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DELIRIUM TRANSLATING RESEARCH INTO PRACTICE

DELIRIUM TRANSLATING RESEARCH INTO PRACTICE. Sharon K. Inouye, M.D., M.P.H. Professor of Medicine Yale University School of Medicine Z:/Inouye/talks&slides/McMaster Talk_Translating research into practice.ppt. WHAT IS DELIRIUM? (Acute Confusional State). Definition:

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DELIRIUM TRANSLATING RESEARCH INTO PRACTICE

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  1. DELIRIUMTRANSLATING RESEARCH INTO PRACTICE Sharon K. Inouye, M.D., M.P.H. Professor of Medicine Yale University School of Medicine Z:/Inouye/talks&slides/McMaster Talk_Translating research into practice.ppt

  2. WHAT IS DELIRIUM?(Acute Confusional State) Definition: • acute decline in attention and cognition Characteristics: • common problem • serious complications • often unrecognized • may be preventable

  3. EPIDEMIOLOGY OF DELIRIUM Prevalence (on admission) 10-40% Incidence (in hospital) 25-60% Hospital mortality: 10-65% 2-20 x controls Excess annual health care expenditures: $>8 billion

  4. CURRENT IMPACT OF DELIRIUM • 35% of the U.S. population aged ≥ 65 years is hospitalized each year, accounting for > 40% of all inpatient days • Assuming a delirium rate of 20%: • 7% of all persons ≥ 65 years will develop delirium annually • Delirium will complicate hospital stay for > 2.2 million persons/year, involving > 17.5 million in-patient days/year • Estimated costs: > $8 billion/year

  5. IMPACT OF DELIRIUM Beyond hospital costs Post-hospital costs • Institutionalization • Rehabilitation • Home care • Caregiver burden Aging of U.S. population

  6. RECOGNITION OF DELIRIUM • Previous studies: 32-66% cases unrecognized by physicians • Yale-New Haven Hospital study (1988-1989): • 65% (15/23) unrecognized by physicians • 43% (10/23) unrecognized by nurses

  7. DEVELOPMENT OF A DELIRIUM INSTRUMENT Ref: Inouye SK, et al. Ann Intern Med. 1990, 113: 941-8.

  8. CONFUSION ASSESSMENT METHOD(CAM) • Developed to provide a quick, accurate method for detection of delirium • For non-psychiatrically trained clinicians • Both clinical and research settings

  9. KEY FEATURES OF DELIRIUM • Acute onset and fluctuating course • Inattention • Disorganized thinking • Altered level of consciousness Note: disorientation and inappropriate behavior not useful diagnostically

  10. SIMPLIFIED DIAGNOSTIC CRITERIA -- Uses 4 criteria assessed by CAM: (1) acute onset and fluctuating course (2) inattention (3) disorganized thinking (4) altered level of consciousness -- The diagnosis of delirium requires the presence of criteria: (1), (2) and (3) or (4)

  11. VALIDATION OF CAM Site ISite II (n=30) (n=26) Sensitivity 10/10 (100%) 15/16 (94%) Specificity 19/20 (95%) 9/10 (90%) Positive predictive accuracy 10/11 (91%) 15/16 (94%) Negative predictive accuracy 19/19 (100%) 9/10 (90%) Likelihood ratio 20.0 9.4 (positive test)

  12. SHORTENED FOLSTEIN MINI-MENTAL STATE EXAMINATION ORIENTATION 1. What is the: (year) (season) (date) (day) (month)? 2. Where are we: (state) (county) (town) (hospital) (floor)? REGISTRATION 3. Name 3 objects: (apple) (table) (penny) Ask the patient all 3 after you have said them. Repeat until all 3 are learned. ATTENTION 4. Spell “WORLD” backwards. RECALL 5. Ask for 3 objects in Q3.

  13. ASSESSMENT FOR INATTENTION • Digit span test • Repetition • Months backwards • Vigilance task (Random “A”) • Trail-making

  14. SPECTRUM OF DELIRIUM Ranging from: Hypoactive delirium (lethargy, excess somnolence) -- often missed to: Hyperactive delirium (agitated, hallucinating, inappropriate)

  15. COMPARATIVE FEATURES OF DELIRIUM AND DEMENTIA

  16. PATHOPHYSIOLOGY OF DELIRIUM • Poorly understood • Functional rather than structural lesion • Characteristic EEG findings (generalized slowing) • Final common pathway of many pathogenic mechanisms—resulting in: • widespread reduction of cerebral oxidative metabolism • Failure of cholinergic transmission

  17. ETIOLOGY Dementia Electrolytes Lungs, liver, heart, kidney, brain Infection Rx Injury, pain, stress Unfamiliar environment Metabolic

  18. MINIMIZE PSYCHOACTIVE MEDICATIONS“Check those drugs” • Frequently access medication list • Minimize psychoactive medications • Avoid PRN’s • Use nonpharmacological approaches • Substitute less toxic alternatives (e.g. antacid or Carafate for H2 blocker Metamucil/Kaopectate for Lomotil) • Reduce dosage 3) Re-evaluate chronic medication usage • Hospital ideal time to make changes • Substrate is not the same

  19. NONPHARMACOLOGICAL SLEEP PROTOCOL • Give a 5 minute back rub • Give a warm drink (patient’s choice of warm milk or herbal tea) • Put on relaxation tapes • Allow one hour to assess effectiveness Ref: McDowell JA, et al. J Am Geriatr Soc. 1998;46:700-5.

