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Mini CHAMP Delirium in the Hospitalized Elder. Shellie Williams, M.D. Assistant Professor of Medicine Section of Geriatric Medicine University of Chicago. Objectives:. Increase recognition of delirium in hospitalized elders.

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Mini champ delirium in the hospitalized elder l.jpg

Mini CHAMPDelirium in the Hospitalized Elder

Shellie Williams, M.D.

Assistant Professor of Medicine

Section of Geriatric Medicine

University of Chicago


Objectives l.jpg
Objectives:

  • Increase recognition of delirium in hospitalized elders.

  • Identify a risk stratification for delirium in hospitalized elder.

  • Gain understanding of prevention for delirium.

  • Enhance ability to evaluate patients for delirium—assessment.

  • Develop a strategy for treatment of delirium from a non-pharmacologic and pharmacologic focus.


Mrs fleming l.jpg
Mrs. Fleming:

  • 75yo female admitted from ER with generalized weakness, UTI and pre-renal azotemia.

  • She is admitted to 5NE with IVF & cipro

  • RN calls post-admit day#1: “She pulled out her IV this morning and ordered me out of her home. She is upsetting her roommate and refused another IV. Shall I initiate a sitter?”


Delirium the data l.jpg
Delirium: The Data

  • Prevalence: 15-70%

  • (20%) 12.5 million elderly admits

  • Admission Onset: 20-33%

  • Post surgical: 30-59%

Rockwood 1990; Francis 1992


Defining delirium l.jpg
Defining Delirium:

  • Disturbance of consciousness and reduced ability to focus, sustain or shift attention.

  • Change in cognition (decline memory, orientation, language, motor) not accounted for by preexisting dementia.

  • Disturbance that develops over short time and fluctuates.

  • Direct physiologic consequences of a specific medical condition, substance intoxication, withdrawal, or multiple causes.

Diagnostic and Statistical Manual of Mental

Disorders, Fourth Edition (DSM-IV)


Delirium pathophysiology l.jpg
Delirium: Pathophysiology

  • Neurotransmitter Theory:

  • Cholinergic deficits: benadryl, scopalmine

  • Norephinephrine excess: antidepressants

  • Dopamine excess: Parkinson meds

  • Cytokines-IL1, IL2, TNF (Infection)

  • Cerebral Hypoxia

  • Stress related hormonal fluctuation


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Why Focus on Delirium? Risk

  • Increased LOS (2x)

  • Increased Mortality (2-7x)

  • 38% & 51% mortality 1yr/5yr post-hosp

  • Increased ADL dependence (2x)

  • Increased instituitionalization (2-3x)

Dolan J of Ger 2000;

Leslie Arch In Med 2005.


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Why Focus on Delirium? Cost

Leslie, D.L. Arch In Med, 2008; 168: 27-32.


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Why Focus on Delirium?: Cognition

  • 60% persistent impairment from baseline

  • 40% Progression dementia 1yr

  • Premorbid Cognitive Impaired:

  • 4% complete resolution prior d/c

  • 20% complete resolution 3-6mo s/p d/c


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Obstacles:Under-recognition

  • Poor recognition:

    Nurse recognition <50%

    Physician recognition 20%

Inouye 2001


Recognize delirium fluctuating faces l.jpg

Hyperactive: 30%

Tremor

Agitation

Picking/Pacing

Vivid hallucinations

Irritability

Aggression

Hyperactive: 30%

Hypoactive: 70%

Sedate

Psychomotor retardation

Poverty speech

Diminished awareness

Recognize Delirium Fluctuating Faces:

Spiller, JA. Pall Med 2006; 20: 17-23.


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Delirium Prevention: Pre-hospital Risk

Inouye,SK. Arch Int Med; 1993, 119: 474-81.


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Risk Stratification Based on Pre-hospital risk:

Inouye,SK. Arch Int Med; 1993, 119: 474-81.


