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Reducing Confusion - Avoiding and managing perioperative delirium. Beth Cummings, MD FRCPC Perioperative Medicine Rounds GIM Fellowship Program, McGill University November 3, 2009. Learning Objectives. Understand the impact of delirium in the perioperative period

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reducing confusion avoiding and managing perioperative delirium

Reducing Confusion - Avoiding and managing perioperative delirium

Beth Cummings, MD FRCPC

Perioperative Medicine Rounds

GIM Fellowship Program, McGill University

November 3, 2009

learning objectives
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
1 the scope of the problem

1. The scope of the problem

(or Why should we care?)

how common is delirium
How common is delirium?

Francis & Kapoor. Journal of General Internal Medicine 5 (1990) 65-79.

how frequently now
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.

the scope of the problem
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.
increased morbidity
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.
poor functional recovery
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.
increased length of stay
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.
slide11
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

ganai et al findings
Ganai et al. - Findings
  • Results
    • Delirium 60%
    • Mortality 20%
    • Prolonged length of stay (≥14 days) 32%
increased costs
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)
2 recognizing delirium
2. Recognizing delirium

http://www.cartoonstock.com/lowres/rni0036l.jpg

often not diagnosed
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
dsm iv criteria
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…
clinical manifestations
Clinical manifestations
  • Wandering attention
  • Easily distracted
  • Hyperactive
    • Especially night-time agitation
  • Hypoactive
    • Daytime lethargy
  • Confusion
  • “He’s just not himself, Doctor”
a case
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?
a different case
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?
what we know
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’”
millar s findings
Millar’s findings
  • Post-operative psychiatric illness
    • Age over 80
    • Major operations
    • Biliary tract or malignant disease
    • Prescription of at least 5 drugs
millar s findings cont d
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 **

slide27
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
inouye et al validation
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
inouye et al outcomes
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
non modifiable risk factors
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

potentially modifiable risk factors
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
precipitants
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
iatrogenic causes
Iatrogenic causes
  • Dehydration
  • Disorientation
  • Drugs
  • Immobilization
  • Sleep deprivation
dr sharon marr s approach
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)
approach to prevention
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
can we prevent delirium
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)

inouye 1999 results
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
slide38

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

4 managing delirium
4. Managing delirium

http://www.acphospitalist.org/weekly/archives/2008/04/30/cartoon.jpg

approach to management
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

consider the less common
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
avoid making things worse
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
slide43
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.

other rx
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.

additional management
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.

caution with physical restraints
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

back to our cases
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?
mrs a s risk
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
a different case50
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?
mrs k s risk
Mrs. K.’s risk
  • Using Inouye et al.’s risk factor model, 2 of vision impairment, severe illness, cognitive impairment, High BUN:Crt
  • INTERMEDIATE delirium risk
  • Will need to use caution with Rx of analgesia, anticholinergics, sedatives
  • Should be assessed daily for development of delirium so investigation/management is not delayed.
take home messages
Take Home Messages
  • Delirium occurs in 10-15% of general surgery patients & is associated with increased mortality, morbidity, length of stay, and costs
  • Delirium may be preventable in intermediate/high risk patients
  • Management of delirium involves identifying and treating the precipitant, judicious use of medications, improving the patient environment, and haloperidol when needed
thank you

Thank you.

Questions?

references
References

Francis J & Kapoor WN. Delirium in Hospitalized Elderly. Journal of General Internal Medicine 1990; 5: 65-79.

Franco K, Litaker D, Locala J, Bronson D. The Cost of Delirium in the Surgical Patient. Psychosomatics 2001; 42: 68-73.

Ganai S, Lee KF, Merrill A, Lee MH, Bellantonio S, Brennan M, Lindenauer, P. Adverse Outcomes of Geriatric Patients Undergoing Abdominal Surgery Who Are at High Risk for Delirium. Archives of Surgery 2007; 142(11): 1072-1078.

Inouye SK, Viscoli CM, Horwitz, RI, Hurst LD, Tinetti ME. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Baed on Admission Characteristics. Annals of Internal Medicine 1993; 119: 474-481.

Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. NEJM 1999; 340(9): 669-676.

Laine C & Williams SV (Eds). In the clinic: Preoperative Evaluation. Annals of Internal Medicine 2009; ITC1: 1-16.

Litaker D, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for post-operative delirium. General Hospital Psychiatry 2001; 23: 84-89.

Millar HR. Psychiatric Morbidity in Elderly Surgical Patients. British Journal of Psychiatry 1981; 138: 17-20.

Noimark D. Predicting the onset of delirium in the post-operative patient. Age and Ageing 2009; 1-6.

O’Keeffe ST. Delirium in the elderly. Age and Ageing 1999; 28-S2: 5-8.

Rubino FA. Perioperative management of patients with neurologic disease. Neurologic Clinics of North America 2004; 22: 261-276.

Tan KM, Austin B, Shaughnassy M, Higgins C, McDonald M, Mulkerrin EC, O’Keefe ST. Irish Journal of Medical Science 2005; 174(3): 28-31.

Thomas DR & Ritchie CS. Preoperative Assessment of Older Adults. Journal of the American Geriatrics Society 1995; 43(7): 811-821.