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Delirium: The Confusion Conundrum
February 4, 2011Mitchell T. Heflin, MDBarbara Kamholz MDJuliessa Pavon, MD
Yvette West, RN, MSN, CNS
Duke GEC
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Case PresentationMr. A
– 82 year old white male post-op day #18 from AAA repair
– Consult for agitation and altered mental statusHPI:
– Pulsatile mass found by PCP on routine exam– Confirmed as 8.2 cm infrarenal AAA on CT– Referred for elective surgical repair
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Case: History• Past Medical History:
– Hypertension– Hyperlipidemia– Smoked 1ppd until quit 1995– s/p finger amputation on left hand from work accident
• Home Medications:– Simvastatin 40 mg daily– Bisoprolol 5 mg bid– ASA 81 mg daily
• ROS: – Denied abd pain, back pain, chest pain, sob, claudication
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Case: History
• Family History:– Alzheimer’s disease in both parents
• Social History:– Lives at home alone, widower for 5 years– Independent in ADLs and IADLs– Physically active, playing golf daily– Son and daughter do not live locally
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Case: Hospital Course• Elective AAA repair on 12/15/10
• POD #0 returned to OR for bleeding from aneurysm
• Following surgery:– Mental status did not return to baseline despite weaning off
sedation– Failed trial of extubation due to AMS
• POD #3: atrial fibrillation and tachycardia– Amiodarone started
• POD #7: Trach and PEG
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Case: Hospital Course• POD #7-14: Restless and agitated
– Pulling at trach and PEG– Attempts to treat with haldol, risperidone and ativan
• POD # 16: Adynamic ileus and aspiration– Vancomycin and ciprofloxacin
• POD # 18: Geriatrics consulted– Assist with management of agitation and altered mental
status
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Case: Medications• Aspirin• Amiodarone• Metoprolol• Vancomycin• Ciprofloxacin• Ativan 1 mg IV q6hrs• Risperidone 0.5 mg VT qhs• Haldol 0.5 – 1.5 mg IV PRN (5 mg in last 24 hrs)• Dilaudid 0.5 mg IV q6hrs PRN (0 mg in last 24 hrs)
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Case: ExamT 36.4 HR 100s BP 90s/60s
Pulse ox 97% on 40 % FiO2
• Gen: – Somnolent but easily
arousable and anxious– Grimacing and
tachypneic– Trach in place on
ventilation
• Ext: Restraints on hands, edema in LE
• Neuro: – Opens eyes to loud voice and
tracks but does not follow simple commands
– moves all extremities– no Babinski or clonus
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Case: Diagnostic Testing
• Head CT: No focal lesions• CXR: Small bilateral effusions• KUB: Mildly distended loops of small bowel• WBC 12K, Hct 28%• Creatinine 1.0, Albumin 2.3, LFT’s and TSH normal• UA: + hematuria• EKG: Afib 100, Cardiac enzymes: normal
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Case: Daughter’s input
• Very physically and socially active• Had problems with forgetfulness, repeating and
perseverations in the prior year• Very hard of hearing and wears glasses for distance
vision• Drank at least two-three glasses of wine each week
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Delirium: Definitions
• Acute disorder of attention and global cognitive function
• DSM IV:– Acute and fluctuating– Change in consciousness and cognition– Evidence of causation
• Synonyms: organic brain syndrome, acute confusional state
• Not dementia
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So what’s the conundrum?
• Highly prevalent• Associated with much suffering and poor
outcomes• Complex and often multifactorial• Preventable but….
Better care requires a shift in paradigm
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Objectives• Describe the prevalence of delirium and its impact
on the health of older patients
• Identify pathophysiology, risk factors and key presenting features
• Describe strategies for prevention and management
• Find opportunities to improve current practice
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A BIG Problem
• Hospitalized Patients over 65: – 10-40% Prevalence– 25-60% Incidence
• ICU: 70-87%• ER: 10-30%• Post-operative: 15-53%• Post-acute care: 60%• End-of-life: 83%
Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009.
