Guideline Name: Delirium (at risk) in the Surgical Patient Approval Signature: May 10, 2012

Transcription

1 Evidence Informed Guideline Guideline Name: Delirium (at risk) in the Surgical Patient Approval Signature: Page 1 of 13 Date: May 10, 2012 Supercedes: 1. Introduction: (Taken from Grace Hospital (GGH) delirium guidelines & Registered Nurses Association of Ontario (RNAO) guidelines) Delirium, also referred to as an acute confusional state, is a serious clinical syndrome associated with mortality rates of 25-33% and increased lengths of hospital stay (McCusker, Cole, Dendukuri & Belzile, 2003). Studies have shown that it is under- recognized by health care workers. People who have experienced a delirium have described it as like being in the twilight zone, a fog bank or in a state of constant terror. Patients often retain bad memories about this experience. Delirium can be an indicator of severe illness and have a grave prognosis. It is often the first sign of an impending illness. It is associated with a higher risk of complications such as urinary incontinence, falls, and pressure ulcers. It is a predictor of morbidity, mortality, cognitive decline, functional decline, longer hospital stays with higher associated costs, and nursing home placements. While many patients do recover their cognitive function completely, some never return to their previous level. Multiple literature sources cite the significance of delirium in the healthcare continuum as an adverse event. It is considered a safety issue in hospitals as well as within the community. The ability to recognize the symptoms and to provide interventions in a preventative or timely manner is a healthcare provider s responsibility. Highlights from the literature: (RNAO Caregiving Strategies for Older Adults with Delirium, Dementia, and Depression (2004) % of patients in acute care settings have a delirium on admission 10 42% of patient develop a delirium during their admission 10 85% of post surgical patients experience delirium 28 61% of older adult patients with a hip fracture develop a delirium 20% of discharged post hip fracture patients still demonstrated evidence of delirium after discharge Length of stay doubled in the presence of delirium Mortality increased 3-5 times May be an indicator for future development of cognitive decline 1

2 2. Purpose: 2.1. Provide assessment and screening tools to determine the surgical patient s risk of developing a delirium Provide guidelines to be used as a resource to all staff caring for the surgical patient who has been diagnosed with or develops a delirium or is at risk of developing a delirium. 3. Definitions: 3.1. Delirium An acute transient pathological disorder which manifests itself with impaired cognitive (often mistaken for dementia), perceptual, emotional and behavioral alterations. Up to 50% of all hospitalized patients will experience a delirium. Delirium can be very distressing for patients and family members; the healthcare team should provide continuing reassurance to all. (HSC Older Adult Resource Committee Delirium Clinical Practice Guideline) An acute change in cognitive function characterized by fluctuating confusion, impaired concentration and attention. The acute confusional state is usually attributed to reversible causes and is characterized by: (Grace General Hospital Delirium & Delirium Guidelines Self Directed Resource Guide) Sudden onset Alterations in level of consciousness Reduced awareness of the environment Fluctuating attention/inability to focus Disorientation Hallucinations Agitation, picking at objects Hyperactive Delirium increased psychomotor activity characterized by: An agitated state Increased psychomotor activity Non-purposeful, repetitive movement Verbal behaviors such as shouting or calling out frequently Hypoactive Delirium decreased psychomotor activity characterized by: Quietly confused Some anxiety Lethargic, withdrawn and difficult to rouse Slow, limited speech Less frequently recognized as it s often dismissed as a transient and insignificant change because of the absence of disruptive, injurious behaviors Mixed Delirium characterized by the patient fluctuating unpredictably between hypo and hyperactive delirium Other manifestations may include: Behavioural o Fear, irritability, combativeness o Attempt to escape the environment 2

3 Feature Onset o Removal of medical equipment (i.e. IV lines, catheters) o Depression or euphoria o Acute sensitivity to light and sound Functional o Incontinence o Falls may be the first clue to delirium Autonomic o Hypertension o Tachycardia Differentiating between Delirium, Dementia, and Depression Delirium/ Acute Confusion Acute/sub acute; develops suddenly over hours or days Short, fluctuating often worse at night Dementia Chronic; insidious Depression Variable; may appear abrupt Course Long, progressive, yet Diurnal effects; stable loss over time typically worse in the morning Progression Abrupt Slow, but even decline Variable; rapid-slow Duration Hours to 1 month; may last longer in seniors Months to years At least 2 weeks; can be months to years Awareness Reduced Clear Clear Alertness Fluctuates; lethargic Generally normal Normal or hyper-vigilant Attention Impaired; fluctuates, unfocused, distracted Generally normal; varies with extent of disease Minimal impairment, but distractible Orientation Impaired; fluctuates in severity Increased impairment over time Selectively intact I don t know Memory Recent and immediate memory impaired Recent and remote memory impaired Selective or patchy memory impairment; islands of intact memory Thinking Disorganized, distorted, fragmented, rambling; may have frank psychotic symptoms. Difficulty with abstraction, judgments poor Intact, but with themes of hopelessness, helplessness or selfdeprecation Delusions Common Sometimes Rare Perception - hallucination Uncommon Distorted; visual, tactile, olfactory hallucinations occur in 40% of cases Rare; hallucinations absent, except in severe cases (psychosis) 3

