june 18, 2013
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June 18, 2013. Brain Failure: Prevention, Assessment, and Management of Delirium in Older Hospitalized Individuals Matthew J. Beelen, MD Geriatric Specialists Lancaster General Health. Case. 79 year old man, baseline mild cognitive impairment (MCI) CABG in July 2012 Post-operative delirium - PowerPoint PPT PresentationTRANSCRIPT
Brain Failure: Prevention, Assessment, and Management of Delirium in Older Hospitalized Individuals
Matthew J. Beelen, MDGeriatric SpecialistsLancaster General Health
June 18, 2013
Case 79 year old man, baseline mild cognitive
impairment (MCI) CABG in July 2012 Post-operative delirium
“mild bouts of confusion” post op “confusion, delusions, and hallucinations” “impulsive”
To rehab facility Confusion gradually improved
Case, continued Returned home – since then:
No longer able to manage finances No longer able to manage medications Confusing dates and appointments Failed driving test (wife does not drive) Unable to continue working part time Depressed Wife distressed about his decline, his
repeating, his depression
Almost 1/3 of hospitalized elderly will develop delirium
Learner Objectives Articulate the significance of delirium Recognize and identify delirium
promptly as it occurs Describe approaches to delirium
prevention and incorporate these into Compare approaches to delirium
management and incorporate these into practice.
What is Delirium? A disturbance in consciousness that:
Has acute onset (hours to days) and fluctuates over the course of the day
Involves reduced ability to focus, sustain, or shift attention
Involves a change in cognition (memory, orientation, language, etc) or perception (hallucinations)
Is associated with an underlying medical etiology
APA; DSM-IV, 1994
Inflammatory Model of Delirium
Marcantonio ER, JAMA . 2012;308:73-81.
Delirium Subtypes Hyperactive
Agitation Increased
vigilance Hallucinations
Hypoactive Somnolent,
lethargic, stupor, coma, decreased psychomotor activity
Often unrecognized 75% of cases in
the elderly Associated with
higher mortality
Delirium or Dementia?Delirium Dementia
Time Pattern Acute changes and fluctuation during the day
Chronic and gradual, possible changes in response to environment, fatigue (“sundowning”)
Level of Consciousness
Often altered Alert
Attention Impaired Usually intact unless severe dementia
Speech Incoherent, disorganized
Ordered, anomic/aphasic
Dementia and delirium often coexist What is the patient’s baseline?
Identification: Confusion Assessment Method
Feature 1: Acute change andfluctuating course of mental
statusAnd
Feature 2: Inattention
And
Feature 3: Altered level of consciousness
Feature 4: Disorganized thinking
Or
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Confusion Assessment Method (CAM) 86-94% sensitive, 89-93% specific Validated in over 1000 patients Used in over 250 original published
studies 28 page training manual…
Improved accuracy with formal training Improved accuracy when using a standard
cognitive screen as part of the CAM (Modified Mini-Cog)
Takes about 5 minutes to performhttp://hospitalelderlifeprogram.org
Modified Mini-Cog Assessment Orientation
1. Time: Day, Year, day/night, last meal, how long in hospital.
2. Place: City/State, Hospital, Floor Registration
3. Name 3 objects: (apple, watch, penny) Ask the patient all 3 after you have said them. Repeat until
all 3 are learned Clock-drawing
4. Draw a circle, draw numbers, and place hands at “ten past eleven”
Recall 5. Ask for 3 objects in question 3
http://hospitalelderlifeprogram.org
Identification in the ICU: CAM-ICU Assesses same domains as CAM
Different questions/methods of assessment used
Ideal for non-verbal patients
Incorporates the Richmond Agitation and Sedation Scale (RASS) To decide if patient can be assessed for
delirium To assess level of consciousness
www.icudelirium.org; Ely EW et al, JAMA. 2001;286:2703-2710.
CAM-ICU: RASS
www.icudelirium.org
Identification Using CAM-ICU 93-100% sensitive, 89-100% specific Validated for ventilated and non-
ventilated critically ill patients 28 page training manual… Takes about 5 minutes to perform Recommended to be done every shift
Evidence of benefit?
www.icudelirium.org; Ely EW et al, JAMA. 2001;286:2703-2710.
