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CHAMP Incident Delirium in the Hospitalized Senior. Andrea Bial, MD Don Scott, MD, MHS University of Chicago. Goals. Facilitate learning and teaching around the topic: “Incident Delirium in Hospitalized Seniors” Reduce the Incidence of Delirium in Hospitalized Seniors

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Champ incident delirium in the hospitalized senior l.jpg

CHAMPIncident Delirium in the Hospitalized Senior

Andrea Bial, MD

Don Scott, MD, MHS

University of Chicago


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Goals

  • Facilitate learning and teaching around the topic: “Incident Delirium in Hospitalized Seniors”

  • Reduce the Incidence of Delirium in Hospitalized Seniors

  • Improve the Care of Hospitalized Seniors who develop Delirium


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ObjectivesSection 1 (Don)

  • Learn More & Teach More About Assessing Risk for Delirium

    • Predicting Older Patients Probability of Developing Delirium

  • Learn More & Teach More About Delirium Prevention Strategies

    • Avoiding Precipitants

    • Prevention Interventions

  • Learn More & Teach More About Diagnosing Delirium: Using the Confusion Assessment Method (CAM)

    • To Diagnose Delirium

    • To Help Distinguish from Dementia


  • Objectives section 2 andrea l.jpg
    ObjectivesSection 2 (Andrea)

    • Learn More and Teach More about the Systematic Approach to the Evaluation of the Hospitalized Senior with Delirium

    • Learn More and Teach More about the Systematic Approach for the Treatmentof the Hospitalized Senior with Agitated Delirium


    Slide5 l.jpg

    HPI:Mrs. G.,87 y.o. woman from home; 4-5 days c fever, cough, malaise, appetite, po; 1 day  DOE

    PHx: DM c neuropathy, HTN, A-Fib, OA, Glaucoma, COPD

    Meds: glipizide, amitriptyline qhs, lisinopril, Digoxin, Vioxx, T#3’s prn, Warfarin, Ditropan

    Soc / Fx Hx: Lives with husband, retired teacher, Ind. in ADLs and IADL’s

    PEx

    • Vitals 381; 155/90,HR 105, RR 20; O2 94% RA, Non-Toxic

      • HEENT: edentulous, dry OP

      • Chest:  BS and Exp Wheezes

      • CV: Syst. M c/w SEM

      • Abd: Benign; g-

      • Ext’s: Trace Pedal Edema

      • Neuro: A&O X 3, Non-Lateralizing, follows commands


    Slide6 l.jpg

    Labs:

    145

    4.6

    105

    22

    43

    1.7

    10.5

    70% N

    10% Bds

    10% L

    298

    185

    16.7

    32.0

    (MCV=85)

    U/A: >20 WBC, +LE / N, Many Bacteria

    U & Bld Cx’s P

    CXR: + COPD Changes / ?RLL Infiltrate

    ECG: A-Fib @ 105

    Dig = 1.4

    Albumin 4.0 (LFT’s WNL)


    Teaching about delirium in hospitalized seniors l.jpg
    Teaching about Delirium in Hospitalized Seniors

    • Teaching Opportunities for:

      • Evidence-Based:

        • Risk Factors for Delirium at Admission?

        • Prediction of Delirium at Admission?

        • Delirium-Producing Insults?

        • Validated Prediction Tool for Delirium?

          • Differentiating Delirium from Dementia?

        • Prevention Strategies?


    Teaching moment alert l.jpg
    Teaching Moment Alert!