4 4. Assessment The Nurse shall assess the patient s risk of developing delirium by reviewing risk factors from the WRHA PREoperative Assessment Patient Questionnaire. The Delirium Clinical Practice Guideline (see Appendix A) and the Delirium Decision Tree (see Appendix B) are used to assist staff to assess the risk of delirium pre and post operatively Risk Factors Causes of delirium may be multifactorial, involving both patient vulnerability and the number and severity of insults. The risk of delirium increases with the number of risk factors present. Risk factors for delirium include but are not limited to: Severe illness, co-morbidities Sensory impairment (vision or hearing impairment, head injury) Increasing age (65 years and over) is associated with increased risk. Older patients have less functional reserve and therefore do not tolerate physiologic insults as well as younger patients Cognitive impairment, history of previous episode(s) of delirium and those with dementia may be at a higher risk of developing delirium Metabolic/electrolyte imbalances, dehydration, malnutrition (as seen by alterations in BUN/Creatinine ratio, changes in serum sodium, potassium, calcium, Vitamin B12, blood glucose, and albumin levels) Multiple medications (6 or more) or new medications, or use of benzodiazepines; review the DPIN for the patient especially noting amounts of benzodiazepines and psychoactive medications prescribed History of alcohol and/or substance abuse Infections (e.g. UTI, upper respiratory infections, etc) Impairment of activities of daily living, (bathing/dressing/elimination/grooming/feeding)and immobilization (e.g. bed rest, restraints, catheters) Pain Depression Poor pre-morbid functional status Recovery from surgery: sleep alterations, unfamiliar environment, sensory overload, room without windows all may contribute to delirium in the post operative patient; orthopedic and post hip fracture repair patients are at particularly high risk NOTE: If more than two (2) risk factors identified from the WRHA PREoperative Assessment Patient Questionnaire or from the risk factors above are present, the patient may be at risk of developing delirium. Additional assessment using a delirium assessment tool may be required Assessment Tools Confusion Assessment Method (CAM) (Inouye et al, 1999) The CAM is one of the most common screening tools for delirium. It does not rate the severity of a delirium but rather the presence. A diagnosis of Delirium requires an answer of yes to and at least one of 3 and 4. 4

5 1) Evidence of acute change in mental status from baseline Did the behaviour fluctuate during the day? Did it tend to come and go or increase and decrease in severity? AND 2) Evidence of inattention did the patient have difficulty focusing attention, for example, being easily distracted or having difficulty keeping track of what was being said? AND EITHER 3) Evidence of disorganized thinking was the patient s thinking disorganized or incoherent, any presence of rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? OR 4) Altered level of consciousness any state other than alert; alterations may include vigilant /hyperalert, lethargic (drowsy, easily aroused) stupor (difficult to arouse) comatose (unarousable) Document the CAM as being positive or negative in the patient s health care record Delirium Elderly At-Risk Instrument (DEAR) Used for predicting post-operative delirium in the elderly. Risk Factors Age: Years 80 years or older 79 years or younger Do you use a hearing aid or have very poor vision? Yes Circle: Hearing Aid Poor Vision No ADL Needs assistance with: (circle) Bathing Yes No Dressing Yes No Toileting Yes No Grooming Yes No Feeding Yes No Cognition 1. Did you ever experience confusion or hallucinations or behavior which was unusual for you, following a surgery? 2. If yes to number 1, then do Mini-Cog (see below) Substance Use 1. Number of alcoholcontaining drinks per week: 2. Benzodiazepine use: Number of times per week: Impairment in any ADL Positive Mini Cog screen or Previous post-op Delirium Ethanol > 3 drinks per week or Benzodiazepines > 3 times per week Independent in all ADL Negative Mini Cog screen and No previous delirium Ethanol 3 drinks per week and Benzodiazepines 3 times per week 5

