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COMPLEX CASES ACROSS THE CONTINUUM OF CARE

COMPLEX CASES ACROSS THE CONTINUUM OF CARE . EXAMPLES IN ACUTE CARE C.Patterson September 20 th 2006 (abbreviated version posted to rgpc.ca). Objectives. By the end of this presentation the participant will:

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COMPLEX CASES ACROSS THE CONTINUUM OF CARE

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  1. COMPLEX CASES ACROSS THE CONTINUUM OF CARE EXAMPLES IN ACUTE CARE C.Patterson September 20th 2006 (abbreviated version posted to rgpc.ca)

  2. Objectives • By the end of this presentation the participant will: • Recognize specific complications of acute illness, and develop an approach to management • Appreciate issues of the “difficult discharge” in today’s acute care setting

  3. Background • Most patients in acute care are elderly • Most now have multiple illnesses and co-morbidities • Lengths of stay are constantly expected to be shorter • Hospitals are funded according to factors such as acuity, complications, length of stay (funding can be withheld for longer than expected stays)

  4. Case 1 • 84 year old lady lives alone independently; some help for finances and driving from daughter • Diagnosed with mild Alzheimer’s disease one year ago, commenced donepezil, with some improvement • Treated for: osteopenia (Calcium and vitamin D): dementia (donepezil 10 mg): hypertension (hydrochlorthiazide 25mg): insomnia (lorazepam 1-2 mg at night)

  5. Case 1 • Monday: • Slipped and fell on sidewalk, injured right hip • Taken by ambulance to emergency department • X-rays confirmed intertrochanteric fracture • Moved to ward after 12 hours

  6. Case 1 • Tuesday: • Surgery under spinal anaesthetic at 0900h went uneventfully • On night of surgery she became confused, verbally abusive and aggressive • Pulled out i.v, climbed out of bed, resistive to care

  7. Case 1 • Wednesday: • Drowsy, hallucinating when more alert • Looses focus while speaking • Picking at bedclothes • Resists care at times, restraints applied • Visiting family are alarmed…

  8. Case 1 • What’s going on? • What more information do we need to know? • Will she recover?

  9. DELIRIUM!

  10. DELIRIUM • 10-40% on admission to hospital • 25-60% incidence during hospitalization • Increased mortality • Prolonged length of hospital stay • Harbinger of future problems 20% annual incidence of dementia

  11. Delirium: Confusion Assessment Measure (CAM)(Inouye et al. Ann Intern Med 1990;113:941) Acute onset, fluctuating course AND Inattention PLUS Disorganized thinking OR Altered level of consciousness [Sensitivity and specificity over 90%]

  12. Clinical data Medications: • meperidine (Demerol) • dimenhydrinate (Gravol) • acetominophen +codeine (Tylenol # 2) • hydrochlorthiazide • lorazepam (Ativan)

  13. Clinical data • Afebrile • P=90/min; RR=20/min; BP110/80 • Inattentive, picking at bedclothes • Lung bases-crackles • Oxygen saturation 88% on room air

  14. Clinical data • Hb: 92 g/l • WBC: 11.2 (9.1 granulocytes) • Urea: 5.1mmol/L • Creatinine: 82 umol/L • Sodium (Na): 125 mmol/L • Potassium (K): 3.5 mmol/L • Urine: many WBC

  15. Causes of delirium: a checklist • D: drugs • Meperidine: semisynthetic opiate with anticholineric properties. Metabolyte accumulates in renal impairment and elderly AVOID! • Dimenhydrinate: antihistamine with anticholinergic properties • Codeine: opiate • Lorazepam: benzodiazepine; problems with withdrawal AND new use • Donepezil: sudden discontinuation may worsen dementia

  16. Causes of delirium: a checklist • E: endocrine • Na 125-mildly lowered may result from medications (hydrochlorthiazide, opiates) or surgery (SIADH)

  17. Causes of delirium: a checklist • M: metabolic causes • Hypoxemia-respirations increased, lung findings, oximetry reading • Chest X-ray confirmed congestive heart failure

  18. Causes of delirium: a checklist • D: drugs-starting or stopping • E: endocrine causes • M: metabolic causes • E: epilepsy or siezures • N: neoplasm or tumour • T: trauma

  19. Causes of delirium: a checklist • T: trauma • Hip fracture, haemorrhage, surgery

  20. Causes of delirium: a checklist • D: drugs-starting or stopping • E: endocrine causes • M: metabolic causes • E: epilepsy or seizure disorder • N: neoplasm or tumour • T: trauma • I: infection

  21. Causes of delirium: a checklist • I: infection • Evidence of urinary tract infection

  22. Causes of delirium: a checklist • D: drugs-starting or stopping • E: endocrine causes • M: metabolic causes • E: epilepsy or siezures • N: neoplasm or tumour • T: trauma • I: infection • A: apoplexy or vascular event