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Risk Stratification: In-Hospital Risk

  • Use of Physical Restraints (RR 4.4, CI 2.5-7.9)

  • Malnutrition (RR 4.0, CI 2.2-7.4)

  • >3 Medications added (RR 2.9, CI 1.2-4.7)

  • Use of Bladder Cath (RR 2.4, CI 1.2-4.7)

  • Any Iatrogenic Event (RR 1.9, CI 1.1-3.2)

Inouye, SK. JAMA. 1996; 275 (11): 852-7.


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Risk Stratification: Delirium at Discharge

Inouye, SK. Arch Intern Med 167 (13): 1406-12.


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Prevention: Elder Life Program

  • Elder Life Program

  • Targeted protocols:

    • Cognitive impairment

    • Sleep deprivation

    • Immobility

    • Visual impairment

    • Hearing impairment

    • Dehydration

Inouye, SK. NEJM 1999; (340) 9: 669-675.


Delirium prevention l.jpg
Delirium Prevention

  • Decreased incidence of delirium

    (9.9% vs 15.0%) p=0.02

  • Decreased days of delirium

    (105d vs 161d) p=0.02

  • No statistically significant change in severity or recurrence of delirium

Inouye, SK. NEJM 1999; (340) 9: 669-675.


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Evaluation of Delirium

  • MULTIFACTORIAL is the rule of thumb (2.8/pt)

  • Focused, patient-centered investigation

  • History guides diagnostics

  • Examination guides diagnostics



Document delirium l.jpg

DOCUMENT DELIRIUM!

Confusion Assessment Method: CAM


Evaluation cam confusion assessment method l.jpg

Acute Onset &

Fluctuating Course

Inattention

AND

plus

either

Disorganized

Thinking

Altered LOC

Evaluation: CAMConfusion Assessment Method

DELIRIUM

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


Evaluation r o dementia l.jpg
Evaluation: R/o Dementia

  • Hx of dementia?

  • Need hx of sundowning to dx it!

  • Agitated dementia = delirium

  • Understand delirium-dementia relationship

    DEMENTIA DELIRIUM



Evaluation physical exam l.jpg
Evaluation: Physical Exam

  • “Head to toe”

    • Vitals (temp, HR, RR, BP, pulse ox)

    • CNS (CVA, bleed, meningitis, sz, blind, deaf)

    • Pulm (pneumonia, PE, CHF)

    • CVS (ischemia, CHF, arrhythmia)

    • GI (ischemia, impaction, bleed)

    • GU (UTI, retention)

    • Extrem (pain, volume status, CVA)

    • Skin (pressure ulcer, volume status)


Evaluation most common causes of delirium l.jpg
Evaluation: Most common causes of delirium

  • Medications 30%

  • Infections 40%

  • Fluid/Electrolyte imbalance 40%


Evaluation medications 30 l.jpg
Evaluation: Medications (30%)

  • Too little (alcohol or other drug withdrawal) 6%

  • Too much

    narcotics

    neuroleptics

    anti-cholinergics

    anti-emetics

  • >3 new medications introduced

Francis 1990, Schor 1999, Lawlor 2002


Evaluation medications l.jpg
Evaluation: Medications

  • Antibiotics (aminogly, PCN, ceph, sulfa)

  • Benadryl

  • Benzodiazepines (triazolam, alprazolam, diazepam)

  • Digoxin

  • GI (Reglan, Bentyl)

  • Lithium

  • Narcotics

  • Neuroleptics

  • Steroids

  • NSAIDs (Indocin)

  • H2 Blockers (Cimetidine,…)

  • Parkinsons drugs (Levodopa, Benztropine, Amantadine)

  • Tricyclics


Evaluation anti cholinergic medications l.jpg
Evaluation: Anti-cholinergic Medications

Fecal/urine impacted, confused, flushed, dry, low bp

Elavil (amitriptyline) Flexeril (cyclobenzaprine)

Cogentin (benztropine) Atarax/Vistaril(hydroxyzine)

Bentyl (dicyclomine) Welbutrin/Zyban (bupropion)

Ditropan (oxybutynin) Antivert (meclizine)

Detrol (tolterodine) Ipratropium (atrovent)

Benadryl (diphenhydramine) Phenergan (promethazine)

Zyprexa (olanzapine) Atropine

Levsin (hyoscyamine) Belladonna Alkoloids


Evaluation brain ct l.jpg
Evaluation: Brain CT?

