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Delirium Teaching Rounds: Recognition

Delirium Teaching Rounds: Recognition. September 2, 2011. Delirium: Definitions. Acute disorder of attention and global cognitive function DSM IV: Acute and fluctuating Change in consciousness and cognition Evidence of causation Synonyms: organic brain syndrome, acute confusional state

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Delirium Teaching Rounds: Recognition

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  1. Delirium Teaching Rounds:Recognition September 2, 2011

  2. Delirium: Definitions • Acute disorder of attention and global cognitive function • DSM IV: • Acute and fluctuating • Change in consciousness and cognition • Evidence of causation • Synonyms: organic brain syndrome, acute confusional state • Not dementia

  3. So what’s the conundrum? • Highly prevalent • Associated with much suffering and poor outcomes • Complex and often multifactorial • Preventable but…. Requires a shift in paradigm

  4. Objectives • Describe the prevalence of delirium and its impact on the health of older patients • Identify risk factors and key presenting features • Find opportunities to improve communication about delirium

  5. A BIG Problem Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009. • Hospitalized patients over 65: • 10-40% Prevalence • 25-60% Incidence • ICU: 70-87% • ER: 10-30% • Post-operative: 15-53% • Post-acute care: 60% • End-of-life: 83%

  6. Costs of Delirium In-hospital complications1,3 UTI, falls, incontinence, LOS Death Persistent delirium– Discharge and 6 mos.2 1/3 Long term mortality (22.7mo)4 HR=1.95 Institutionalization (14.6 mo)4 OR=2.41 Long term loss of function Incident dementia (4.1 yrs)4 OR=12.52 Excess of $2500 per hospitalization 1-O’Keeffe 1997; 2-McCusker 2003; 3-Siddiqi 2006; 4-Witlox 2010

  7. The experience… • Difficult for everyone: • 101 terminally ill cancer patients—54% recalled the experience • Distress scale 1 (least severe)  4 (most severe) • Patients 3.20 • Family member 3.75 • Nurses 3.10 Brietbart 2002.

  8. Grade for Recognition: D- Inouye 1998 ;Bair 1998. • 33-95% of in hospital cases are missed or misdiagnosed as depression, psychosis or dementia • ER: 15-40% discharge rate of delirious patients • 90% of delirium missed in ED is then also missed in hospital!

  9. Clinical Features of Delirium • Acute or subacute onset • Fluctuating intensity of symptoms • Inattention – aka “human hard drive crash” • Disorganized thinking • Altered level of consciousness • Hypoactive v. Hyperactive • Sleep disturbance • Emotional and behavioral problems

  10. Clinical Features of Delirium • Acute or subacute onset • Fluctuating intensity of symptoms • Inattention – aka “human hard drive crash” • Disorganized thinking • Altered level of consciousness • Hypoactive v. Hyperactive • Sleep disturbance • Emotional and behavioral problems

  11. In-attention • Cognitive state DOES NOT meet environmental demands • Result= global disconnect • Inability to fix, focus, or sustain attention to most salient concern • Hypoattentiveness or hyperattentiveness • Bedside tests • Days of week backward • Immediate recall

  12. This Can Look Very Much Like… • ….depression • 60% dysphoric • 52% thoughts of death or suicide • 68% feel “worthless” • Up to 42% of cases referred for psychiatry consult services for depression are delirious • Farrell 1995

  13. Mrs. Smith-1

  14. Improving The Odds of Recognition • Prediction by risk • Predisposing and precipitating factors • Team observations • Nursing notes • Clinical examination • CAM • MDAS

  15. Risk Factors Predisposing factors: Adjusted RR • Vision impairment 3.5 • Severe illness (>APACHE 2) 3.5 • Cognitive impairment (MMSE<24) 2.8 • BUN/Cr >18 2.0 Precipitating factors: Adjusted RR • Physical restraints 4.4 • Malnutrition (wt loss, alb) 4.0 • >3 meds added 2.9 • Bladder catheter 2.4 • Any iatrogenic event 1.9 Inouye 1996

  16. Putting it all together... Precipitating Factors Predisposing Factors Inouye 1996

  17. Predisposing • Advanced age • Preexisting dementia • History of stroke • Parkinson disease • Multiple comorbid conditions • Impaired vision • Impaired hearing • Functional impairment • Male sex • History of alcohol abuse Precipitating • New acute medical problem • Exacerbation of chronic medical problem • Surgery/anesthesia • New psychoactive medication • Acute stroke • Pain • Environmental change • Urine retention/fecal impaction • Electrolyte disturbances • Dehydration • Sepsis Common Risk Factors for Delirium Marcantonio, 2011.

  18. Nursing Input Kamholz, AAGP 1999 • Chart Screening Checklist • Nurses’ commonly charted behavioral signs (Sensitivity= 93.33%, Specificity =90.82% vs CAM) • Pulling at tubes, verbal abuse, odd behavior, “confusion”, etc • 97.3% of diagnoses of delirium can be made by nurses’ notes alone using CSC • 42.1% of diagnoses made by physicians’ notes alone using CSC

  19. Confusion Assessment Method (CAM) • Acute onset and fluctuating course • Inattention • Disorganized thinking • Altered level of consciousness Or Inouye 1994

  20. CAM • Recent systematic review2 • Sensitivity 86% (74-93) • Specificity 93% (87-96) • LR + 9.4 (5.8-16) • LR – 0.16 (0.09-0.29) • Other tools: • CAM-ICU • Delirium Rating Scale (DRS) 1 Inouye 1996; 2 Wong 2010.

  21. Memorial Delirium Assessment Scale (MDAS) • Rates severity of delirium • Validated in palliative care • 10 item, 4 point clinician-rated scale (0-30) • Awareness, orientation, memory, digit span, attention, organization, perception, delusions, psychomotor activity, sleep-wake cycle • Cut-off of 13 for diagnosis of delirium • Sensitivity 71%, Specificity 94% Brietbart 2007.

  22. Mrs. Smith- 2

  23. Summary • Maintain a high level of suspicious • Screen for delirium using a validated tool • Document findings in the chart • Discuss with other members of the team • Inform/educate patients and families

  24. Psychosocial Assess substance use Address stress and distress Educate patient and family Assess decision making Consider function and safety • Physiologic • O2 and BP • Food and fluids • Sleep/wake cycle • Activity and mobility • Bowel and bladder • Pain • Infections Pharmaceutical Reduce/avoid certain meds - Benadryl, Benzo’s Monitor for S.E.’s of pain meds Low dose neuroleptic Benzo’s for withdrawal • Environmental • Reorientation • Continuity in care • Family or sitters • Hearing aids, glasses • QUIET at night • No restraints

  25. A better way…. NP’s Physiologic PA’s Psychosocial Medicine Nursing Environmental Social work Pharmacologic Patients and Caregivers Pharmacy Nutrition Administrators PT/OT

  26. Delirium Teaching Rounds:Insult to Injury October 7, 2011

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