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Costs of Delirium• In-hospital complications1,3
– UTI, falls, incontinence, LOS– Death
• Persistent delirium– Discharge and 6 mos.2 1/3• Long term mortality (22.7mo)4 HR=1.95• Institutionalization (14.6 mo)4 OR=2.41
– Long term loss of function• Incident dementia (4.1 yrs)4
OR=12.52• Excess of $2500 per hospitalization
1-O’Keeffe 1997; 2-McCusker 2003; 3-Siddiqi 2006; 4-Witlox 2010
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The experience…
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Grade for Recognition: D-
• 33-95% of in hospital cases are missed or misdiagnosed as depression, psychosis or dementia
• ER: 15-40% discharge rate of delirious patients
– 90% of delirium missed in ED is then also missed in hospital!
Inouye 1998 ;Bair 1998.
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Clinical Features of Delirium
• Acute or subacute onset• Fluctuating intensity of symptoms • Inattention – aka “human hard drive crash”• Disorganized thinking• Altered level of consciousness
– Hypoactive v. Hyperactive• Sleep disturbance• Emotional and behavioral problems
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In-attention• Cognitive state DOES NOT meet
environmental demands• Result= global disconnect
– Inability to fix, focus, or sustain attention to most salient concern
• Hypoattentiveness or hyperattentiveness• Bedside tests
– Days of week backward– Immediate recall
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This Can Look Very Much Like…
….depression• 60% dysphoric• 52% thoughts of death or suicide• 68% feel “worthless” • Up to 42% of cases referred for psychiatry consult
services for depression are delirious
Farrell 1995
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Improving The Odds of Recognition
• Clinical examination– CAM
• Team observations– Nursing notes
• Prediction by risk– Predisposing and precipitating factors
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Confusion Assessment Method (CAM)
1. Acute onset and fluctuating course2. Inattention3. Disorganized thinking4. Altered level of consciousness
Or
Inouye 1994
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CAM
• Geropsychiatry assessment standard• Recent systematic review2
– Sensitivity 86% (74-93)– Specificity 93% (87-96)– LR + 9.4 (5.8-16) – LR – 0.16 (0.09-0.29)
• Other tools: – CAM-ICU
– Delirium Rating Scale
1 Inouye 1996; 2 Wong 2010.
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Nursing Input• Chart Screening Checklist• Nurses’ commonly charted behavioral signs
(Sensitivity= 93.33%, Specificity =90.82% vs CAM)• Pulling at tubes, verbal abuse, odd behavior,
“confusion”, etc• 97.3% of diagnoses of delirium can be made by
nurses’ notes alone using CSC• 42.1% of diagnoses made by physicians’ notes alone
using CSC
Kamholz, AAGP 1999
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Risk FactorsPredisposing factors: Adjusted RR
– Vision impairment 3.5– Severe illness (>APACHE 2) 3.5– Cognitive impairment (MMSE<24) 2.8– BUN/Cr >18 2.0
Precipitating factors: Adjusted RR– Physical restraints 4.4– Malnutrition (wt loss, alb) 4.0– >3 meds added 2.9– Bladder catheter 2.4– Any iatrogenic event 1.9
Inouye 1996
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Putting it all together...
0 RF 1-2 RF 3-4 RF
0 RF 0 0 0
1-2 RF 0 3.2 13.6
3-4 RF 1.4 4.9 26.3
Precipitating Factors
Pre
disp
osin
g F
acto
rs
Inouye 1996
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Oxidative StressModel: ARDS
• ANY source of ischemia– Low cardiac output– Impaired pulmonary function/oxygenation– Low Hgb/Hct
• Mechanisms: – Ca++ influx, imbalance of neurotransmitters– Neuronal damage, including decreased synaptic
transmission & cell death
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Inflammatory ProcessModel: Sepsis
• Peripheral interleukins (IL6,TNF IL1B) induce symptoms of delirium– Increase permeability of BBB– Alter neurotransmission
• TNF can persist for months in CNS• May share inflammatory mechanisms with dementia
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Pathophysiology of delirium
• Delirium in frail patients often associated with disturbances of most basic substrates and cellular functions:– Impaired oxygenation (blood loss, pulmonary disease)– Metabolic disturbances (Na, Calcium)– Infection/inflammation (UTI, Pneumonia)– Medications
• Primary CNS causes are in the distinct minority
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Multicomponent Intervention to Prevent Delirium
• 852 patients over 70 on Gen Med– IM risk (1-2 RF’s) or High risk (3-4 RF’s)
• Randomized by units with prospective matching• Standardized protocols for 6 risk factors• ID Team: Nurse specialist, PT, RT, MD and volunteers• Outcomes assessed daily by CAM
Inouye 1999.