6 Number of risk factors: MINI-COG The Mini-Cog is a newly developed, reliable, and valid instrument used to screen for cognitive impairment consisting of a three-item recall test and a clock-drawing test (Doerflinger, D., 2007) How to administer: 1. Instruct the patient to listen carefully to and remember 3 unrelated words and then to repeat back the words. 2. Instruct the patient to draw the face of a clock, either on a blank sheet of paper or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask them to draw the hands at a specific time, such as 11:20. These instructions can be repeated, but no additional instructions can be given. Give the patient as much time as needed to complete the task. *The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time. 3. Ask the patient to repeat the 3 previously presented words. Scoring: 1 point for each recalled word after the CDT distracter. A score of 0 indicates a positive screen for cognitive impairment. A score of 1 or 2 with an abnormal CDT is a positive screen for cognitive impairment. A score of 1 or 2 with a normal CDT is a negative screen. A score of 3 is a negative screen On Admission: Establish a baseline; for example using a timed test of attention such as the time taken to count backwards from 20 to 0, or the time taken to recite the months of the year in reverse order Assess for the presence of any risk factors, and communicate/ document these findings Use risk screening tools i.e. Confusion Assessment Method (CAM) within 8 hours 4.4. Ongoing Care: If CAM is positive, continue to assess using CAM q shift and prn (with any cognitive and/or functional changes) If CAM is negative, continue to assess using CAM Q24 hours and prn (with any cognitive and/or functional changes) 4.5. Post surgery: Review baseline level of functioning. If behavioral changes are noted: o Communicate to other healthcare team members and document in the patient health record. o Review all pre-admission medications; look for recent changes in medications 6

7 Perform Confusion Assessment Method (CAM) for all surgical patients a minimum of once (1) per shift. Document in the patient s health record the results as negative (-) or positive (+). 5. Care Strategies and Interventions Causes of delirium are often multifactorial. Patient vulnerability to development of delirium may be due to increasing age and/or poor health status plus hospital-related procedures, treatments and/or environment, therefore health care professionals should implement multiple interventions to: Identify and treat reversible causes Maintain a safe environment that promotes recovery Maintain behavioral control o o Behavioral interventions Consider use of antipsychotic medications (when indicated) such as haloperidol Anticipate and prevent/manage complications Restore function 5.1 Look for Causes and Contributing Factors: I Infection (pneumonia, UTI, meningitis, syphilis, encephalitis, brain abscess, sepsis) W Withdrawal (ETOH, (delirium tremens), benzodiazepines, opioids, other drugs) A Acute Metabolic (diabetes, renal failure, elevated BUN, electrolyte imbalances) T Trauma (closed head injury, hyperthermia, burns, postop, shock) C CNS Pathology (CVA, tumors, abscesses, hemorrhages, metastatic disease) H Hypoxemia (anemia, drop in BP, cardiac failure, carbon monoxide poisoning) D Deficiencies (vitamins/ minerals, Degenerative brain diseases(ms,huntington s) E Endocrine Abnormalities (hypo/hyper: thyroidism, glycemia,calcemia A Acute Vascular (shock, CVA, infarcts, arteriosclerosis, decreased bloodsupply) T Toxins (drugs: prescription, OTC, street drugs, especially narcotics) H Heavy Metals (lead poisoning) (Wise, M.G., Hilty, D.M., Cerda, G.M., Trzepacz, P.T., 2002) Review recent and baseline diagnostic imaging and laboratory results. Monitor vital signs, fluid balance, blood glucose, elimination. Assess and manage pain. Focus on correcting underlying causes rather than treating symptoms. 5.2 Non-Pharmacological Interventions (Should always be tried first before using medications) Communication Establish eye contact Make contact at eye level Identify self by name at each contact Call patient by his/her preferred name Speak to patient calmly and slowly 7

8 Tell patient what you want done Validate patients fears and concerns Use short simple sentences Do not disagree/argue Reorient with each contact or validate Provide choices, but not > 2 Elicit family input regarding patient s interests and work history Ask family to complete patient information record Encourage regular visits by family Ensure patient s glasses, hearing aides, dentures, etc are in place and functioning Encourage reminiscing Provide frequent reassurance to patient and family 5.1. Environmental Minimize noise Minimize staff changes Modify activity re: need for less or more stimulation Encourage/permit and facilitate mobilization Provide food/fluids if appropriate Ask family to bring in familiar objects Promote night time sleep by keeping on bedtime routine, promoting ingestion of foods (warm milk, yogurt, salmon, turkey, ½ banana), encourage bedtime voiding, avoid caffeine, minimize lights and noise Structure daily routine Use clocks, calendars to assist with orientation to day time and place Allow television during day with daily news Increase/decrease lighting dependent on time of day Increase/decrease stimulation if appropriate Limit number of visitors Promote short rest periods throughout the day Ask family to stay with patient Provide repetitive tasks (i.e. fold laundry) Adjust/monitor room temperature Avoid room changes Use music appropriate to the patient 5.2. Physiologic Encourage and facilitate early and ongoing activity and mobility Implement pain assessment and management as per the WRHA Pain Assessment and Management Regional Clinical Practice Guideline Assess for hypoxia, hypoglycemia, fever, dehydration and infection Assess and ensure adequate hydration Check for and manage constipation and fecal impaction Check for and manage urinary retention Assess medication regimen 8

