Reducing Confusion - Avoiding and managing perioperative delirium

1. Reducing Confusion - Avoiding and managing perioperative delirium Beth Cummings, MD FRCPC Perioperative Medicine Rounds GIM Fellowship Program, McGill University November 3, 2009

2. Learning Objectives • Understand the impact of delirium in the perioperative period • Identify modifiable and non-modifiable risk-factors for perioperative delirium • Develop an approach to reducing the incidence of perioperative delirium • Develop an approach to the management of perioperative delirium

3. 1. The scope of the problem (or Why should we care?)

4. How common is delirium? Francis & Kapoor. Journal of General Internal Medicine 5 (1990) 65-79.

5. How frequently now? • All hospitalized patients (medical + surgical) • 22-31% overall • 14% - 56% of elderly Inouye SK et al. Annals of Internal Medicine 1993; 474-481. Ganai S et al. Arch Surg 2007; 1072-1078. • Postoperative patients • 47% overall Noimark D. Age and Ageing 2009; 1-6. • 37-74% of geriatric patients Ganai S et al. Arch Surg 2007; 1072-1078. • 10-15% of general surgery patients • 50% of hip fractur patients Francis & Kapoor. Journal of General Internal Medicine 1990; 5: 65-79. Rubino FA. Neurol Clin N Am 2004; 261-276.

6. The scope of the problem • Postoperative delirium associated with higher mortality1, 2, 4, 5 • Mortality ratios 1.6 – 19.71 • 2.0 in controls matched for age, sex, and diagnosis • 10% - 65% of patients died1 • In hospital, at 3 mos, at 6 mos, at 12 mos, at 2 yrs • Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79 • Rubino, FA. Neurol Clin N Am 2004; 22: 261-276. • Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821. • Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73. • Inouye SK et al. Ann Int Med 1993; 119:474-481.

7. Increased Mortality

8. Increased Morbidity • Post-operative delirium associated with higher morbidity2, 3, 4 • More falls & fractures • More disruptive behaviour • More incontinence  Foley  UTI • More physical & chemical restraints • Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79 • Rubino, FA. Neurol Clin N Am 2004; 22: 261-276. • Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821. • Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73. • Inouye SK et al. Ann Int Med 1993; 119:474-481.

9. Poor functional recovery • Poor functional recovery2 • Greater need for LTC or assisted living on discharge from hospital1, 4, 5 • Worse functional outcome 6 months after surgery3 • Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79 • Rubino, FA. Neurol Clin N Am 2004; 22: 261-276. • Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821. • Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73. • Inouye SK et al. Ann Int Med 1993; 119:474-481.

10. Increased length of stay • Longer length of stay1, 2, 5 • Length of stay ≥ 14 days4 • Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79 • Rubino, FA. Neurol Clin N Am 2004; 22: 261-276. • Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821. • Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73. • Inouye SK et al. Ann Int Med 1993; 119:474-481.

11. Retrospective Chart Review • Inclusion criteria • ≥70 y/o • 2-3 of visual impairment, cognitive impairment, dehydration (BUN: Crt ≥18) • Severe illness requiring “major abdominal surgical procedures” – eg. open exploration for bowel perforation, obstruction, bleeding, ischemia, infection, and cancer • Excluded “less serious diseases” eg. uncomplicated hernia repair or cholecystectomy Arch Surg. 2007;142(11):1072-1078

12. Ganai et al. – Indications for Surgery

13. Ganai et al. - Findings • Results • Delirium 60% • Mortality 20% • Prolonged length of stay (≥14 days) 32%

14. Table 5. Univariate Analyses of Association of Clinical Factors With Adverse Outcomes

15. Increased costs ($) • Franco, Litaker, Locala, Bronson (2001) • Economic analysis • Preop assessment by internal medicine for elective, inpatient, non-cardiac procedures • Patients ≥ 50 y/o • Expected length of stay > 2 days • 11.4% had post-op delirium • LOS 6.0 days vs. 4.6 days (p<0.001)

16. Costs

17. 2. Recognizing delirium http://www.cartoonstock.com/lowres/rni0036l.jpg

18. Often not diagnosed • May be missed in up to 50% of cases Franco, Litaker, Locala, Bronson (2001) • More often noted by nursing than by MDs

19. DSM IV criteria • Delirium • Disturbance of consciousness with reduced ability to focus, sustain, or shift attention • A change in cognition or the development of a perceptual disturbance that is not accounted for by dementia • Develops over hours to days and fluctuates • Direct physiological consequence of underlying general medical condition, substance use, substance withdrawal, medication side-effect…

20. Clinical manifestations • Wandering attention • Easily distracted • Hyperactive • Especially night-time agitation • Hypoactive • Daytime lethargy • Confusion • “He’s just not himself, Doctor”

21. 3. Risk factors for delirium

22. A Case… • Mrs. A. • 72 year-old admitted for elective right hemicolectomy for colon Ca • PMH & Baseline • Hypertension – well controlled on HCTZ • Plays golf regularly in spring & summer; cross-country skiing in winter • Retired accountant; now “does the books” for a local not-for-profit organization • What’s her delirium risk?