Elder Life ProgramRisk factor Protocol Outcome
Cognitive impairment
Orientation and therapeutic activities Orientation score
Sleep deprivation
Non-Rx sleep protocolQuiet nights
Use of sleep meds
Immobility Early mobilizationRemoval of tethers
ADL score
Vision problems
Visual aids and adaptive equipment Early vision correction
Hearing loss Wax disimpaction, amplifying devices, other comm. techniques
Whisper test
Dehydration Early recognition and volume repletion BUN/Cr < 18
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Results of Multicomponent Intervention Trial *
Control Intervention
Delirium incidence
15.0% 9.9%
Days of delirium 161 105
Inouye 1999.
* p< 0.02 for both outcomes
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Results• Most effective for IM risk group• No change in severity of delirium• Cost
– $327/pt– $6341/case prevented
• No lasting beneficial effect on functional status or resource utilization
• Benefit replicated
Inouye 1999; Rizzo 2001; Bogardus 2003
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Reducing Delirium After Hip FractureGeriatrics Consultation
• CNS oxygen delivery• Fluid and electrolytes• Treatment of pain• Unnecessary
medications• Bowel/bladder • Early mobilization
• Prevention, early detection and treatment of complications
• Nutrition• Environmental stimuli• Agitated delirium
Marcantonio 2001.
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Results
• No change in length of stay• Most effective in patients without
– Pre-existing dementia– ADL impairment
Control (n=64)
Intervention (n=62)
RR
Any delirium
50% 32% 0.64 (0.37-0.98)
Severe delirium
29% 12% 0.40 (0.18-0.89)
Marcantonio 2001.
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Pharmacotherapy
• Dopamine blockade1
– Haldol (1.5 mg daily) prophylaxis in high risk hip fracture patients
– No change in incidence– Decrease in severity and duration
• Acetylcholinesterase inhibitor2
– Donepezil did not decrease incidence or severity of delirium
1 Kalisvaart 2005, 2 Liptzin 2005.
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Treating pain
• Prospective cohort study >500 hip fracture patients with and without delirium
• Patients receiving <10 mg IV Morphine/day were 5x more likely to become delirious
• Patients reporting severe pain 10x more likely to develop delirium
Morrison 2003.
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Delirium Management: Key Points
• Early recognition of high risk patients and situations is key to effective management
• Prevention is more effective than treatment• Address:
– Physiologic– Environmental– Pharmacologic– Psychosocial
• Enlist a team
Sendelbach and Guthrie, 2009.
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PsychosocialAssess substance useAddress stress and distressEducate patient and familyAssess decision makingConsider function and safety
PharmaceuticalReduce/avoid certain meds- Benadryl, Benzo’sMonitor for S.E.’s of pain medsLow dose neuroleptic Benzo’s for withdrawal
PhysiologicO2 and BPFood and fluidsSleep/wake cycleActivity and mobilityBowel and bladderPainInfections
EnvironmentalReorientationContinuity in careFamily or sittersHearing aids, glassesQUIET at nightNo restraints
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PsychosocialWatch for w/d symptoms off AtivanEducate patient and familyProvide reassurance and means
of communication
PharmaceuticalTaper AtivanMonitor for S.E.’s of OxycodoneRisperidone 0.5 mg bid
PhysiologicControl HR, BP improvedTreat aspirationBowel regimenSchedule oxycodone and acetaminophenIncrease trach sizeAdvance tube feeds
EnvironmentalLight, activity, orientation during dayQUIET at night—avoid VS, meds, etc.Remove restraintsGlasses on, loud voice and lip reading
What about Mr. A?
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Geriatrics
• Inpatient consult service• Assistance with older adults with:
– Delirium and other cognitive disorders– Multiple, complex medical problems– Medications, medications, medications– Goals of care
• Pager 970-0370
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Old way….
