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Post-operative Delirium. Kyle C. Moylan, MD Assistant Professor of Clinical Medicine University of Missouri - Columbia. Background. Delirium is common Delirium is often unrecognized Delirium is life-threatening Delirium is potentially predictable and preventable. Consequences.

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Post operative delirium l.jpg

Post-operative Delirium

Kyle C. Moylan, MD

Assistant Professor of Clinical Medicine

University of Missouri - Columbia


Background l.jpg
Background

  • Delirium is common

  • Delirium is often unrecognized

  • Delirium is life-threatening

  • Delirium is potentially predictable and preventable


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Consequences

  • Increased morbidity

  • Increased mortality

  • Increased costs

  • Often a trigger of a “downward spiral” resulting in loss of independence, disability, and institutionalization


Delirium is common l.jpg
Delirium is Common

  • Complicates the course of 20% of the 12.5 million patients over age 65 hospitalized every year

  • Prevalence at admission – 14-24%

  • Incidence during hospitalization – 6-56%

  • Post-operative incidence – 15-53%

  • ICU incidence - 70-87%

  • Incidence in post-acute care - 60%


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Delirium is Costly

  • Adds $2500 to hospitalization per patient

  • Accounts for $6.9 billion of Medicare hospital expenditures

  • Increases cost for institutionalization, rehabilitation, home health services, and informal caregiving


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Delirium is Underdiagnosed

  • Diagnosis is clinical

  • Requires careful bedside evaluation and cognitive assessment

  • Fluctuating nature

  • Confused with dementia

  • Significance underappreciated

  • Diagnosis is not considered or sought


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Delirium – Diagnostic Criteria

  • Confusion Assessment Method (CAM)

  • Requires -

    • Acute Onset and Fluctuating Course

    • Inattention

  • AND Either

    • Disorganized thinking OR

    • Altered Level of Consciousness

  • Sensitivity: 94%-100%

  • Specificity: 90%-95%

  • Used as gold standard in almost every study

  • Only + or – so does not distinguish levels of severity

  • CAM-ICU has also been developed

Inouye SK. Ann Intern Med 1990


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Confusion Assessment Method

  • CAM positive IF 1 and 2, plus 3a or 3b

  • 1. Acute Onset and Fluctuating Course

  • Is there evidence of an acute change in mental status from the patient’s baseline?

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

  • 2. Inattention

    • Did the patient have difficulty focusing attention (e.g. being easily distractible) or have difficulty keeping track of what was being said?

  • 3a. Disorganized Thinking

    • Was the patient’s thinking disorganized or incoherent: such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

  • 3b. Altered Level of Consciousness

    • Overall, how would you rate this patient’s level of consciousness? (alert [normal], vigilant [hyper-alert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [un-arousable]). Positive for any answer other than “alert”.


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Delirium subtypes

  • Hyperactive

    • More easily recognized

    • Tends to be more severe and associated with worse outcomes

  • Hypoactive

    • Less recognized but more common

    • up to 70% of cases in post-hip fracture repair

  • Can coexist in a single patient over time


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Etiology

  • Complex interaction of the patient, predisposing and precipitating factors

  • More susceptible patients may require minimal insult

  • Less susceptible patients will require more substantial insults

  • Often multifactorial

  • Pathophysiology poorly understood


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Risk Factors for Post-Op Delirium

  • Older age

  • Cognitive impairment

  • Functional impairment

  • Decreased post-op hemoglobin

  • Markedly abnormal Na, K, glucose

  • BUN/Cr >18

  • Alcohol abuse

  • Noncardiac thoracic surgery

  • Aortic aneurysm surgery

  • History of delirium

  • Preoperative use of narcotics

  • Low postoperative oxygen saturation

  • History of cerebrovascular disease

  • Untreated pain

Marcantonio JAMA 1994; Kalisvaart J Am Geriatr Soc 2006


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Drugs Implicated in Post-Op Delirium

  • Anticholinergic medications

    • Diphenhydramine, antispasmodics, TCA’s, antiemetics

  • Opiates

    • Meperidine

  • Benzodiazepines

  • Antiparkinsonian drugs


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Evaluation

  • Physical Exam

    • Blood sugar, pulse oximetry

    • Targeted evaluation for underlying causes

    • Exclude focal neurologic process

  • Electrolytes, CBC, LFT’s, urinalysis, ECG, PCXR, ABG

  • Non-constrast head CT in select patients

    • Patients with trauma, anticoagulants, metastatic disease, focal neuro findings or unable to complete adequate neuro exam

  • EEG rarely helpful



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Questions

What year is this?