  23. Causes of delirium: a checklist • A: apoplexy or vascular event • Reason for congestive heart failure was a myocardial infarction (heart attack) occurring during or immediately after surgery

  24. Causes of delirium: a checklist • D: drugs-starting or stopping • E: endocrine causes • M: metabolic causes • E: epilepsy or siezures • N: neoplasm or tumour • T: trauma • I: infection • A: apoplexy or vascular event

  25. A concept: “the bits” Her delirium resulted from: • A bit of hyponatremia • A bit too much medication • A bit of heart failure • A bit of infection i.e. delirium is often caused by multiple factors

  26. Who is at increased risk for delirium? • Older people • Preexisting cognitive changes (especially dementia) • Poor functional status • Electrolyte imbalance (Na, K, Glu) • Poor vision, hearing • Alcohol abuse

  27. Precipitants of delirium • 3 or more additional medications • Physical restraint • Bladder catheters • Malnutrition • Any iatrogenic event • Certain surgery (AAA, hip repair…) Inouye & Charpentier JAMA 1996;275:852, Marcantonio et al JAMA 1994;271:134

  28. Management of delirium • TREAT UNDERLYING CAUSES! • Protect patient and carers • Familiar surroundings especially familiar people • Cautious sedation • Many authorities prefer haloperidol (Haldol) in small regular doses • Benzodiazepines (BZP) for alcohol and BZP withdrawal

  29. Outcome of delirium • About 50% recover • About 25% persist for prolonged periods or permanently • About 25% decease in hospital (22-76%) • One year mortality 35-45%

  30. Prevention of delirium (by 40%) The HELP program • Early mobilization • Adequate hydration and nutrition • Vision aids • Hearing • Orientation • Non pharmacological sleep measures S Inouye et al NEngJMed 1999;340:669

  31. Case 2 • 87 year old man, collapsed in grocery store • Brought to hospital by ambulance • Febrile, unkempt, dirty • Confused, cooperative • Dehydrated, consolidation in lung • Chest X-ray showed right lower lobe pneumonia • Blood glucose 18.0 mmol/L = diabetes mellitus

  32. Case 2 • Treated with i.v. fluids, oxygen, antibiotics, insulin then oral hypoglycemics • Confusion improved, regained mobility • Day 3, keen to go home; attending MD planned discharge on day 4. • Nursing staff expressed concern about his safety at home • Patient insisted that he would be fine

  33. Case 2: day 4, morning • Ward staff received call from son in USA concerned about his imminent discharge Staff called: • His family physician- who had not seen him for 2 years; non adherent with prescriptions.. • His pharmacy- periodic prescriptions from drop-in clinic for NSAIDS

  34. Case 2: day 4, midday • He insists on going home • Permission obtained to call neighbour-reported squalid conditions at home • OT asked to see re safety at home • SW referral requested

  35. Case 2: day 4, midday • He insists on going home • Permission obtained to call neighbour-reported squalid conditions at home • OT asked to see re safety at home • SW referral requested • Angry doctor/manager/surgeon/discharge planner calls “We need that bed! He must go to LTC if he cannot go home!”

  36. Case 2: day 4 pm • Agreed to stay one more day • Re examined; clinically improved; no major neurological findings • Lab tests (calcium, TSH, B12,)-normal • Brainscan

  37. Case 2: OT assessment • BADLs OK • Concern re safe meal preparation, medications (antibiotics, hypoglycemics0 • MMSE 27 (stm, temp orientation) • MOCA 20 (exec, fluency, abstraction) • Poor insight, poor judgement, • Impaired verbal reasoning/problem solving • Recommends home visit

  38. Case 2 • What to do now? • Safe to go home?

  39. How much risk?(After Patterson & Rosenthal Lancet 1997; 350: 1164)

  40. Capable of deciding? Does he have the ability to: Understand his problems Understand proposed treatments Understand alternatives Understand option of refusing proposed treatments Appreciate consequences of accepting or refusing proposed treatments Make decision not based on delusion or depression After: Etchells et al CMAJ 1996;155:657

  41. Case 2: follow up • 2 months after discharge • Living at home • Neighbours continue to be supportive • MOW cancelled, resumed his own shopping (neighbours take him) • Minimal requirement for medications • Son has withdrawn from scene

  42. Conclusions • Importance of complete, relevant data collection • Be not content with one explanation (e.g. “the bits” and delirium) • Bring in the troops to help assess risk (OT, SW, pharmacist…) • Mobilize community resources (e.g. family, neighbours, parishioners + CCAC) to manage risk

  43. Conflicts of interest • Research funds from Pfizer • Research funds from Janssen-Ortho • Speakers fees from Pfizer, Janssen-Ortho, • Consultation fees from Pfizer

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