23. A different case… • Mrs. K. • 72 year-old admitted for elective right hemicolectomy for colon Ca • PMH & Baseline • CRF due to DM2 – creatinine 198, on insulin 4x/d • Lives by herself but has help from her children to pay bills • What’s her delirium risk?

24. What we know… • Millar (1981) • Consecutive series of 100 patients, ≥65 y/o • 48 bed general surgical unit (3 surgeons) • “psychiatrically assessed before and in the first week after elective surgery” • Standardized interview • Cognitive test • Nurses recorded “any psychiatric abnormality in the ‘cardex’”

25. Millar’s findings • Post-operative psychiatric illness • Age over 80 • Major operations • Biliary tract or malignant disease • Prescription of at least 5 drugs

26. Millar’s findings cont’d • Post-operative intellectual impairment • Abnormal electrolytes/urea • Cardiovascular problems • Respiratory disease • Wound infection • Morphine or diamorphine analgesia • IV infusions • Foley catheters ** … mental status changes were an early sign of complications **

27. Independent risk factors for the development of delirium • Vision impairment ARR 3.51 (1.15 - 10.72) • Severe illness ARR 3.49 (1.48 - 8.23) • APACHE II > 16 or nurse rating of severe • Cognitive impairment ARR 2.82 (1.19 - 6.65) • MMSE <24 • High BUN:Crt ARR 2.02 (0.89 - 4.60) • Ratio ≥18

28. Inouye et al. - Validation Delirium Risk • Low risk patients = 0 points • RR 1.0 • Intermediate risk patients = 1-2 points • RR 2.5 in development cohort • RR 4.7 in validation cohort • High risk patients = 3-4 points • RR 9.2 in development cohort • RR 9.5 in validation cohort

29. Inouye et al. - Outcomes Death or nursing home placement • Low risk (0 points) • 9% development cohort / 3% validation cohort • Intermediate risk (1-2 points) • 16% development cohort / 14% validation cohort • High risk (3-4 points) • 42% development cohort / 26% validation cohort

30. Non-modifiable risk factors • Risks inherent to the patient • Neurological disease Myasthenia gravis, Parkinson’s, previous CVA • Psychiatric disease Depression, BAD, anxiety, psychosis • Mild cognitive impairment or dementia • Severe chronic systemic illness Chronic renal failure, chronic liver disease HTN, DM, MI, CVA, A-fib, PAD, CHF, ASA ≥3

31. Potentially modifiable risk factors • Anaesthesia • General anaesthesia increases risk for 24-48hrs Rubino FA. Neurol Clin N Am 2004; 261-276 • Presence of delirium preoperatively • Pre-operative • Hypoalbuminemia • Abnormal sodium, potassium, glucose • Hypermagnesemia • High BUN: Crt • Leukocytosis

32. Precipitants • Systemic disease • Infection, organ failure • Toxins and drugs • Withdrawal of EtOH, benzos, sedatives • Primary cerebral disease • Acute CVA, seizure • Psychophysiologic states • Anxiety, sensory deprivation, overstimulation, unfamiliar environment

33. Iatrogenic causes • Dehydration • Disorientation • Drugs • Immobilization • Sleep deprivation

34. Dr Sharon Marr’s approach • D rugs • E lectrolyte abnormalities • L ack of drugs (eg. Benzo withdrawal) • I nfection • R educed sensory input • I ntracranial process (CVA, seizure, bleed) • U rinary retention / fecal impaction • M yocardial (MI, CHF)

35. Approach to prevention • Minimize potential precipitants in patients at high risk of delirium • Use lower dose narcotics • Avoid benzodiazepines • Avoid anticholinergics (including Gravol) • Enable normal sleep-wake patterns • Promote early mobilization • Allow access to H2O unless contraindicated