    • Why Thinking about Delirium in Vulnerable Older Adults is as Important


    Delirium in hospitalized seniors significance l.jpg
    Delirium in Hospitalized Seniors: Significance

    1. The Prototypical Geriatric Symptom

    • Medical Emergency THE Cardinal Symptom

      • “Brain Failure” Congestive Heart Failure

        2. Independent Risk Factor for:

        • Mortality • Functional Decline

        • Length of Stay • Nursing Home Placement

    • (? cognitive decline)

      3. Common: Gen Med Wards

      --Incidence = 14-25% (>70)


    Delirium in hospitalized seniors significance10 l.jpg
    Delirium in Hospitalized Seniors: Significance

    4. Potential Iatrogenic Complication of Hospitalization (X 2)

    5. Costly

    6. Preventable



    Sharon inouye s work l.jpg
    Sharon Inouye’s Work Delirium

    Develop a Useable Diagnostic Tool and Validate

    Identify Baseline Risk Factors & Develop Predictive Model for Incident Delirium

    Identify Precipitating Insults Causing Incident Delirium and Develop Predictive Model

    Develop and Test a Prevention Strategy


    Delirium multifactorial model l.jpg

    Predisposing Factors/ Delirium

    Vulnerability

    Precipitating Factors/

    Insults

    High Vulnerability

    Noxious Insult

    Low Vulnerability

    Less Noxious

    Insult

    Delirium:Multifactorial Model

    Inouye, S, et. al. JAMA. 1996; 275:852- 857.


    Predicting delirium predisposing risk factors l.jpg
    Predicting Delirium Delirium:PreDisposing Risk Factors

    • Purpose: Develop and Validate a Predictive Model for Occurrence of Incident Delirium in persons > 70 years

    • Design: Prospective Cohort Study

      • Development Cohort • Validation Cohort

    • Setting: Univ-Based Teaching Hospital; Gen. Med. Service

    • 10 Outcome: Incident Delirium via CAM

      • Assessed within 24 of Admission & Daily

    • Analysis: ID Risk Potential Ind Risk Factors c Bivariate  Stepwise Prop. Hazards Model to ID Ind Risk Factors  Predictive Model

    Inouye SK , et al. Ann Intern Med. 1993;119:474-481


    Predicting delirium predisposing risk factors15 l.jpg

    DEVELOPMENT COHORT Delirium

    N=107 RR

    1.  Vision 3.5(1.2-10.7)

    2. Severe Illness 3.5(1.5-8.2)

    3.  Cognition 2.8(1.2-6.7)

    4. BUN/Cr > 182.0 (1.1-4.6)

    ROC = 0.74 (0.63, 0.85)

    VALIDATION COHORTN=174 RR

    Low Risk (0) 1.0

    Int. Risk (1-2) 2.5

    High Risk (3-4) 9.2

    ROC = 0.66 (0.55-0.77)

    (SEE Pocket Card)

    Predicting Delirium:PreDisposing Risk Factors

    • NOTE: COG. IMPAIRMENT (MMSE < 24); VISION IMPAIRMENT > 20/70; BUN/CR > 18/1; SEVERE ILLNESS= APACHE II > 16 OR CHARLSON ORDINAL CLINICAL = RATED AS SEVERE

    • ROC= 0.74 (0.63-0.85)

    Inouye SK , et al. Ann Intern Med. 1993;119:474-481


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    Teachable Moment ALERT ! Delirium

    Teachable Moment 1: Risk Stratification

    • Predicting Older Patients Probability of Developing Delirium

      Triggers: The Long-Call or Short Call Presentation

      Standing at the Bedside with an At- Risk Patient


    Teachable moment alert17 l.jpg
    Teachable Moment ALERT ! Delirium

    • Teachable Moment 1 (Cont’d)

      • Risk Stratification  Targeting  Efficiency

      • What do you think this patient’s risk is of developing delirium?

        • Was Vision Checked? Glasses?

        • Was a MMSE or other Cognitive Screen Performed ?

        • Does Patient appear Severely Ill?

        • BUN/Cr and Volume Status ?

      • ? Risky Meds ? PRN’s?

      • Delirium Risk Score = 2 (Vision & Azotemia)

        (SEE 3X5 Card)


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    Learn More & Teach More About Diagnosing Delirium: Using the Confusion Assessment Method (CAM)

    • To Diagnose Delirium

    • To Help Distinguish from Dementia


    Delirium diagnosis cam l.jpg

    1. Acute Onset & Confusion Assessment Method (CAM)

    Fluctuating Course

    2. Inattention

    AND

    plus either

    3. Disorganized

    Thinking

    4. Altered LOC

    Delirium: Diagnosis--CAM

    DELIRIUM

    Inouye SK et al. Ann Intern Med 1990;113:941-948.


