Delirium: The Confusion Conundrum

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Delirium The Confusion Conundrum

• February 4, 2011
• Mitchell T. Heflin, MD
• Barbara Kamholz MD
• Juliessa Pavon, MD
• Yvette West, RN, MSN, CNS

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Case Presentation

• Mr. A
• 82 year old white male post-op day 18 from AAA
  repair
• Consult for agitation and altered mental status
• HPI
• Pulsatile mass found by PCP on routine exam
• Confirmed as 8.2 cm infrarenal AAA on CT
• Referred for elective surgical repair

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Case History

• Past Medical History
• Hypertension
• Hyperlipidemia
• Smoked 1ppd until quit 1995
• s/p finger amputation on left hand from work
  accident
• Home Medications
• Simvastatin 40 mg daily
• Bisoprolol 5 mg bid
• ASA 81 mg daily
• ROS
• Denied abd pain, back pain, chest pain, sob,
  claudication

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Case History

• Family History
• Alzheimers disease in both parents
• Social History
• Lives at home alone, widower for 5 years
• Independent in ADLs and IADLs
• Physically active, playing golf daily
• Son and daughter do not live locally

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Case Hospital Course

• Elective AAA repair on 12/15/10
• POD 0 returned to OR for bleeding from aneurysm
• Following surgery
• Mental status did not return to baseline despite
  weaning off sedation
• Failed trial of extubation due to AMS
• POD 3 atrial fibrillation and tachycardia
• Amiodarone started
• POD 7 Trach and PEG

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Case Hospital Course

• POD 7-14 Restless and agitated
• Pulling at trach and PEG
• Attempts to treat with haldol, risperidone and
  ativan
• POD 16 Adynamic ileus and aspiration
• Vancomycin and ciprofloxacin
• POD 18 Geriatrics consulted
• Assist with management of agitation and altered
  mental status

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Case Medications

• Aspirin
• Amiodarone
• Metoprolol
• Vancomycin
• Ciprofloxacin
• Ativan 1 mg IV q6hrs
• Risperidone 0.5 mg VT qhs
• Haldol 0.5 1.5 mg IV PRN (5 mg in last 24 hrs)
• Dilaudid 0.5 mg IV q6hrs PRN (0 mg in last 24
  hrs)

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Case Exam

• T 36.4 HR 100s BP 90s/60s Pulse ox 97 on 40
  FiO2
• Gen
• Somnolent but easily arousable and anxious
• Grimacing and tachypneic
• Trach in place on ventilation

• Ext Restraints on hands, edema in LE
• Neuro
• Opens eyes to loud voice and tracks but does not
  follow simple commands
• moves all extremities
• no Babinski or clonus

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Case Diagnostic Testing

• Head CT No focal lesions
• CXR Small bilateral effusions
• KUB Mildly distended loops of small bowel
• WBC 12K, Hct 28
• Creatinine 1.0, Albumin 2.3, LFTs and TSH normal
• UA hematuria
• EKG Afib 100, Cardiac enzymes normal

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Case Daughters input

• Very physically and socially active
• Had problems with forgetfulness, repeating and
  perseverations in the prior year
• Very hard of hearing and wears glasses for
  distance vision
• Drank at least two-three glasses of wine each
  week

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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

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So whats the conundrum?

• Highly prevalent
• Associated with much suffering and poor outcomes
• Complex and often multifactorial
• Preventable but.
• Better care requires a shift in paradigm

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Objectives

• Describe the prevalence of delirium and its
  impact on the health of older patients
• Identify pathophysiology, risk factors and key
  presenting features
• Describe strategies for prevention and management
  
• Find opportunities to improve current practice

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A BIG Problem

• 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

Levkoff 1992 Naughton, 2005 Siddiqi 2006
Deiner 2009.
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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 HR1.95
• Institutionalization (14.6 mo)4 OR2.41
• Long term loss of function
• Incident dementia (4.1 yrs)4 OR12.52
• Excess of 2500 per hospitalization

1-OKeeffe 1997 2-McCusker 2003
3-Siddiqi 2006 4-Witlox
2010
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The experience
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Grade for Recognition D-

• 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!

Inouye 1998 Bair 1998.
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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

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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

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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
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Improving The Odds of Recognition

• Clinical examination
• CAM
• Team observations
• Nursing notes
• Prediction by risk
• Predisposing and precipitating factors

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Confusion Assessment Method (CAM)

• Acute onset and fluctuating course
• Inattention
• Disorganized thinking
• Altered level of consciousness

Or
Inouye 1994
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CAM

• Geropsychiatry assessment standard
• 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

• 1 Inouye 1996 2 Wong 2010.

