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Concept Mapping
Caroline Harada, MD
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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
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Becomes a geriatrician
Example of a Concept MapApplies to geriatrics fellowship
Accepted to geriatrics fellowship
Spends a year learning geriatrics
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Example Concept Map
Tired person Skips exercise
Eats muffins
Drinks lots of coffee
Gains weight
Doesn’t sleep well at night
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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?
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Is this confusion delirium?
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Delirium & the Hospitalized Older Patient
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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
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What is Delirium?
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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
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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
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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
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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
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Do you hear the term “DELIRIUM” used often?
• Delirium is often called something else:– Altered mental status– Dementia– Confusion– Agitation– Sundowning– Loopy
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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
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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
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Epidemiology
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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
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Impact of Delirium
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Cost
• Adds $2,500 to the hospital cost per patient
• $6.9 billion of Medicare expenditures due to delirium
Inouye SK. NEJM 2006
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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
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What causes delirium?
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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
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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
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What can we do to prevent delirium?
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Prevention
Yale Delirium Prevention Trial• Targeted common risk factors:
– Cognitive impairment– Immobilization– Psychoactive drugs– Sleep deprivation– Vision/hearing impairment– Dehydration
Inouye SK, NEJM 1999
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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
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– 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
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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
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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?
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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
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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
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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
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– Vision/hearing impairment
– Dehydration
– Sleep deprivation
Put on her glasses
D/c low cholesterol diet, RN educated on signs of dehydration
See next slide
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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
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List 3 things that increase the risk of delirium where you work
THAT COULD REALISTICALLY CHANGE RIGHT NOW
Create an Action Plan
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List 3 things you would like to make available to your patients to reduce delirium where
you work
Create a Wish List
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Practice Audits
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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
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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?
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• The doctor orders lorazepam and restraints. • The patient becomes even more agitated, and
she pulls out her Foley catheter.
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Why did the delirium get worse?
• Restraints and benzodiazepines tend to cause or worsen delirium and agitation.
• What works better?
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Management: What can we do once delirium occurs?
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Management: 3 Components
Eliminate Triggers
Avoid Complications
Manage Symptoms
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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
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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
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• 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
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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.
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Back to Concept Maps
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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
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Draw a Concept Map
• How did Mrs. T get so confused?
Blood in stools
Delirium
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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
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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