  20. EFFECTIVENESS OF SLEEP PROTOCOL(N = 111) • Feasible, with adherence rate of 74% • Effective with dose-response relationship --quality of sleep correlated with number of parts of protocol received --reduced use of sleep medications from 54% to 31% (p<0.002) • Nontoxic, acceptable to patients

  21. SLEEP • Schedule medications, vital signs, procedures to allow uninterrupted sleep • Lights off and decreased noise-level at night • No naps during the day

  22. EVALUATION AND MANAGEMENT OF DELIRIUM • Cognitive Evaluation: Folstein Mini-Mental State Examination and Confusion Assessment Method Determine if acute change (e.g., family member) • Search for underlying etiology: Physical examination (including neurological exam) and vital signs Review medication list (current and preadmission), alcohol history Targeted metabolic work-up: CBC, lytes, BUN/Cr, Glucose, LFT’s, Calcium, p02, EKG Search for occult infection Neuroimaging or LP in < 5% cases

  23. CRITERIA FOR NEUROIMAGING • History of recent falls or head trauma • Signs of head trauma • Focal neurologic changes • Fever/acute mental status changes, suspicion of encephalitis • No identifiable etiology of acute mental status change

  24. DELIRIUM MANAGEMENTPHARMACOLOGIC APPROACHES Indications: reserved for patients with severe agitation which will: • cause interruption of essential medical therapies (e.g., intubation) • pose safety hazard to patient or staff Treatment: • Haloperidol 0.5-1.0 mg IM or po (IV short acting) • Repeat dose Q 30 minutes until sedation achieved (maximum haloperidol dose 3-5 mg/24 hours) • Maintenance: 50% loading dose in divided doses over next 24 hours • Taper dose over next few days

  25. THE YALE DELIRIUM PREVENTION TRIAL Inouye SK. N Engl J Med 1999;340:669-76.

  26. YALE DELIRIUM PREVENTION PROGRAM • Designed to counteract iatrogenic influences leading to delirium in the hospital • Multicomponent intervention strategy targeted at 6 delirium risk factors Risk FactorIntervention Cognitive Impairment………………………………….Reality orientation Therapeutic activities protocol Sleep Deprivation…………………………………….. Nonpharmacological sleep protocol Sleep enhancement protocol Immobilization………………………………………… Early mobilization protocol Minimizing immobilizing equipment Vision Impairment…………………………………….. Vision aids Adaptive equipment Hearing Impairment………………………………….. Amplifying devices Adaptive equipment and techniques Dehydration…………………………………………… Early recognition and volume repletion

  27. YALE DELIRIUM PREVENTION TRIAL RESULTS

  28. THE HOSPITAL ELDER LIFE PROGRAM(HELP) A model of care to prevent delirium and functional decline in hospitalized older patients Inouye SK, et al. J Am Geriatric Soc. 2000;48:1697-1706

  29. HOSPITAL ELDER LIFE PROGRAMGOALS An innovative approach to improving hospital care for older patients, with primary goals of: • Maintaining physical and cognitive functioning throughout hospitalization • Maximizing independence at discharge • Assisting with the transition from hospital to home • Preventing unplanned readmission

  30. DELIRIUMHEALTH POLICY IMPLICATIONS Delirium serves as a marker for quality of hospital care for the elderly • Often iatrogenic • Linked to processes of care • Common, bad outcomes Delirium serves as a window for identifying quality – improving changes. Inouye SK. Am J Med. 1999;106: 565-73

  31. RISKS OF IATROGENIC COMPLICATIONS • Rates of iatrogenic complications in 29-38% older hospitalized patients (Reichel 1965, Steel 1981, Becker 1987). • Increased risk of complications in older 3 – 5 fold patients (Gillick 1982, Brennan 1991).

  32. ENSURING PATIENT SAFETY • Human beings, in all lines of work, make errors • People working in health care are among the most educated and dedicated workforce in any industry. The problem is not bad people; the problem is that the system needs to be made safer. • Errors can be prevented by designing systems that make it hard for people to do the wrong thing and easy for people to do the right thing. - Committee on Quality of Health Care in America, Institute of Medicine, 2000

  33. WHAT CAN WE DO • Cognitive Assessment: MMSE and CAM • Medication chest biopsy • Use of nonpharmacologic approaches to management of sleep, anxiety, agitation • Avoid bedrest orders • Make sure glasses, hearing aids, dentures available • Let patients know their schedule (tests, etc.) Keep them involved in their care.

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