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Nursing Input

• 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

Kamholz, AAGP 1999
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Risk Factors

• Predisposing factors Adjusted RR
• Vision impairment 3.5
• Severe illness (gtAPACHE 2) 3.5
• Cognitive impairment (MMSElt24) 2.8
• BUN/Cr gt18 2.0
• Precipitating factors Adjusted RR
• Physical restraints 4.4
• Malnutrition (wt loss, alb) 4.0
• gt3 meds added 2.9
• Bladder catheter 2.4
• Any iatrogenic event 1.9

Inouye 1996
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Putting it all together...
Precipitating Factors
Predisposing Factors
Inouye 1996
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Oxidative StressModel ARDS

• ANY source of ischemia
• Low cardiac output
• Impaired pulmonary function/oxygenation
• Low Hgb/Hct
• Mechanisms
• Ca influx, imbalance of neurotransmitters
• Neuronal damage, including decreased synaptic
  transmission cell death

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Inflammatory ProcessModel Sepsis

• Peripheral interleukins (IL6,TNFa, IL1B) induce
  symptoms of delirium
• Increase permeability of BBB
• Alter neurotransmission
• TNFa can persist for months in CNS
• May share inflammatory mechanisms with dementia

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Pathophysiology of delirium

• Delirium in frail patients often associated with
  disturbances of most basic substrates and
  cellular functions
• Impaired oxygenation (blood loss, pulmonary
  disease)
• Metabolic disturbances (Na, Calcium)
• Infection/inflammation (UTI, Pneumonia)
• Medications
• Primary CNS causes are in the distinct minority

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Multicomponent Intervention to Prevent Delirium

• 852 patients over 70 on Gen Med
• IM risk (1-2 RFs) or High risk (3-4 RFs)
• Randomized by units with prospective matching
• Standardized protocols for 6 risk factors
• ID Team Nurse specialist, PT, RT, MD and
  volunteers
• Outcomes assessed daily by CAM

Inouye 1999.
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Elder Life Program
Risk factor Protocol Outcome
Cognitive impairment Orientation and therapeutic activities Orientation score
Sleep deprivation Non-Rx sleep protocol Quiet nights Use of sleep meds
Immobility Early mobilization Removal of tethers ADL score
Vision problems Visual aids and adaptive equipment Early vision correction
Hearing loss Wax disimpaction, amplifying devices, other comm. techniques Whisper test
Dehydration Early recognition and volume repletion BUN/Cr lt 18
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Results of Multicomponent Intervention Trial
Control Intervention
Delirium incidence 15.0 9.9
Days of delirium 161 105
plt 0.02 for both outcomes
Inouye 1999.
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Results

• Most effective for IM risk group
• No change in severity of delirium
• Cost
• 327/pt
• 6341/case prevented
• No lasting beneficial effect on functional status
  or resource utilization
• Benefit replicated

Inouye 1999 Rizzo 2001 Bogardus 2003
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Reducing Delirium After Hip FractureGeriatrics
Consultation

• CNS oxygen delivery
• Fluid and electrolytes
• Treatment of pain
• Unnecessary medications
• Bowel/bladder
• Early mobilization

• Prevention, early detection and treatment of
  complications
• Nutrition
• Environmental stimuli
• Agitated delirium

Marcantonio 2001.
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Results
Control (n64) Intervention (n62) RR
Any delirium 50 32 0.64 (0.37-0.98)
Severe delirium 29 12 0.40 (0.18-0.89)

• No change in length of stay
• Most effective in patients without
• Pre-existing dementia
• ADL impairment

Marcantonio 2001.
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Pharmacotherapy

• Dopamine blockade1
• Haldol (1.5 mg daily) prophylaxis in high risk
  hip fracture patients
• No change in incidence
• Decrease in severity and duration
• Acetylcholinesterase inhibitor2
• Donepezil did not decrease incidence or severity
  of delirium

1 Kalisvaart 2005, 2 Liptzin 2005.
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Treating pain

• Prospective cohort study gt500 hip fracture
  patients with and without delirium
• Patients receiving lt10 mg IV Morphine/day were 5x
  more likely to become delirious
• Patients reporting severe pain 10x more likely to
  develop delirium

Morrison 2003.
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Delirium Management Key Points

• Early recognition of high risk patients and
  situations is key to effective management
• Prevention is more effective than treatment
• Address
• Physiologic
• Environmental
• Pharmacologic
• Psychosocial
• Enlist a team

Sendelbach and Guthrie, 2009.
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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, Benzos Monitor for S.E.s of pain
meds Low dose neuroleptic Benzos for withdrawal
Environmental Reorientation Continuity in
care Family or sitters Hearing aids,
glasses QUIET at night No restraints
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What about Mr. A?