36. Can we prevent delirium? • Inouye et al. (1999) • Controlled clinical trial – general medical service • Patients matched for age, sex, baseline delirium risk • Interventions aimed at addressing 6 risk factors Cognitive impairment (orientation, therapeutic activities) Sleep deprivation (warm drink, quiet ward, less done overnight) Immobility (early mobilization) Visual impairment (visual aids) Hearing impairment (amplifiers, communication techniques) Dehydration (encouraged po fluids)

37. Inouye (1999) - Results • Decreased rate of delirium • 9.9% vs. 15%, p=0.02 (42 vs. 64 cases) • Fewer total number of days of delirium • 105 vs. 161 days, p=0.02 • Fewer total number of episodes of delirium • 62 vs. 90 episodes, p=0.03 • Average cost $6341 per case of delirium prevented

38. Holroyd-Leduc, CMAJ 2009.Table 2. Examples of strategies that targeted risk factors in multicomponent intervention for the prevention of delirium

39. 4. Managing delirium http://www.acphospitalist.org/weekly/archives/2008/04/30/cartoon.jpg

40. Approach to management • Identify precipitant and reverse/treat it • Infection CBC, U/A, UCx, +/- CXR, +/- wound Cx, +/- blood Cx • Hypoxemia, hypercarbic resp failure, hypoglycemia ABG, O2 sat, CBGM • Dehydration, electrolyte disturbance SMA-10 (Na, Ca, Crt, BUN), volume status • Pain Poorly controlled pain or side-effects from medications

41. Consider the less common • Consider other causes of delirium not directly related to the OR • EtOH/benzo withdrawal • Acute CVA or seizure • Good history and exam – Most patients do not need CT head or EEG • Intracranial bleed • Any patient on full-dose anticoagulation or with hx of head trauma due to fall from bed

42. Avoid making things worse… • Judicious use of medications • Reduce doses of narcotics • Eliminate benzos and anticholinergics • Consider Imovane (zopiclone) if qhs sleep medication is still needed • Non benzodiazepine • May still worsen confusion or agitation • Start with 3.75 mg po qhs prn

43. Rx • Treat with antipsychotics – Haldol (haloperidol) • Risperdal, Zyprexa, Seroquel, Clozaril  1.6x death rate in dementia, not approved for delirium • Unlikely to cause EPS in short term • Can start with low doses (0.5 mg) but can increase doses as needed • Can Rx po or IM • Avoid IV (arrhythmia and sudden cardiac death) • Watch for NMS Fever, muscle rigidity, AMS, high CK Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79. O’Keefe ST. Age and Ageing 1999; 28-S2: 5-8.

44. Other Rx • Use benzodiazepines only for EtOH/sedative withdrawal • Otherwise, may worsen confusion & agitation Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79. O’Keefe ST. Age and Ageing 1999; 28-S2: 5-8.

45. Additional management • Family members / sitters at bedside • Eyeglasses / hearing aids • Provide calendars / clocks • Avoid multiple room switches Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79. Rubino FA. Neurol Clin N Am 2004; 22: 261-276.

47. Caution with physical restraints • Bedrails and restraints often used • No evidence of efficacy • Vest restraints can cause death from strangulation and contribute to pneumonia & decubitus ulcers • Falls more likely to result in injury 55% of falls result in injury (vs. 29%) Injuries were more severe (p<0.0001) Francis & Kapoor. Journal of General Internal Medicine 1990; 65-79 Tan KM et al. Irish Journal of Medical Science 2005; 174(3): 28-31 Rubino FA. Neurol Clin N Am 2004; 22: 261-276

48. Back to our cases • Mrs. A. • 72 year-old admitted for elective right hemicolectomy for colon Ca • PMH & Baseline • Hypertension – well controlled on HCTZ • Plays golf regularly in spring & summer; cross-country skiing in winter • Retired accountant; now “does the books” for a local not-for-profit organization • What’s her delirium risk?

49. Mrs. A.’s risk • Using Inouye et al.’s risk factor model, 0 of vision impairment, severe illness, cognitive impairment, High BUN:Crt • Using other known risk factors, has good functional capacity and good cognitive function at baseline. Only has well-controlled hypertension. • LOW delirium risk. No specific intervention needed

50. A different case… • Mrs. K. • 72 year-old admitted for elective right hemicolectomy for colon Ca • PMH & Baseline • CRF due to DM2 – creatinine 198, on insulin 4x/d • Lives by herself but has help from her children to pay bills • What’s her delirium risk?