First, Do No Harm: The Geriatric Patient. Objectives. What is Delirium? 5/3/2011

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1 First, Do No Harm: The Geriatric Patient Debbie Harrell M.S., DPh Sandy McGill RN, MSN, MBA Laurence Solberg MD Amber Velasquez MSN, ANP BC Objectives The Learner will be able to: Identify the risks for and causes of delirium Recognize the clinical presentation and assessment of a patient with delirium Recommend or provide treatments for behaviors and pharmacologic strategies to minimize the personal, social, and financial impact of the patient and family What is Delirium? DSM IV TR: A transient organic mental syndrome characterized by reduced level of consciousness, reduced ability to maintain attention, perceptualdisturbances disturbances, andmemory impairment Meiner, S. and Luechenotte, A. (2006). Gerontological Nursing. 3 rd Edition. Mosby/Elsevier: St. Louis. 1

2 Delirium is a MEDICAL EMERGENCY! Onset: Acute Description of Delirium Duration: Short (hours to days) Progress: Wax and wanes but typically resolves Risk Factors Advanced Age (>75 y.o.) Dementia Medical Illness Multiple Medications (>5) ETOH Abuse Male Gender Relocation Poor functional status Depression Pain Increased BUN/creatinine ratio Sensory Impairment Fann, J.R. (2000). The epidemiology of delirium: A review of studies and methodological issues. Seminars in Clinical Neuropsychiatry, 5, Evidence Level Systematic Review. Elie, M.,Cole, M.G., Primeaus, F.J., & Bellavance, F. (1998). Delirium risk factos in elderly hospitalized patients. Journal of General Internal Medicine, 13, Evidence Level 1: Systematic Review. Delirium: A Medical Emergnecy. Retrieved September 3,

3 Why should we care about delirium? Significant prevalence in hospitalized population, especially older adults up to 25% of older adults are hospitalized with delirium, and up to 56% develop delirium during hospitalization. Increases other risks: Delirium increases the patient s risk of increased morbidity (illness) and mortality (death). Inouye, SK. Delirium in older persons. N Engl J Med 2006; 354(11): Inouye, SK, et al. Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. J of Gen Intern Med 1998; 13(4): How does delirium affect the nurse? Caring for a delirious patient can increase the nurse s workload by: Re insert/reapply needed medical equipment/devices (IV s s, bandages, woundsvacs vacs, catheters) that have been pulled out/off by the patient Increase need to view patient with delirium because of high risk for falls Increase need for frequent nursing interventions in the delirious vs. non delirious patient Orientation Appropriate Sensory Stimulation Facilitate Sleep Facilitate Sleep Familiarity Maximize Mobility Communicate Clearly Minimize Invasive Interventions Hydration/Nutrition Care Strategies 3

4 What Beers Criteria are NOT: Developed for hospitalized older adults Perfect Strict Do s and Don ts Set in stone A substitute for clinical judgment Applicable to all patient populations End of life patients often require Beers meds for symptom management A basis for punitive interventions Therefore Beers medications are referred to as Potentially Inappropriate Medications in Older Adults Adverse Outcomes Associated with Use of Beers Medications Delirium Cognitive Impairment Depression Constipation Immobility Falls resulting in hip fracture Over sedation Increased health care utilization/cost Increased rates of ED visits, hospitalization Increased mortality Fick et al, Am J Mange Care. 2004; 10: ; Fick et al, J Mange Care Pharm 2001; 7: : Dedhiya et al, Am J Geriatric Pharmacotherapy. 2010;8: What about Beers Medications in Hospitals? 13 50% of hospitalized older adults receive at least 1 Beers medication In a large study of 40 academic health centers, 7 most common Beers meds in hospitalized older adults were: 1. Diphenydramine 20% 2. Promethazine 10% 3. Amiodarone 7% 4. Meperidine 5% 5. Clonidine 5% 6. Ketorolac 5% 7. Diazepam 5% Shorter mean LOS in older adults NOT prescribed a Beers drug 4.86 ±6.5 days vs 7.87 ± 10.1 days, p<0.05 Egger et al. Drug Agign, 2006; 23: Onder et al, Eur J Clin Pharmocol 2005; 61: Page et al, Am J Geriatr Pharmacother 2006;4: Bonk et al, Am J Health Syst Pham 2006;62:

