Delirium assessment and management. Dr Kim Jeffs Northern Health

Transcription

1 Delirium assessment and management Dr Kim Jeffs Northern Health

2 What do you need to know? Epidemiology How big is the problem? Who is at risk? Assessment Tools for diagnosis Prevention Evidence base Management Interdisciplinary strategies

3 Delirium how common is it? Situation Prevalence Incidence Emergency department 10% - Medical inpatients 5 80% 5 53% Surgical inpatients 10% 9 52% Intensive care units 7-83% - Subacute care 15 23% - Palliative care 45% 43%

4 Australasian epidemiology Iseli (2007) 18% on admission, 2% incident Incomplete follow up and ad hoc testing Holden (2008) 23% on admission, 5% incident? Follow up Jeffs (2004) 21% prevalent delirium Jeffs (2008) 4% excluded as documented as having delirium, 5% found to have delirium on baseline assessment, 5% incident delirium Iseli R. Internal Medicine Journal. 2007;37(12): Holden J.Internal Medicine Journal Aug;38(8): Jeffs K 2004; Fremantle: Internal Medicine Journal; Jeffs Internal Medicine Journal 2008; 38 (Suppl. 5): A121

5 Subsyndromal delirium Some features of delirium but not meeting DSM criteria Poor outcomes in a continuum between no symptoms and delirium Recovery predicts outcome Different phenotypes, attentional deficits Cole et al J Am Geriatr Soc Nov;56(11): Cole et al J Am Geriatr Soc. 2003;51(6): Jeffs et al Internal Medicine Journal; 2004

6 Recognition awareness is the key DSM IV disturbance of consciousness, difficulty in sustaining or shifting attention, change in cognition/perceptual disturbance not better accounted for by dementia, disturbance develops over a short period of time and tends to fluctuate, identifiable underlying cause

7 Delirium CAM 1) evidence of acute change, fluctuation 2) inattention 3) disorganised thinking 4) altered level of consciousness diagnosis made: 1+2, & either 3 or 4 validated against psychiatric interview Inouye et al. Ann Intern Med Vol 113 (12)

8 NQR ALWAYS consider delirium Use tools such as the CAM Evidence linking partial syndromes with adverse outcomes means it is better to have false positives

9 Delirium risk Most studies are in hospital patients Little research in sub-acute, residential aged care and community populations

10 Baseline vulnerability Pre-existing cognitive impairment, sensory impairment, severe underlying medical illness, depression, alcohol misuse, pre-admission dehydration Multiple observational studies of variable quality

11 Precipitants Hospital environment Frequent rooms changes, absence of clock or watch, ICU environment Our medical and nursing care Restraints, IDC, adding >3 medications in a day, any iatrogenic event, malnutrition

12 Risk is multiplicative Pre-admission risk group Rate of delirium (per 100 person-days) Precipitating factors risk group Low Intermediate High Low Intermediate High Adapted from: Inouye et al JAMA 1996; 275:

13 Prevention - HELP Largest trial in medical patients: Inouye 852 patients, prospectively matched for age, sex, baseline risk of delirium as per predictive model HELP: geriatric nurse-specialist, Elder Life specialists, recreation specialist, physiotherapist, geriatrician, volunteers Quality control measures

14 Prevention - HELP Orientation protocol Non pharmacological sleep protocol Early mobilisation, minimal use of immobilising equipment Visual protocol glasses, lenses Portable amplifying devices, earwax Early recognition of dehydration

15 Prevention - HELP Incidence of delirium 9.9% vs 15% No change in severity or recurrence rates Cost benefit for patients at intermediate risk but not at high risk

16 Prevention - Jeffs RCT of 642 medical inpatients >65 Intervention: twice daily mobilisation and orientation protocol Delirium detected using 2 nd daily CAM Assessments blinded

17 Prevention - Jeffs Incident delirium: 6% in usual care arm, 5% in intervention arm No effect of the intervention on functional, residential or hospital utilisation outcomes Poor outcomes for those with delirium Prior cognitive impairment and impaired ADLs predictors of delirium risk

18 Prevention - Vidan Controlled trial acute geriatric ward vs. usual care Pts >70 with 1 delirium risk factor Assessed daily with the CAM Functional decline measured using a summary score of 6 basic ADLs Allocation not concealed? Analysis did attempt to account for differing practices Vidan. JAGS :

19 Prevention - Vidan 542 patients: 170 in treatment group, significantly older, more dependent and at higher delirium risk at baseline Reduced delirium in treatment group 12% vs 19% ( 37% relative risk) No difference in delirium severity, recurrent delirium or functional decline in those with delirium, only effective at intermediate risk Increased length of stay in the treatment group despite decreased functional decline

20 Management Non-pharmacological management Many of the same principles of prevention Communication strategies 1:1 nursing/sitter to reduce risk falls/aggression No good evidence that any management strategy reduces delirium outcomes.

21 Pharmacological management Rationale reduce distress worrying perceptual disturbance patient safety safety of others Significant side effects Worsen delirium

22 Pharmacological management Paucity of good quality trials Agents antipsychotics benzodiazepines cholinesterase inhibitors melatonin Drug prevention