duke gec delirium teaching rounds: insult to injury october 7, 2011

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www.interprofessionalgeriatrics.duke.edu

Delirium Teaching Rounds: Insult to Injury

October 7, 2011

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Objectives

• Identify risk factors and key presenting features of delirium

• Appreciate the role of different professions in recognition and management

• Find opportunities to improve communication about delirium

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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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Clinical Features of Delirium

• Acute or subacute onset• Fluctuating intensity of symptoms • Inattention • Disorganized thinking• Altered level of consciousness

– Hypoactive v. Hyperactive• Sleep disturbance• Emotional and behavioral problems

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Insult to Injury

• Mrs. F is a 78 year old resident of Durham admitted after a fall in her home…..

• Gather with others in your profession• Read the case and discuss the questions• Designate a spokesperson• Have fun!

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Improving The Odds of Recognition

• Prediction by risk– Predisposing and precipitating factors

• Team observations– Nursing notes

• Clinical examination– CAM

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Common Risk Factors for DeliriumPredisposing• Advanced age• Preexisting dementia• History of stroke• Parkinson disease• Multiple comorbid conditions• Impaired vision• Impaired hearing• Functional impairment• Male sex• History of alcohol abuse

Precipitating• New acute medical problem• Exacerbation of chronic medical problem• Surgery/anesthesia• New psychoactive medication• Acute stroke• Pain• Environmental change• Urine retention/fecal impaction• Electrolyte disturbances• Dehydration• Sepsis

Marcantonio, 2011.

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Rudolph J et al, 2011

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Team 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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1 month before adm PCP Note Episode of confusion following her knee surgery. She does not feel confused presently.

Presents to ED 20:20 ED Verbally converses and oriented 5

Day Admitted 01:25 Adm Data She can’t tell me how many stairs she fell down. She is a little disoriented…reports ~2 beers per day which puts her at risk for withdrawal...monitor closely for signs/symptoms of withdrawal.

Day Admitted 03:05 PRM 10:40 AM BSN Findings: Independent prior to admission: Newly dependent

Hospital Day 1 03:10 Nursing Patient is very drowsy.

Hospital Day 1 10:14 OT Cognition: Alert, changed to lethargic once medication had taken affect.

Hospital Day 1 11:40 PT Cognition: Impaired…Oriented to self, place, time, situation, with significant prompting.

Hospital Day 1 17:25 Post Anesthesia Reports mild post-operative confusion, but per husband significantly better anesthesia recovery than the previous surgery 1 year prior.

Hospital Day 1 18:55 Nursing Pt a/o x 3, unaware of correct date/time…pulling at soft cast on left hand but reorients well.

Hospital Day 1 22:22 Nursing Pt is alert and orientedx4, with mild anxiety present…pulling wrap to arm…told numerous times to leave it alone…order for a hand mitt restraint…is aware if tugging again will be restrained.

Hospital Day 2 03:03 Nursing alert and orientedx2-3, with mild anxiety and occasional hallucinations… pulled out foley catheter...pulled at cast… Bilat hand mitts and wrist restraints were applied.

Hospital Day 2 14:04 Nursing Pt. AOx1-2, very agitated and restless at times... Pt. resting quietly at this time. Family at bedside.

Hospital Day 4 15:00 PT The patient reports "Take this off of me (referring to restraints and mits) so I can run an errand."

Hospital Day 4 18:52 Nursing Pt s/p right radial fracture, right hip fracture, now with delirium r/t possible alcohol w/d.

Hospital Day 5 05:08 Nursing Has been agitated…Sitter at bedside. Restraints. Pt not agitated at the time the BP taken.

Hospital Day 5 18:32 Nursing A&ox4 today with some stm deficits noted.

Hospital Day 5 15:01 Nursing PATIENT CAN BE IMPULSIVE AT TIMES…EMOTINOAL SUPPORT GIVEN

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Substance Abuse and Older AdultsAlcohol can trigger/exacerbate serious

problems including:

• High blood pressure, arrhythmias and heart attacks

• Stroke • Impaired immunity • Cirrhosis / liver diseases • Osteoporosis • GI bleeding • Depression, anxiety, and other

mental health problems • Malnutrition • Sleep disturbances

• Alcohol is the major substance abuse/misuse problem among older adults.

• Approx. 2.5 million older adults in the US have alcohol related problems.

• Physiological changes affecting alcohol metabolism with aging:– Decrease in body water – Increased sensitivity/

decreased tolerance – Decrease in the metabolism in

GI tract

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Substance Abuse and Older AdultsEarly Onset – “hardy survivor”

• Majority are early onset drinkers – Drink for the same reasons younger

people do - to cope with psychosocial or medical problems

• Comorbidities include depression, bipolar disease, and thought disorders

• More health problems

• Continue established drinking patterns as age

Late Onset• 1/3 of older adults with drinking problems

• Psychologically and physically healthier – too “normal," to raise suspicions

• More likely to have increased drinking due to recent losses: death of a spouse divorce, change in health status, life changes

• Milder and more amenable to treatment than early onset drinking problems sometimes resolves spontaneously.

Both appear to use alcohol almost daily; in social settings and at home alone.

Both more likely to use alcohol as palliative/self-medicating measure in response to hurts, losses, and affective changes.

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Management• Benzodiazepines

– Diazepam or lorazepam– Older adults may require lower doses

• Symptom triggered therapy– Clinical Institute Withdrawal Assessment Scale for Alcohol

(CIWA-A)

• Supportive therapy– Comorbidities– Hydration and nutrition

• Team care

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Mrs. F

History:•Delirium with knee replacement in 2010•4 beers a day and 2mg Clonazepam twice dailyOn presentation:•BAL=80•Na=128

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Mrs. F

Hospital Course and beyond:•Pain management•Sitters and family•Activity•Clonazepam•Geriatrics consultation

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Summary

• Maintain a high level of suspicion– Screen for alcohol use

• Document findings in the chart• Discuss with other members of the team• Inform/educate patients and families

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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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Delirium Teaching Rounds “Itching for a Fight!”

November 4, 2011

duke gec delirium teaching rounds: insult to injury october 7, 2011

Documents

duke gec

delirium slide

diagnoses of delirium

costs of delirium

delirium teaching rounds

risk predisposing

common risk factors

postacute care