5 Case #1 Birdie Situation Shift Report Birdie is a 78 y.o. woman who was admitted yesterday after being found on the floor in her home. From the ED report she was combative and confused when she arrived. Background Birdie was unable to give much information due to being upset last night but from her medical record she lives alone and has a history of intermittent dizziness and shortterm memory loss. Assessment At the present time, Birdie is calm and is not acting aggressive to the staff. When transferring her into the hospital bed last night, she continued to repeat Why are all these people in my house? [Bedside report: note Birdie picking at the air] Recommendations She hasn t tried to get out of bed but the staff is taking turns keeping a close eye on her. Also double check her ordered medications for appropriateness with the team when they round this morning. Medications Home Medications Lortab 10/500 PRN twice a day Amitripyline 50mg PO at bedtime Metoprolol 25mg PO twice a day Prilosec 20mg PO daily Boniva 150mg PO monthly Benefiber PRN Citalopram 40mg daily Klonipin 1mg at bedtime Lisinopril 20mg daily Hospital Medications Lortab 10/500 PRN twice a day Amitipryline 50mg PO at bedtime Metoprolol 25mg PO twice a day Ranitidine 150mg twice a day Citalopram 40mg daily Lorazepam 1mg every 6hrs for agitation Lisinopril 20mg daily Diphenhydramine 25mg PRN for itching 5

6 Later in the shift Four hours has passed the urinalysis for Birdie is reported from the laboratory as being positive for Leukoesterase, Nitrite, and numerous bacteria and WBCs. She is started on an antibiotic. Infection: increase risk for delirium Case #2 Burley Shift Report Situation Burley is a 80 y.o. POD#1 ORIF (open reduction internal fixation) of the right hip resulting from a fall. Background Nursing home resident with moderate dementia, HTN, CAD and GERD Assessment Burley has been agitated all night and pulling at lines and tele box, restraints were placed for safety. Incision is clean and dry. [Bedside Report: note patient is resting comfortably] Recommendations Keep the restraints applied, he can be very agitated. 6

7 Head to Toe Assessment 0715; patient is sleeping soundly VS: BP 142/86, RR 22, Temp 98.2, HR 65 Patient wakes up when you are taking his vital signs but he is groggy and difficult to understand. He attempts to move his arms and struggles against the restraints. Later in the shift During 10am med pass, you go into the room to give his medications, you find him awake and struggling against the restraints. He starts yelling when he sees you Lucy, Lucy! You try and assess him for pain but he won t answer and keeps repeating Lucy! You ask him if he needs to go to the bathroom, again he does not answer. You attempt to give him medications but he spits them out. If the restraints had been removed at 7:15am when Burley was sleeping and calm would he be as agitated and restless at 10am? 7

8 In the afternoon At 1pm PT/OT arrives for initial consult. Unable to assess due to restraints. Burley eats very little l over the course of the day due to his agitation and restraints. You sign off to the night shift Debrief: Was this a harmful day for Burley? POD#2 Patient is again sleeping when you enter the room, he wakes easily but is still agitated and pulling at the restraints. The geriatric consultant instructed you to remove the restraints, foley, telemetry and get the patient up to a chair for meals. He now has scheduled dose of Lortab 5mg po three times a day. PT/OT daily. 8

9 Burley s Outcomes The nurse removed the telemetry, foley and restraints. The CP assisted him to a chair for breakfast. Burley starts reaching for his food and feeding himself. Lortab was given during 10am med pass. PT/OT arrived at 11am and was able to participate in therapy. His mental status has improved throughout the day and is now following commands. When in bed he is calm and not struggling against anything. His daughter Lucy comes in to visit most of the afternoon. By evening he is tired and sleeps through the night. Summary The Learner can now: Recognize the risks for and causes of delirium Recognize the clinical presentation of a patient with delirium Preform an assessment of a patient with delirium Recommend or provide treatments for behaviors and pharmacologic strategies to minimize the personal, social, and financial impact of the patient and family Questions? 9