  • Controversy on routine ordering

  • Low yield if lack focal neuro findings

  • Documented head trauma with new neuro findings or high risk bleed

Francis, J. Clin Res 1991 (abstract); 39: 103.


Evaluation additional tests l.jpg
Evaluation: Additional tests

  • Labs

    • CBC, lytes, liver, renal

    • Consider TSH, B12

  • Drug levels (digoxin, valproic, phenytoin)

  • Urine tox, UA/culture

  • CXR

  • EKG

  • EEG**


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Management: Plan before Pills

  • Prevention of delirium

  • Correction underlying causes

  • Non-pharmacologic intensify

  • Pharmacologic (agitation)


Management non pharmacologic help prevention l.jpg
Management: Non-pharmacologicHELP Prevention

  • Cognition: orientation board (carry pen!), (day) open drapes, clock, calendar, family photos

  • Sleep: min deprivation (d/c 2am labs & o/n BD/vitals; meds when awake); warm drink; limited pm awake

  • Mobility: Early OOBchair ; PT/OT; no foley/restraints

  • Vision: glasses

  • HOH: get aids; adapt environment (stethoscope!)

  • Dehydration: po fluids; observe at mealtime

  • Feeding: assist with meals

  • Activity: Involve family (rotate members) or get sitter; move pt to room close to RN station, current events

Inouye, SK. JAGS 2006; 54: 1492-1499.


Management non pharmacologic restraint use l.jpg
Management: Non-pharmacologicRestraint Use

  • AVOID!

  • 4x increased risk protracted delirium

  • Increase risk of falls, injury, & delirium

  • Use only in emergency, for as short a duration as possible with frequent re-evaluations, and d/c asap

  • Absolutely no “sheeting”

Inouye, SK. Arch Intern Med 167 (13): 1406-12.


Management pharmacologic l.jpg
Management: Pharmacologic

  • 30/244 AIDS patients admitted to hospital with AIDS related illness, developed delirium

  • Double blind randomization to lorazepam, chlorpromazine or haloperidol

  • Early cessation of lorazepam arm due to worsening sedation, confusion & ataxia

  • Chlorpromazine & haldoperidol arm improvement in delirium per DRS score, limited EPS and improved MMSE in chlorpromazine group @ 2d

Breitbart, W. Am J. Psych, 1996; 153: 231-237.


Management pharmacologic anti psychotics l.jpg
Management: Pharmacologic Anti-psychotics

Typical: Haldol

Advantages: min sed

Disadvantages: lower sz thrshld; more EPS (even at low dose); not FDA-app for IV; can incr QTc; Torsades

Dose: 0.25-0.5mg po, IM, IV; can repeat in 30 mins x1; then dose q4h

t1/2=21h (10-38)

APA 1999


Management pharmacologic antipsychotics l.jpg
Management:Pharmacologic Antipsychotics

Atypical:

Advantages: min sed, less EPS, hyperglycemia

Disadvantages: take time to work, no evidence in short-term; recent Black Box warning: vascular events!

Risperidone 0.25-0.5mg po bid t1/2=20-30h

EPS with high dose

Olanzapine (Zyprexa) 2.5-5mg po qd t1/2=30 (21-54h)

more anticholinergic

Quetiapine (Seroquel) 12.5-25mg po bid t ½=6h

less EPS risk

Van Zyl. Geriatrics 2006; 61(3): 18-21.


Management pharmacologic benzodiazepines l.jpg
Management: PharmacologicBenzodiazepines

Used best in w/d

Lorazepam 0.5-1mg po, IM, IV q6-8

(no first-pass, no renal adjustment)

t1/2=12h


Conclusion l.jpg
Conclusion:

  • Prevent delirium.

    • Evaluate risk factors pre-admit, during and post hospitalization.

    • Adjust admit orders

  • It is important to develop a systematic approach for diagnosis of delirium, THEN (DOCUMENT!).

  • First use non-pharmacologic measures, then pharmacologic, to treat delirium.