9 Assess for continued need of indwelling catheter, intravenous catheters (IVs) and other tubes Encourage good nutrition, as appropriate Initiate toileting routine as appropriate 5.3. Safety Use bed/chair alarms Consider moving patient closer to the nurses station Implement fall prevention protocol as per the WRHA Falls Prevention and Management Regional Clinical Practice Guidelines Ensure safe room set-up Leave bed in lowest position with brakes on Remove sharp objects Remove extra furniture from room Ensure proper footwear with non-skid soles Ensure walking aides are within reach Increase level of observation (e.g. close observation such as q 15 minute checks) 5.4. Pharmacological Management Focus on correcting underlying cause rather than just treating symptoms Use a single medication (rather than two) to decrease the potential for side effects/drug interactions Review current medications; many may contribute to delirium in the older adult Start with lowest dose Order regularly scheduled doses of analgesia (around the clock) with PRN for breakthrough pain Choose medications with lowest anti-cholinergic activity Try to discontinue medications as soon as possible Avoid use of benzodiazepines such as alprazolam, diazepam, clonazepam, lorazepam, triazolam Consider short-term, low and tapered dose use of antipsychotic medications for agitated delirium (use of risperidone or onlazapine is recommended in the current literature and is associated with less risk than Haloperidol) (Huybrechts, K.F., Gerhard, T. Crystal, S.,et al Feb 2012) Conclusion In the elderly, delirium may be the first sign of an impending illness. An organized, systematic approach with an emphasis on prevention, early diagnosis and effective management is of the greatest importance for a positive outcome. Think of delirium as nature s wake-up call to draw your attention to a serious health threat. Delirium is a medical emergency. 9

10 6. References: 6.1 Australian Health Minister s Advisory Council (2006) Clinical Practice Guidelines for the Management of Delirium in Older People. Victorian Government Department of Human Resources, Australia : Melbourne 6.2 British Geriatrics Society (2005). Predicting post-operative delirium in elective orthopedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Age and Ageing 2005; 34: pp Devies, B., Danseco, E., Ploeg, J., Heslin, K., Stansfield, M., Santos, J., and Edwards, N. (2006). Nursing Best Practice Guideline Evaluation User Guide: Restraint Prevalence Tools. Nursing Best Practice Research Unit, University of Ottawa, Canada. pp Doerflinger,D. (2007). The Mini-Cog. American Journal of Nursing, December 2007, Vol 107: 12. pp Grace General Hospital Delirium & Delirium Guidelines Self Directed Resource Guide Huybrechts, K.F., Gerhard, T. Crystal, S.,et al Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. British Medical Journal(BMJ) Feb23, HSC Older Adult Resource Committee Delirium Clinical Practice Guideline Inouye, S.K., The Confusion Assessment Method (CAM): Training Manual and Coding Guide. 2003; Yale University School of Medicine. 6.9 McMusker,J., Cole, M., Dendukuri, N.,and Belzile,E. (2003). Does Delirium Increase Hospital Stay? Journal of the American Geriatric Society, Vol 51:11 pp NICE Clinical Guideline 103 (2010) Delirium: diagnosis, prevention, and management National Institute for Health and Clinical Excellence Registered Nurses Association of Ontario. Caregiving Strategies for Older Adults with delirium, Dementia, and Depression. (June 2004) SOGH Using the Delirium Protocol Surgery Program (2009) Wise, M.G., Hilty, D.M., Cerda, G.M., Trzepacz, P.T., (2002). Delirium (confusional states). In: Wise, M.G. and Rundell, J.R. (Eds.), the American Psychiatric Press Textbook of Consultation Liaison Psychiatry, (2 nd ed.). Washington (DC): American Psychiatric Press, pp WRHA Falls Prevention and Management Regional Clinical Practice Guidelines (2011) 6.15 WRHA Clinical Practice Guideline Pain Assessment and Management (November 2010) 6.16 WRHA Policy # Restraints Minimization Acute Care Facilities (Adult). 10

11 7. Contributing Authors: Delirium Protocol Working Group members: Wendy Rudnick Michele Lepp Vera Duncan Christine Johnson Leslie Dryburgh Cheryl Bilawka Ember Benson Ann Reichert Valerie Hiebert Rayan Horswell-Tees Carol Knudson Lisa Anthony 8. Consultants: Dr. Claire Dionne (Anesthesia) 9. Reviewers: Dr. Barry Campbell Kathleen Klassen Graciana Medeiros WRHA Surgery Standards Committee: Rod Onotera Suyin Lum Min Andrew Mis 11

12 Appendix A Delirium Clinical Practice Guideline 12

13 Appendix B Delirium Decision Tree 13