• Psychosocial
• Watch for w/d symptoms off Ativan
• Educate patient and family
• Provide reassurance and means
• of communication

• Physiologic
• Control HR, BP improved
• Treat aspiration
• Bowel regimen
• Schedule oxycodone and acetaminophen
• Increase trach size
• Advance tube feeds

• Pharmaceutical
• Taper Ativan
• Monitor for S.E.s of Oxycodone
• Risperidone 0.5 mg bid

• Environmental
• Light, activity, orientation during day
• QUIET at nightavoid VS, meds, etc.
• Remove restraints
• Glasses on, loud voice and lip reading

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Geriatrics

• Inpatient consult service
• Assistance with older adults with
• Delirium and other cognitive disorders
• Multiple, complex medical problems
• Medications, medications, medications
• Goals of care
• Pager 970-0370

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Old way.

• D Dehydration
• E Electrolytes (including glucose, Ca)
• L Low oxygen
• I Infection
• R Retention of urine/stool
• I In pain
• U Under-diagnosed withdrawal
• M Medications

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A better way.
Physiologic
PAs
NPs
Psychosocial
Medicine
Nursing
Environmental
Pharmacologic
Social work
Patients and Caregivers
Pharmacy
Nutrition
Administrators
PT/OT
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• 5 year, 1.2 million project funded by HRSA
• Goal Create Geriatrics Education Hub
• Staffed by interprofessional faculty
• Focused on improving the care of older adults
  with or at risk for delirium
• Learning resources, clinical experiences and
  practice improvement projects
• Part of six school consortium addressing this
  issue

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Delirium Nursing StrategiesDuke
NICHEGeriatric Resource Nurse Initiative
Kristin Nomides RN Grace Kwon RN Samantha Badgley
RN Duke Hospital 2100
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Supporting Literature Nursing Interventions

• Yale Delirium Prevention Program
  multi-component interventions
• Cognitive impairment with Reality Orientation
• Sleep enhancement protocol
• Sensory impairment with therapeutic activities
  protocol
• Sensory deprivation
• Dehydration
• Reduction in delirium 9.95 (c) vs. 15 (i)
  LOS episodes
• Inouye, s. 2004
• Delirium education for team (MD and RN)
• Provided post program support and learning
  reinforcement
• 250 acute admit patients gt 70 recruited on 2
  units
• Delirium 12/122 intervention unit vs. 25/128
  control unit
• Tabet N,, et al, 2005
• Post op multi-factorial intervention educational
  program
• Teamwork and care planning on prevention and
  treatment of delirium
• Targeted delirium risk factors
• Post op delirium compared to controls (56/102
  and 73/97)
• Lundrtrom, et al. 2007

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Nursing Interventions

• Delirium Risk Factors Staff Education
• Activity Cart / Busy Apron
• Stimulate cognitive and motor skills
• All About Me Poster
• Orientation Information
• Me File
• Orientation information provided by patient /
  family for high risk patients
• Question Mark
• Identification of patients with AMS

? Altered Mental Status
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Summary

• RESPECT delirium. Its common and caustic.
• PREDICT delirium. Assess for common predisposing
  and precipitating factors.
• RECOGNIZE delirium. It can be diagnosed with
  simple tools (e.g. CAM).
• PREVENT delirium. It can be averted with
  multicomponent strategies.
• RECRUIT team members to improve care.

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GEC crew

• Sandro Pinheiro, PhD
• Robert Konrad, PhD
• Emily Egerton, PhD
• Heidi White, MD
• Kathy Shipp, PT, PhD
• Deirdre Thornlow, RN, PhD
• Lisa Shock, MHS, PA-C
• Michelle Mitchell, LMBT
• Michele Burgess, MCRP
• Joan Pelletier, MPH
• Sujaya Devarayasamudram, RN, MSN
• Loretta Matters, RN, MSN

• Eleanor McConnell, RN, MSN, PhD
• Anthony Galanos, MD
• Jason Moss, PharmD
• Julie Pruitt, RD
• Cornelia Poer, MSW
• Gwendolen Buhr, MD
• Mamata Yanamadala, MD
• S. Nicole Hastings, MD
• Jennie De Gagné, PhD, MSN, MS, RN-BC
• Katja Elbert-Avila, MD