Case revisited l.jpg
Case Revisited:

  • Mrs. Fleming is a 75 year old female with htn, OA, dm, cri (1.3) baseline and chronic AF. She lives alone in a 3 story home.

  • Meds: (Home)

    Lisinopril 20mg qam

    Asa 81 mg

    Celebrex 200mg qam

    Metformin 500mg bid

    Hctz 25mg qam

    Elavil 50 mg qhs


Medicines in hospital l.jpg

Lisinopril 10mg qam

Hctz 25mg qam

Regular Insulin SS

0.9NS 150 cc/hr x 36hr

Elavil 50mg qhs

ASA 81mg qam

Darvocet N 1 q 6hr

Prosom 15mg qhs prn

Benadryl 25mg q 6hr itching, sleep

Vicodin 5/500mg q 4hr prn

Morphine 2-4 mg iv q 4hr

Zofran 4mg q 6hr prn n/v

Medicines In-hospital:


Case revisited41 l.jpg
Case revisited:

  • Currently, pt is quietly sitting in chair, picking at skin.

  • When asked what is she doing she notes, “ It is a shame you can’t afford extermination in this place!”

  • She then returns to her activity.

  • Her daughter notes she has not slept in 3 days and was incontinent of urine 2 days PTA.

  • Roommate notes she was lethargic and not answering questions a few moments ago.


Cam assessment is she delirious l.jpg
CAM Assessment: Is she Delirious?

  • Acute/fluctuating?

  • Inattentive?

  • Disorganized thinking?

  • Decreased level of consciousness?



Review dementia l.jpg
Review Dementia?

  • Dementia

    • Get further hx from family of baseline

    • Was dx missed or never made?

    • Prior hx of delirium during hospitalization?

    • Do serial cognitive assessment: MMSE


Review other risks for delirium l.jpg
Review Other Risks for Delirium:

  • Recent physical symptoms? Cough, chills, SOB

  • Psychiatric symptoms? None

  • Alcohol/Illicit drug use? 1 Highball nightly

  • Recent CNS trauma? No trauma other than hip

  • Recent stroke symptoms? No


Case revisited exam l.jpg
Case Revisited: Exam

  • Sat 88% ra, rr 28, p 100, bp 100/50, pain grimace

  • HEENT: Dry mucosa, no evidence cns contusion

  • Neck: No adenopathy or thyromegaly or jvd

  • Lungs: Increase fremitus and percussion dullness rt. base no use acc muscles

  • Heart: Irregular rhythm, rate 100, no murmur, rub or gallop

  • Abdomen: +bs, soft non distended, non tender

  • GU: +foley, no evidence retention

  • Neuro: Inattentive, disoriented, poor recall of hospital events, hyperalert at times, motor strength symmetric, normal sensory function, no hyper-reflexia, antalgic gait


Case cont d l.jpg
Case, cont’d

  • Labs: 10.5

    13.2 192

    33.0

    148 110 56 128

    5.2 30 1.8

    UA: +LE, nitrite, 1.025, bacteria, rbc

    ECG: A. Fib rate 60s, no acute ST changes



Case revisited what factors predisposed this patient for delirium l.jpg

Foley

Poor po intake

Poor vision

> 3 new medications

Sensory impairment

Use of restraints

Bed bound status

>30 bun/creatinine ratio

Baseline cognitive deficits

Lack of pain control

Poor sleep

Case Revisited: What factors predisposed this patient for delirium?


Case revisited what factors precipitated delirium l.jpg

Stroke

UTI

Pneumonia

Anti-cholinergics

Dehydration

Hypoxia

Anemia

Hypotension

Metabolic derangements

Alcoholism

Illicit drugs

Cardiac ischemia

Case Revisited: What factors precipitated delirium?


Case revisited how should we treat this patient l.jpg

Add lorazepam

Initiate sleep orders

Stop elavil

Stop lisinopril

Schedule tylenol

Add vicodin schedule

Stop combo analgesic

Explain condition to daughter

Zosyn 3.25 mg q 6h

Initiate oral hydration protocol

Start IVF

Reorientation protocol

Remove foley

Oxygen therapy

Case Revisited: How should we treat this patient?



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