What month is this?

What day of the week is this?

Three item recall (1 minute) 

Apple

Table 

Penny

Total possible

Point Value

1

1

1

1

1

1

6

Six Item Screener


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Delirium Management

  • Treat underlying causes

    • Don’t stop looking after finding one potential cause

  • Supportive Care and Environment

  • Targeted symptom-based treatment

  • First have to make the diagnosis


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Supportive Measures

  • Remove unnecessary intrusions

    • Indwelling urinary catheters, telemetry, IV’s

  • Avoid interrupting sleep

    • Are the 3am vitals really needed for this patient?

  • Sensory Aids (hearing aids, glasses)

  • Family support

  • Early mobilization, avoid restraints

  • Provide reorientation (view of clock, calendars, familiar objects)

  • Adequate lighting and temperature

  • Include Fall Prevention protocols


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Interventions

  • Numerous studies showing successful multifactorial interventions to prevent and reduce the severity of delirium (Inouye et al. NEJM 1999)

  • Generally address non-pharmacologic factors

    • Sensory enhancement, hydration, mobilization, improved sleep, avoiding problem medications

  • Difficult for a single person to implement

  • Often led by teams of geriatricians, nurse partners, others

  • May be part of an ACE unit


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Pharmacologic Management

  • Usually NOT indicated

  • Reserve for patients whose symptoms threaten their own safety or that of others

    • May be a substitute for physical restraints

  • Oral therapy is preferred when possible

  • Stopping medications may be more effective

  • Outcomes of intervention studies are disappointing


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DR. NO Approach

  • D – Describe the behavior, Document

  • R – Reason for the behavior

  • N – Non-pharmacologic management

  • O – Order medications last

  • Assess the effect


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Benzodiazepines

  • NOT first line therapy

  • May paradoxically worsen delirium

  • Implicated as etiology of delirium in many patients

  • Benzo use predicts development of delirium in post-op and ICU patients

  • Can cause oversedation or respiratory depression

  • Lorazepam – 0.5-1.0mg orally, repeated every 4H as needed


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Trazadone

  • No controlled studies

  • Preferred by some experts

  • May cause oversedation

  • 25-50mg orally at bedtime, plus every 4-6H as needed


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“Typical” Antipsychotics

  • Haloperidol is the drug of choice

  • Effective in RCT’s

  • 0.5-1.0mg oral BID or at bedtime

  • Repeat Q4H PRN

  • Peak effect 4-6H

  • Same dose can be given IM with peak effect in 20-40 minutes

  • IV not FDA approved and should be avoided

  • EPS, prolonged QT. Contraindicated in PD pts


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“Haloperidol Prophylaxis for Elderly Hip-Surgery Patients at Risk for Delirium: A Randomized Placebo-Controlled Study” (Kalisvaart KJ et al. J Am Geriatr Soc. 2005;53:1658-1666)

  • Patients - 430 pts. in the Netherlands

    • Aged 70 and older at risk for delirium

    • Mostly elective hip replacements (75%)

  • Intervention – Haloperidol 1.5mg/daily or placebo.

    • Started on admit and continued to POD #3.

    • All patients with geriatrics consult.