The Role of CAM and CAM-ICU Evidence of
benefit of screening is lacking
“We cannot manage delirium or decrease its complications unless we recognize it”
Useful as a means to monitor for delirium as part of QI process
Delirium is Common
ED
Admission
Gen M
ed
Post O
pICU
DC to EC
F0%
10%20%30%40%50%60%70%80%90%
100%
MaximumMinimum
Prevalence of Delirium at Various Points of Hospitalization
Delirium Has Significant Impacts For patients while in the hospital
For patients after they leave the hospital
For society Population management
Impact in the Hospital physical function nutrition post-op
complications (2-5x risk)
self-extubation or removal of lines
death: 22-76% mortality rate (10-fold risk)
pneumonia falls pressure ulcers exposure to
physical and chemical restraints
family distress burden on
nurses and patient care staffInouye SK. N Engl J Med 2006;354:1157-65
Marcantonio ER. JAMA 2012;308:73-81
Impact Post-Hospitalization 3-fold increased risk of institutional
placement at discharge 2-fold risk of 30-day readmission
from ECF Death
3 fold risk of death at 6 months Every day an ICU patient spends in delirium
increases risk of death at 6 months by 10% 1 year mortality rate is 35-40% Risk of higher mortality persists for up to 2
years Ely EW et al. JAMA 2004;291:1753-1762Marcantonio ER et al. J Am Geriatri Soc 2005;53:963-969
Inouye SK. N Engl J Med 2006;354:1157-65Marcantonio ER. JAMA 2012;308:73-81
Impact Post-Hospitalization Worsening cognition in those with pre-
existing cognitive impairment
Patients with Alzheimer’s who develop delirium: Rate of cognitive decline is doubled in
the year after delirium compared to those without delirium More rapid rate of decline persists for 5 years
Gross AL et al. Arch Int Med 2012;172:1324-1331Fong TG et al. Ann Int Med 2012;156:848-856Fong TG et al. Neurology 2009;72:1570-1575
Delirium and Cognitive Decline
Saczynski JS et al. N Engl J Med 2012;367:30-39
Impact Post-hospitalization New cognitive impairment:
Greater then 10-fold increase risk in new development of dementia over the next 4 years
Cognitive reserve theory
Witlox J et al. JAMA 2010;304:443-451.
Cognitive Reserve and Delirium
delirium
Impact on Society Increased length of stay
2-5 days longer than those without delirium Increased ICU and ventilator days
Increased costs of care $60,000 incremental costs over the
following year $6.9 billion annual cost to Medicare to treat
delirium Impact on caregiver burden
Assistance with activities of daily living Emotional impact
Marcantonio ER. JAMA 2012;308:73-81.O’Mahony R et al. Ann Intern Med 2011;154:746-751.
Delirium - Cost to Society
Monthly Health Care Costs After Discharge from Hospital
Leslie DL. Arch Int Med 2008;168:27-32
Approach to Delirium Prevention
Recognize Risk
Reduce Risk
Prevention of Delirium “At least 30-40% of cases may be
preventable. Prevention is the most effective strategy for reducing delirium frequency and complications.” (Inouye, 2006)
“We should not wait for delirium to happen but must work to implement proven interventions that prevent delirium” (Ely, 2012)
“Effective strategies that prevent delirium should be a high priority for health care systems.” (O’Mahony, 2011)
Risk Factors for Delirium
Inouye SK. J Geriatr Psychiatry Neurol 1998;11:118-125.
Predisposing Factors Baseline
cognitive impairment***
Vision Impairment
Hearing Impairment
Older age Low educational
level ADL impairment
From ECF
Depression Alcohol abuse Multiple
significant chronic conditions
High numbers of home medications
Use of opioids or benzodiazepines prior to admission
Predisposing Factors Dehydration
Bun/Cr > 18 Severe Illness
on Admission Sepsis/SIRS/
infection Acute organ
failure Electrolyte/
metabolic Acute cardiac
event Stroke/seizures
Malnutrition Surgical patient
Hip fracture Fracture/trauma Prior stroke Parkinson’s Prior delirium*
Predictive Value of Risk Factors 4 predisposing risk factors (low vision,
cognitive impairment, dehydration, severe illness)Initial Initia
lValidation
Validation
# of RFs
Risk Group
Rate (%)
RR Rate (%) RR
0 Low 9 1.0 3 1.0
1-2 Intermediate
23 2.5 16 4.7
3-4 High 83 9.2 32 9.5“Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.”
