Critical themes in Ageing - Delirium

Transcription

1 Critical themes in Ageing - Delirium Peteris Darzins BMBS PhD FRACP FRCPC Professor of Geriatric Medicine, Monash University, and Executive Clinical Director of Aged Medicine, Eastern Health Penelope Casey RN, BEd, BNurs(Hons) PhD Candidate, Monash University, and Clinical Nurse Educator, Eastern Health

2 Overview delirium introduction effects of delirium: - on people - on society - on health-care systems the future?

3 Delirium - introduction brain problem defined as a clinical syndrome many, many causes can occur to anyone, but is more common in older people

4 Delirium clinical syndrome sudden onset, fluctuating course, and inattention, and disorganised thinking, or altered level of consciousness

5 Example of delirium alcohol intoxication sudden onset, fluctuating course, and inattention, and disorganised thinking, or altered level of consciousness contrast with other conditions of brain failure dementia, depression

6 Pathophysiology of Delirium No specific pathology

7 Pathophysiology of Delirium No specific pathology? Multiple pathologies that look similar clinically recognised as delirium Condition A Condition B Condition C

8 Pathophysiology of Delirium No specific pathology? Multiple pathologies that look similar? Final common pathway delirium B

9 Pathophysiology of Delirium No specific pathology? Multiple pathologies that look similar? Final common pathway Specific brain pathology is a rare cause of delirium

10 Vulnerability and insults in causation of delirium High vulnerability Low vulnerability Low level High level insult insult

11 Vulnerability and insults in causation of delirium High vulnerability Low vulnerability Low risk of delirium Low level High level insult insult

12 Vulnerability and insults in causation of delirium High vulnerability Moderate to high risk of delirium Low vulnerability Low level High level insult insult

13 Vulnerability and insults in causation of delirium High vulnerability Low vulnerability Moderate to high risk of delirium Low level High level insult insult

14 Vulnerability and insults in causation of delirium High vulnerability Very high risk of delirium Low vulnerability Low level High level insult insult

15 Vulnerability and insults in causation of delirium High vulnerability Moderate to high risk of delirium Very high risk of delirium Low vulnerability Low risk of delirium Moderate to high risk of delirium Low level High level insult insult

16 Delirium effect on individuals can be profoundly emotionally disturbing

17 Delirium effect on individuals can be profoundly emotionally disturbing embarrassing

18 Delirium effect on individuals can be profoundly emotionally disturbing embarrassing causes other bad physical outcomes

19 Delirium adverse events Mortality death rate increased (doubled at 12/12) Morbidity more falls and other complications than similar patients without delirium

20 Delirium complicated by

21 Delirium complicated by pressure injury falls pneumonia

22 Dementia and Delirium Dementia Delirium

23 Dementia and Delirium Dementia Delirium

24 Delirium adverse events Mortality death rate increased Morbidity more falls and other complications than similar patients without delirium Cost increased increased LOS increased institutionalisation

25 so how much delirium is there?

26 Clinical Tests n sensitive n specific n if both sensitive and specific, then usually expensive and / or invasive

27 Sensitive tests detect all or most instances of the condition of interest but also label some persons as diseased when actually do not have the condition of interest (false positive) (PID positive in disease)

28 Detection of delirium 10x10 = 100 inpatients

29 Detection of delirium 17 have delirium

30 Detection of delirium apply a quick, cheap, minimally invasive test high sensitivity

31 Detection of delirium 45 have abnormal cognition screen delirium or something else

32 Detection of delirium Cannot rely on sensitive screening test to determine the presence of the condition of interest (delirium)

33 Specific test only abnormal when the condition of interest is present not triggered by similar conditions (NIH negative in health) normal when delirium is not present test only those screened abnormal by sensitive test

34 Detection of delirium x x x x x x x x x x x x x x x x x x x x x x x x x x x x x specific test is negative when the condition of interest is not present

35 Delirium at Eastern Health

36 Detection of delirium at Eastern Health Penelope Casey PhD student Supervisors Prof Peteris Darzins Prof Wendy Cross Prof Claire Johnson Delirium surveys Pilot study April 2016 Survey July 2016, April 2018, July 2018

37 4AT (4 A s Test)

38 4AT Test Outcomes

39 Three-Minute Diagnostic Interview for the Confusion Assessment Method Assessment 1. Patient interview 2. Assessor observations Four Features: 1. Acute Onset AND Fluctuating Course 2. Inattention 3. Disorganised thinking 4. Altered level of consciousness 3D CAM Training Manual for Clinical use. Boston: Hospital Elder Life Program.

40 Three-Minute Diagnostic Interview for the Confusion Assessment Method Delirium Feature 1 and Feature 2 PLUS Feature 3 and/or Feature 4 Specificity for detecting delirium in people with dementia 67-96% without dementia 91-99%

41 Survey Process Recruit and train clinicians Survey Recruit Patient Screen Assess Record outcome

42 Delirium at Eastern Health % 4AT Screen Score 0 Cognitive Impairment or Delirium Unlikely 932 Score 1-3 Possible Cognitive Impairment % Score 4 Possible Delirium ± Cognitive Impairment 464 3D-CAM Detection No Delirium 249 Delirium 55 Delirium 238 No Delirium 226 Delirium Detected %

43 Critical themes in Ageing - Delirium disturbingly common

44 Critical themes in Ageing - Delirium disturbingly common troubling poorly understood opportunities for research biological mechanisms ( novel therapies?) epidemiology prevalence, incidence health economics health services research etc

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