  • Results – No difference in rate of delirium (15.1vs. 16.5%)

    • Decreased severity and duration (5.4 vs 11.8 days)

    • Decreased LOS (17.1 vs 22.6 days)

    • No adverse effects of haloperidol were noted

  • Limitations

    • Lower than expected incidence of delirium (underpowered)

    • Cognitively intact elective surgery patients

    • Geriatrics consultation may have benefited both groups

    • LOS longer than most US hospitals for this surgery


Atypical antipsychotics l.jpg
Atypical Antipsychotics at Risk for Delirium: A Randomized Placebo-Controlled Study”

  • Little data available but frequently used

  • No evidence of superiority to haloperidol

  • Concerns about increased risk of death in studies of dementia related behavioral problems (Schneider et al, JAMA 2005)

  • Typical doses

    • Risperidone 0.5 mg BID

    • Olanzapine 2.5-5.0 mg daily

    • Quetiapine 25 mg twice daily


Post discharge care l.jpg
Post-Discharge Care at Risk for Delirium: A Randomized Placebo-Controlled Study”

  • Delirium may persists for weeks or even months

  • Should have regular follow-up of mental status until back to baseline

  • Diagnosis and current mental status needs to be communicated to post-acute physician (and nursing)

    • Poorer rehab outcomes

    • 30% Rehospitalized from post-acute facilities (Marcantonio JAGS 2005)

  • Risk of new diagnosis of dementia increased at least threefold

    • 18% at one year (vs 5%) (Rockwood Age Ageing 1999)

    • 69 % at five years (vs 20%) (Lundstrom JAGS 2003)

  • Likely to have substantial long term needs

    • Only 1/3 will still live independently at 2 years (McCusker CMAJ 2001)


Prevention elective surgery l.jpg
Prevention – Elective Surgery at Risk for Delirium: A Randomized Placebo-Controlled Study”

  • Add to pre-op evaluation for elderly pts

  • Baseline MMSE

  • Get family and caregivers involved

  • Bring glasses, hearing aids to hospital

  • Medication review

  • Discuss with anesthesia


Conclusions l.jpg
Conclusions at Risk for Delirium: A Randomized Placebo-Controlled Study”

  • If you aren’t making the diagnosis frequently, look harder

  • Try using a simple screen for cognitive impairment for the next month

  • Set an example for learners by evaluating for delirium and cognitive impairment

  • Include delirium in the perioperative management of your patients

  • Document and communicate the problem with other providers


References l.jpg
References at Risk for Delirium: A Randomized Placebo-Controlled Study”

  • Inouye SK. “Current Concepts: Delirium in Older Persons.” N Engl J Med. 2006;354;1157-1165a.

  • Amador LF, Goodwin JS. “Postoperative Delirium in the Older Patient.” J Am Coll Surg. 2004;200:767-773.

  • Inouye SK, et al. “Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium.” Ann Intern Med. 1990;113: 941-948.

  • Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40: 771-781.

  • Marcantonio ER, Goldman L, Mangione C, et al. “A Clinical Prediction Rule for Delirium After Elective Noncardiac Surgery.” JAMA. 1994;271:134-139.

  • Kalisvaart KJ, Vreeswijk R, deJonghe JF et al. “Risk Factors and Prediction of Postoperative Delirium in Elderly Hip-Surgery Patients: Implementation and Validation of a Medical Risk Factor Model.” J Am Geriatr Soc. 2006;54:817-822.

  • Marcantonio ER, Juarez G, Goldman L, et al. “The Relationship of Postoperative Delirium with Psychoactive Medications.” JAMA. 1994;272:1518-1522.

  • Inouye SK, Bogardus ST, Charpentier PA, et al. “A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients.” N Engl J Med. 1999;340:669-676.

  • Kalisvaart KJ et al. “Haloperidol Prophylaxis for Elderly Hip-Surgery Patients at Risk for Delirium: A Randomized Placebo-Controlled Study.” J Am Geriatr Soc. 2005;53:1658-1666.

  • Rockwood K, Cosway S, Carver D, et al. “The Risk of Dementia and Death after Delirium.” Age Ageing. 1999;28:551-556.

  • Lundstrom M, Edlund A, Bucht G, et al. “Dementia after Delirium in Patients with Femoral Neck Fractures.” J Am Geriatr Soc. 2003;51:1002-1006.

  • McCusker J, Cole M, Dendukuri N, et al. “Delirium in Older Medical Inpatients and Subsequent Cognitive and Functional Status: a Prospective Study.” CMAJ 2001;165:575-593.

  • Marcantonio ER, Kiely DK, Simon SE, et al. “Outcomes of Older People Admitted to Postacute Facilities with Delirium.” J Am Geriatr Soc. 2005;53:963-969.


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