Delirium and cognitive impairment in the perioperative

Transcription

1 Delirium and cognitive impairment in the perioperative period Richard Sztramko Assistant Professor, McMaster University Divisions of Geriatrics and General Internal Medicine

2 Disclosures Chief Medical Officer - Reliq Health Technologies Director - Virtual Ward Medicine Corp Director - Apollo Healthcare Technologies

3 Objectives Demonstrate an understanding of the morbidity and mortality associated with acute delirium Describe key bedside tests to diagnose delirium Integrate evidence-based and evidence-informed management principles of peri-operative delirium into clinical practice Describe principles for dealing with cognitively impaired individuals in the peri-operative period

4 What is delirium? Acute confusional state characterized by: Fluctuation Inattention Depressed level of consciousness Disorganized thinking Perceptual disturbances - hallucinations/illusions Emotional dysregulation - anxiety/paranoia/depression/apathy

5 What is delirium? Not better explained by pre-existing cognitive impairment - dementa/abi etc Usually explained by a general medical condition, medication, status post-op Delirium = ATN of the brain - weak brain/weak insult - strong brain/strong insult

6 Pathophysiology Inflammation Stress and related hormonal imbalances Neurotransmitter abnormalities

7 Clinical Causes DIMSUS Drugs - OTC, intoxication, withdrawal Infection - systemic Metabolic - liver, kidneys, 02/c02, lytes, tsh, glucose, acidosis Structural - blood, tumor, pus, vascular insults***, inflammation, Urinary Retention Fecal Impaction/Constipation Pain, sleep debt, change in environment, restraints

8 Risk Factors Age Dementia Previous delirium Medical comorbidities Polypharmacy Frailty

9 Incidence of delirium

10 Morbidity/Mortality $164 billion in health care costs in US annually Increased risk of: Falls Functional Decline Dementia (30% of delirium cases display cog. 6 months) Prolonged hospital stay Institutionalization Estimated 30-40% of delirium cases are preventable

11 Delirium Prediction Poor cognitive performance before surgery Low hemoglobin levels Low albumin levels Cerebrovascular disease Increased CRP Prior delirium No one validated score, but many multi-variate regressions studies to identify RF s Hard to operationalize aside from picking out RFs at baseline

12 Diagnosis at the bedside Inattention: Not following commands/conversation Serial 7 s/world backwards/months/days backwards Digit Span - normal 6 forward, 4 backwards Somnolent/tired/withdrawn A person should be able to have a reasonable conversation with you - even if they are tired/in pain, if they can t there s something wrong

13 Diagnosis at the bedside Inattention: Mini-Mental State Examination MoCA Not created for the purpose of screening for delirium If a sudden drop in performance, than it supports a diagnosis Ensure that if the patient is delirious, a score isn t permanently reflected in their medical record

14 Diagnosis at the bedside Confusion Assessment Method (CAM) 1.Acute onset and Fluctuant 2.Inattention 3.Altered level of consciousness 4.Disorganized thought 1 AND 2 plus 3 OR 4 Long form is very onerous - 8 pages, 3D Cam is more pragmatic

15 Diagnosis at the bedside ity 95%, Specificity 95% - works in demented/non-demented pat

16 Diagnosis at the bedside Marcantonio et al Annal Int Med.

17 Prevention Modifiable Variables for Intervention: Orientation protocols Cognitive stimulation Facilitating sleep Early mobilization/minimizing restraints Visual/hearing aids Monitoring for offending medications Managing pain Bowel and bladder management

18 Prevention Prototypic - Hospital Elder Life Program - Delirium Prevention Trial - Inouye et al. NEJM 2004 Hydration/Nutrition Sleep Cognitive stimulation Mobility Vision/Hearing

19 Prevention

20 Figures Prevention

21 Prevention Incident Delirium

22 Prevention Incident Falls

23 Prevention Pre-printed orders (PPOs) Rockwood

24 Prevention Pre-printed orders (PPOs) Rockwood

25 Prevention Preoperative Geriatrics Consultation 10 specific modules of recommendations No more than 5 recommendations at one time No more than 3 recommendations subsequently Focused on many of the non-pharmacological strategies already discussed

26 Prevention RR 0.64 Delirium RR 0.40 Severe Delirium

27 Non-pharmacologic Prevention Non-pharmacologic strategies are extremely effective (pooled 0.45 OR, or RR 0.60 in a very high quality RCT) Standardized protocols are the common theme, not necessarily the practitioners - but experience helps

28 Pharmacologic Prevention

29 Prevention Antipsychotics Theory to prevent or quiet down altered neurotransmission before it gets started

30 Prevention

31 Prevention

32 Prevention

33 Antipsychotics Prevention (OFF LABEL) No guidelines to suggest prophylaxis with antipsychotics No predictive model practically used to identify high risk people and treat accordingly Fairly robust signal to noise ratio, but generally reserved for treatment, not for prevention Perhaps in the future

34 Prevention Antipsychotics No impact on length of stay No impact on severity of delirium No differences in adverse events One study suggests risk of 18% is the risk level below which treatment may not be beneficial

35 Prevention

36 Prevention (OFF LABEL) Melatonin Mixed evidence Much lower rate of side effects/well tolerated No guidelines to suggest its use at this time Explaining risks/benefits to patients and let them decide

37 Prevention Cholinesterase Inhibitors Gabapentin

38 Treatment Step 1 - find and treat an underlying cause or causes (DIMSUS) Step 2 - regulate sleep Step 3 - regulate agitation Step 4 - modify all other variables outlined in non-pharmacologic prevention

39 Treatment Step 1 - find and treat an underlying cause or causes (DIMSUS) - you all know what do do Don t forget the PVR or AXR!

40 Treatment (OFF LABEL) Step 2 - sleep regulation Mild - Melatonin 3 mg po qhs - regular, increased to 6 mg Moderate - night time quetiapine 12.5 mg - 25 mg - regular, loxapine 5 mg-10 mg SC ohs Severe - sundowning and 2100 doses of quetipine and loxapine

41 Treatment (OFF LABEL) Step 3 - regulate agitation Haldol 0.5 mg IM/IV q30 minutes If more than 3 mg is required, consider alternative diagnosis and call psych Risperidone mg po bid, titrate up to 0.5 mg po bid

42 Treatment Step 4 - modify all other factors HELP to see if available, volunteers or pastoral care if no HELP program dc restraints, foley catheters if possible, sometimes it s not Up to chair tid for meals if non-mobile or decreased exercise tolerance Orthostatic vitals Regular laxatives OT - glasses/hearing aids/gait aids at bedside PT - involvement for mobility Counsel family on reorientation strategies and value of having them at the bedside

43 Cognitively Impaired Highest risk for delirium Call family/caregivers and ask about their baseline cognition/function Place a high priority on non-pharmacologic strategies - family to take shifts, call family in the middle of the night Discuss strategies with nurses

44 Cognitively Impaired Parkinson s Disease 38% rate of neuroleptic sensitivity Dementia with Lewy Bodies 50% rate of neuroleptic sensitivity Avoid Haldol, Risperidone, Loxapine - call a Geriatric Psychiatrist or Geriatrician for these patients as reactions can be permanent

45 Thank you! Questions and Discussion