Inouye SK. J Geriatr Psychiatry Neurol 1998;11:118-125
Precipitating FactorsDerangements in
Normal Functions: Fluid intake
Bladder emptying Nutrition intake
Bowel movements Oxygen intake
CO2 release Sleep/wake cycle Mobility
New Acute Conditions:
Metabolic Acid/base Electrolyte Glucose
Anemia Infection/fever CNS
event/condition Cardiac
event/condition Hypotension/shock
Precipitating FactorsExtrinsic Factors Procedures /
Surgery Ventilators / ICU Tubes, lines,
catheters, restraints, devices
Environment change
Other Symptoms Pain Emotional
Distress
Medications >3 added the
previous day “polypharmacy” Benzodiazepine
s Anticholinergics ETOH or drug
withdrawal Opioids (+/-)
Prevention Strategies Prevention should focus on those at
intermediate to high risk
Effective prevention must address the complex array of precipitating risk factors Limited evidence of benefit for isolated
interventions
Prevention requires cooperative interdisciplinary effort
Multi-Component Interventions Methods and specific interventions vary
widely
Reston JT and Schoelles KM. Ann Intern Med. 2013;158:375-380.
Hospital Elder Life Program (HELP) Age ≥ 70 on a general medicine unit, ≥1
risk factor (impaired cognition, elevated BUN/Cr ratio, vision impairment, severe illness) = medium to high risk
Additional risks assessed in the first 48 hours: Sleep deprivation: interview and nurse
input Immobility: ADL assessment scale Hearing impairment: Whisper test
Initial and daily assessment for delirium: CAM
Inouye SK et al. N Engl J Med 1999;340:669-676
The HELP Team Elder Life Nurse Specialist – Masters
level with geriatric training and experience
Elder Life Specialist/Volunteer Coordinator Performs screening, develops care plans,
oversees and coordinates volunteers, training, data collection
Masters level with experience with human services or healthcare, geriatrics, supervisory experience
Geriatrician Program Director (may be one of the
above) Volunteers (3-4 hours, 1-2 times per
week)
Inouye SK et al. N Engl J Med 1999;340:669-676
HELP - Intervention What did the HELP Team do?
Performed initial and ongoing assessments Administered a set of care protocols for at-
risk patients Targeted 6 risk factors for delirium
Provided ongoing staff education Led interdisciplinary meetings and rounds Led ongoing CQI process
HELP Interventions for 6 Risk Factors
Targeted Risk Factor Standardized Intervention
Cognitive impairmentOrientation & therapeutic activity protocol(discuss current events, word games, reorient, etc)
Sleep deprivationSleep enhancement & nonpharm sleep protocol(noise reduction, back massages, schedule adjustment)
ImmobilityEarly mobilization protocol(active ROM, reduce restraint use, ambulation, remove catheters)
Visual impairment*Vision protocol(glasses, adaptive equipment, reinforce use)
Hearing impairment*Hearing protocol(amplification devices, hearing aids, earwax disimpaction)
Dehydration*Dehydration protocol(early recognition of dehydration & volume repletion)
HELP Outcomes – Original Study
852 patients Delirium
incidence 9.9%
intervention 15% controls
Decrease in total number of days of deliriumInouye SK et al. N Engl J Med 1999;340:669-676
Subsequent HELP Outcomes Disseminated to sites worldwide Less functional and cognitive decline,
falls, and pressure ulcers during hospitalization
Little impact on delirium severity once it occurred*
Cost effectiveness has been demonstrated
Cost savings to hospitals has been demonstrated
Improves geriatric education within the hospital
Volunteer use benefits the community Implementation support is available
Inouye SK et al. J Am Geriatr Soc 2000;48Rubin FH et al. J Am Geriatr Soc 2011;59:359-365.
General Prevention Recommendations
Early risk assessment and develop plan to address risk factors
Plan carried out by competent inter-disciplinary team
Minimize staff and location changes
Orienting interventions
Familiar visitors
Treat pain Minimize infection
risk Optimize:
hydration and nutrition
bowel/bladder function
oxygenation activity and
mobility medications sensory input sleep
O’Mahony R et al. Ann Intern Med 2011;154:746-751.