D = DehydrationE = Electrolytes (including glucose, Ca)L= Low oxygenI = InfectionR = Retention of urine/stoolI = In painU = Under-diagnosed withdrawalM = Medications
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A better way….
PsychosocialPsychosocial
PharmacologicPharmacologic
PhysiologicPhysiologic
EnvironmentalEnvironmental
Medicine
Nursing
PT/OT
Pharmacy
Social work
Nutrition
PA’s
Patients and
Caregivers
Administrators
NP’s
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• 5 year, $1.2 million project funded by HRSA• Goal: Create Geriatrics Education Hub
- Staffed by interprofessional faculty- Focused on improving the care of older adults with
or at risk for delirium- Learning resources, clinical experiences and
practice improvement projects- Part of six school consortium addressing this issue
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Delirium: Nursing Strategies
Duke NICHEGeriatric Resource Nurse Initiative
Kristin Nomides RNKristin Nomides RN
Grace Kwon RNGrace Kwon RN
Samantha Badgley RN Samantha Badgley RN
Duke Hospital 2100Duke Hospital 2100
Duke GEC
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Supporting Literature: Nursing InterventionsYale Delirium Prevention Program : multi-component interventionsYale Delirium Prevention Program : multi-component interventions
Cognitive impairment with Reality OrientationCognitive impairment with Reality Orientation Sleep enhancement protocolSleep enhancement protocol Sensory impairment with therapeutic activities protocol Sensory impairment with therapeutic activities protocol Sensory deprivation Sensory deprivation DehydrationDehydration
Reduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodesReduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodesInouye, s. 2004Inouye, s. 2004
Delirium education for team (MD and RN)Delirium education for team (MD and RN) Provided post program support and learning reinforcement Provided post program support and learning reinforcement 250 acute admit patients > 70 recruited on 2 units250 acute admit patients > 70 recruited on 2 units
Delirium 12/122 intervention unit vs. 25/128 control unitDelirium 12/122 intervention unit vs. 25/128 control unitTabet N,, et al, 2005Tabet N,, et al, 2005
Post op multi-factorial intervention educational programPost op multi-factorial intervention educational program Teamwork and care planning on prevention and treatment of deliriumTeamwork and care planning on prevention and treatment of delirium Targeted delirium risk factorsTargeted delirium risk factors
Post op delirium compared to controls (56/102 and 73/97) Post op delirium compared to controls (56/102 and 73/97) Lundrtrom, et al. 2007Lundrtrom, et al. 2007
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Nursing Interventions:• Delirium & Risk Factors Staff EducationDelirium & Risk Factors Staff Education• Activity Cart / Busy ApronActivity Cart / Busy Apron
– Stimulate cognitive and motor skillsStimulate cognitive and motor skills• All About Me All About Me PosterPoster
– Orientation InformationOrientation Information• MeMe File File
– Orientation information provided by patient / Orientation information provided by patient / family for high risk patientsfamily for high risk patients
• Question MarkQuestion Mark– Identification of patients with AMSIdentification of patients with AMS ??
AlteredMental Status
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Summary
• RESPECT delirium. Its common and caustic.• PREDICT delirium. Assess for common
predisposing and precipitating factors.• RECOGNIZE delirium. It can be diagnosed with
simple tools (e.g. CAM).• PREVENT delirium. It can be averted with
multicomponent strategies.• RECRUIT team members to improve care.
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GEC crew• Eleanor McConnell, RN, MSN,
PhD• Anthony Galanos, MD• Jason Moss, PharmD• Julie Pruitt, RD• Cornelia Poer, MSW• Gwendolen Buhr, MD• Mamata Yanamadala, MD• S. Nicole Hastings, MD• Jennie De Gagné, PhD, MSN, MS,
RN-BC • Katja Elbert-Avila, MD
• Sandro Pinheiro, PhD• Robert Konrad, PhD• Emily Egerton, PhD• Heidi White, MD• Kathy Shipp, PT, PhD• Deirdre Thornlow, RN, PhD• Lisa Shock, MHS, PA-C• Michelle Mitchell, LMBT• Michele Burgess, MCRP• Joan Pelletier, MPH• Sujaya Devarayasamudram, RN,
MSN• Loretta Matters, RN, MSN