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    CAM (Confusion Assessment Method) Confusion Assessment Method (CAM)

    • Feature 1: Acute Onset & Fluctuating Course

      • This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions:

        • Evidence of sudden change in mental status from baseline?

        • Did the abnormal behavior fluctuate during the day, that is, tend to come and go, or increase or decrease in severity?

          Inouye SK et al. Ann Intern Med 1990;113:941-948


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    Validity of CAM Confusion Assessment Method (CAM)

    • Inouye S, et. al. Clarifying confusion: The confusion assessment method. Ann Intern Med. 1990; 113: 941- 948

      • Comparison = DSM III-R Interview

      • Sens 94 & 100% Spec 90 & 95% PPV 91 & 91% NPV 90 & 100%

    • Ely EW., et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286(21):2703-10.

      • Comparison DSM IV Interview

      • Sens 93 & 100% Spec 98 & 100% inter-rater reliability  = 0.96

    • Monette J., et al. Evaluation of the confusion assessment method (CAM) as a screening tool for delirium in the emergency room. Gen. Hosp. Psychiatry. 2001;23(1):20-5.

      • Comparison: “Geriatrician Interviewer”

      • Sens 86% Spec 100%


    Distinguishing delirium from dementia see pocket card l.jpg
    Distinguishing Delirium from Dementia Confusion Assessment Method (CAM)(See Pocket Card)


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    Teachable Moment 2: Using the Confusion Assessment Method (CAM)

    • To Diagnose Delirium

    • As a Springboard To Help Distinguish Delirium from Dementia (see Pocket Card)

      BEDSIDE TEACHING TRIGGERS

  • Suspected Delirious Patient, Dementia Patient

  • DEMONSTRATE USE OF CAM TO DIAGNOSE HYPOACTIVE DELIRIUM

    OR

  • USE OF CAM TO DIAGNOSE AND DISTINGUISH HYPOACTIVE DELIRIUM VS. DEMENTIA

    (see Pocket Card)



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    Learn More & Teach More About Delirium Prevention Strategies (CAM)

    • Precipitating Factors

    • A Successful Prevention Strategy


    Predicting delirium precipitating risk factors l.jpg
    Predicting Delirium: (CAM)Precipitating Risk Factors

    • Purpose: To prospectively Develop and Validate a Model for Incident Delirium based on Precipitating Factors During Hospitalization

    • Design: Prospective Cohort Study

    • Setting: Univ-Based Teaching Hospital; Gen. Med. Patients

    • 10 Outcome: Incident Delirium via CAM

      (precipitating factor must proceed > 240)

    • Analysis: Group Risk Factors on 4 Axes (a priori assumption)  Reduce variables on each axis using Multivariable Binomial Regression Models (ID’s Ind Risk Factors from each Axis)  Predictive Model

    Inouye SK , et al. Ann Intern Med. 1993;119:474-481


    Predicting delirium precipitating risk factors27 l.jpg

    DEVELOPMENT COHORT (CAM)

    N=196 RR

    1 Phys. Restraints4.4 (2.5-7.9)

    2 Malnutrition4.0 (2.2-7.4)

    3  3 meds added2.9 (1.2-4.7)

    4 Bladder Catheter2.4 (1.2-4.7)

    5Iatrogenic Event1.9 (1.1-3.2)

    (SEE Pocket Card)

    VALIDATION COHORT N=312 (RR)

    1. Low Risk (0 Points)1.0

    2. Intermed Risk (1-2)7.1(3.2-15.7)

    3. High Risk (3-5)17.5(8.1-27.4)

    Predicting DeliriumPrecipitating Risk Factors

    Inouye SK, et. al. JAMA 1996: 275; 852- 857


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    Learn More & Teach More About Delirium Prevention Strategies (CAM)

    • Precipitating Factors

    • A Successful Prevention Strategy


    A multicomponent intervention to prevent delirium in hospitalized older adult patients nejm 1999 l.jpg
    A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Adult Patients. NEJM. 1999.