Prevention - Interdisciplinary Team
Balas MC et al. Crit Care Nurse 2012;32:35-47
Patient
Nurses
Physicians
Respiratory
Therapist
Physical Therapist
Pharmacist
The Health System
Barriers to Optimal Prevention Culture change is needed – proactive vs.
reactive System change is required
To ensure interdisciplinary team coordination QI processes related to key components of
prevention Initial assessment Development of management plan Completion of individual components of plan Monitoring for delirium for early detection and for
monitoring effectiveness of program Institutional support (“buy-in” and
resources)
Treatment of Delirium
Management of Delirium There is little rigorous evidence of
benefit Non-pharmacologic measures show a
trend toward: Shorter duration of delirium Decreased severity Shortened hospital LOS
Medications: as of 2011 there was only one randomized placebo-controlled trial – it showed no difference in outcomes
So what can we do?Flaherty JH. Med Clin N Am 2011;95:555-577.
Management – Team Approach Communicate the diagnosis
To team members To family In the medical record: “encephalopathy” - $
$ irony Multi-factorial assessment of
precipitating factors Management plan to address these
factors Sound familiar?
Brain Failure: serious problem, possible emergency Immediate attention is crucial
Review Precipitating FactorsDerangements in
Normal Functions: Fluid intake
Bladder emptying Nutrition intake
Bowel movements Oxygen intake
CO2 release Sleep/wake cycle Mobility
Acute Illnesses: Metabolic
Acid/base Electrolyte Glucose
Anemia Infection/fever CNS
event/condition Cardiac
event/condition Hypotension/shock
Review Precipitating FactorsExtrinsic Factors Procedures /
Surgery Ventilators Tubes, lines,
catheters, restraints, devices
Environment change
Other Symptoms Pain Emotional
Distress
Medications >3 added the
previous day “polypharmacy” Benzodiazepine
s Anticholinergics ETOH or drug
withdrawal Opioids (+/-)
Management – Focus on Safety Environment
Optimize orientation, comfort, sleep/wake cycle
1:1 supervision or “sitter” Family or friend presence Is a room or unit change indicated? “Don’t neglect the hypoactive”
For severe distress or risk of harm to self or others Consider medication Consider restraints – the least necessary
Treatment With Medications Limited, small studies
Only 1 with a blinded placebo comparison group
Underlying dementia either not mentioned or was used as exclusion criteria in most studies
Delirium subtypes were not accounted for No clear evidence that medications
decrease severity or shorten duration No clear evidence that newer
antipsychotics are more favorable than haloperidol
People with delirium get better without medications…
Seitz DP et al. J Clin Psychiatry 2007;68:11-21.Campbell N et al. J Gen Intern Med 2009;24:848-853.
Flaherty JH et al. J Am Geriatr Soc 2011;59:S269-S276.
Treatment with Medications No FDA approved medications for
delirium Haloperidol
0.25-0.5mg PO Q4 hours PRN 0.5-1.0mg IM q30-60min IV doses have much shorter duration of
action: q60min Atypical antipsychotics – oral
Risperidone 0.25mg-0.5mg Q12-24 hours Olanzapine 2.5-5.0mg Q12-24 hours Quetiapine 12.5-25mg Q12-24 hours
Treatment With Medications Antipsychotics
Can prolong the QT interval (get baseline EKG)
Can cause parkinson-like symptoms at high doses
Can cause worsening or irreversible decline in Parkinson’s or Lewy Body dementia Quetiapine is thought to be best choice for
these conditions If used – start with low end of dose range
Benzodiazapines 2nd line or last resort (unless alcohol
withdrawal) Can induce, worsen, or prolong delirium
Final Case Nov. 2012: 87-year-old woman admitted to
hospital from nursing home with mental status change, tachycardia, tachypnea, fever. Baseline MCI.
3 day hospital stay E coli UTI New onset Atrial fibrillation, fluid overload /
CHF NSTEMI Confused, lethargic, “encephalopathy”
Discharged to nursing home “comfort care, hospice consult, NPO”
Now – back to baseline!
Summary Delirium has significant impacts,
especially after discharge Watch for the hypoactive subtype We may be able to prevent 1/3 of cases Prevention is the best treatment Effective prevention and treatment
requires a careful assessment for risk factors and a plan to minimize them – culture and system change
Medications: limited role
Questions?