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CHAMP Incident Delirium in the Hospitalized Senior

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

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  1. CHAMPIncident Delirium in the Hospitalized Senior Andrea Bial, MD Don Scott, MD, MHS University of Chicago

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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)

  7. 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?

  8. Teaching Moment Alert! • Why Thinking about Delirium in Vulnerable Older Adults is as Important

  9. 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)

  10. Delirium in Hospitalized Seniors: Significance 4. Potential Iatrogenic Complication of Hospitalization (X 2) 5. Costly 6. Preventable

  11. Learn More & Teach More About Assessing Baseline Risk for Delirium

  12. Sharon Inouye’s Work 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

  13. Predisposing Factors/ 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.

  14. Predicting 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

  15. DEVELOPMENT COHORT 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

  16. Teachable Moment ALERT ! 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

  17. Teachable Moment ALERT ! • 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)

  18. Learn More & Teach More About Diagnosing Delirium: Using the Confusion Assessment Method (CAM) • To Diagnose Delirium • To Help Distinguish from Dementia

  19. 1. Acute Onset & 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.

  20. CAM (Confusion Assessment Method) • 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

  21. Validity of 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%

  22. Distinguishing Delirium from Dementia(See Pocket Card)

  23. 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)

  24. Video Clip & Practice Using CAM

  25. Learn More & Teach More About Delirium Prevention Strategies • Precipitating Factors • A Successful Prevention Strategy

  26. Predicting Delirium: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

  27. DEVELOPMENT COHORT 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

  28. Learn More & Teach More About Delirium Prevention Strategies • Precipitating Factors • A Successful Prevention Strategy

  29. 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

  30. Targeted Interventions Cognitive Impairment Sleep Deprivation Immobility Orientation/ Activities Early Mobilization Non-drug; sleep enhancement

  31. Targeted Interventions Visual Impairment Hearing Impairment Dehydration Visual Aids, Devices Hearing devices, Remove earwax Early recognition & po repletion

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

  33. Results • 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.

  34. Back to Case 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

  35. Teachable Moment ALERT ! • 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

  36. Teachable Moment 3: 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?

  37. Break Time

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