    • Design: Prospective, Matched, 852 patients, Medicine Service

    • Inclusion: Age > 70, Not delirious at admit, Intermed. or High Risk

    • Intervention --Focused on 6 risk factors for delirium: Cognitive Impairment, Sleep Deprivation, Immobility, Visual impairment, Hearing impairment, Dehydration

    • 1o End Point = Incident Delirium  Assessed daily until discharge

    Inouye SK, et al. NEJM. 1999;340:669-676


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    Targeted Interventions Hospitalized Older Adult Patients. NEJM. 1999.

    Cognitive

    Impairment

    Sleep Deprivation

    Immobility

    Orientation/

    Activities

    Early

    Mobilization

    Non-drug; sleep

    enhancement


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    Targeted Interventions Hospitalized Older Adult Patients. NEJM. 1999.

    Visual

    Impairment

    Hearing Impairment

    Dehydration

    Visual Aids,

    Devices

    Hearing devices,

    Remove earwax

    Early recognition

    & po repletion


    Prevention protocols l.jpg
    Prevention Protocols Hospitalized Older Adult Patients. NEJM. 1999.

    Inouye SK, et al. NEJM. 1999;340:669-676 SEE CHALK


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    Results Hospitalized Older Adult Patients. NEJM. 1999.

    • USUAL CARE = 15.0%

    • PREVENTION GROUP = 9.9%

    • OR 0.60 (CI 0.39- 0.92)

    • RRR= 40% ARR= 5.1%

    • NNT = 20

    • NO BENEFIT ONCE DELIRIUM OCCURED

    Inouye SK, et al. NEJM. 1999;340:669-676.


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    Back to Case Hospitalized Older Adult Patients. NEJM. 1999.

    HPI: Mrs. S., 87 y.o. woman from home; 4-5 days c lethargy, appetite, po; 1 day n/v, no po

    DX:Cystitis and Possible Pyelonephritis

    A/P

    • IV Abx and NS; Clear Liquid, ADA Diet; Foley to Gravity; Bed Rest

    • Continue Out-Patient Medicines

    • SSI & FS qac & qhs

    • PRN’s: MOM, Compazine, Prosom, T#3’s

    • DVT Prophylaxis

    • AM lABS

    • Abd/Renal U/S & AM Labs


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    Teachable Moment ALERT ! Hospitalized Older Adult Patients. NEJM. 1999.

    • Teachable Moment 3: “Preventing” Delirium

    • Potential Triggers

      • Post-Call or Short Call Presentation

      • Bedside

        • Room Dark, TV Blaring, Tethered to Bed, No Glasses, No Hearing Aids, Dry Board with Wrong Day and Other Info

      • Ask re Out of Bed, Diet (and ?eating / drinking), BM’s?

        • Why is the Patient in Bed

        • Where’s the Geri-/Cardiac Chair ?

      • What is Happening Overnight ?

      • MAR Review


    Teachable moment 3 preventing delirium avoiding precipitants prevention interventions l.jpg
    Teachable Moment 3 Hospitalized Older Adult Patients. NEJM. 1999.: Preventing DeliriumAvoiding Precipitants & Prevention Interventions

    • ? Pt’s Baseline Risk ?

    • What Meds have we Added? What psychoactive medications are on the MAR? (Time for MAR Review?) (SEE 3X5 Card)

    • ?Any “regular Meds” that could have been temp. D/C’s?

    • ? Vision and Hearing ?  Are Glasses and Hearing Aids Present; Is a “Pocket Talker” Needed (?Available)

    • Is a Foley Present and if so what is the indication?

    • What are the plans for getting the Patient out of Bed? Can we find a Cardiac / Geri Chair? Has PT been Ordered? Family and Pt encouraged? Are IV Fluids Really Needed

    • Does the patient really need to be awakened for am labs and vitals ? Really need FS qac and qhs?

    • Is the patient eating? Has the Diet been Advanced? Is the patient pooping?


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    Break Time Hospitalized Older Adult Patients. NEJM. 1999.


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