be available to clinicians as another vital sign in the accordion section of eSummit.
S An ICDSC score of 1-3 will prompt the “At risk for delirium” plan for the nursing plan of care.
S An ICDSC score of ≥ 4 will prompt “delirium” to be incorporated as a problem in the nursing plan of care.
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Delirium order set changes
S If a patient has a ICDSC score of ≥ 4, the provider should be notified.
S Patients with suspected delirium should have the dx confirmed by a physician using the Confusion Assessment Method (CAM).
S When available and ordered by the provider, Clinical Pharmacy will perform a one-time screen of medications within 24 hours. This review will be an option providers can choose on the delirium order set.
JAMA 2010; 304 (7): 779-786; NICE clinical guideline 103, July 2010; Annal Intern Med 1990; 113: 941-948)
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So what can you do?
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Call us to discuss
S Think about Delirium
S Try warm milk before po Rx sleep aids.
S Feel free to call us to discuss if concerned about delirium.
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“Restraint rounds”
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Quick review
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Who is at risk for developing delirium?
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Patients at risk for developing delirium
S Age 65 or older
S Cognitive impairment (past or present) or dementia
S Current hip fracture
S Serious illness
(NICE clinical guideline 103, July 2010)
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Summary
S Think about delirium.
S Remember those risk factors.
S Use the screening tool.
S Remember you are a very important member of the team. If concerned please discuss with the provider.
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This man is 100 years old. On October 19th, 2011 Fauja Singh, became the world’s oldest person to complete a marathon, when he crossed the finish line at 8 hours and 25 minutes.
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Delirium Preventing delirium or recognizing it early has the potential to reduce costs, dramatically improve safety as well as decrease morbidity and mortality for our patients.