Geriatric Refresher Day April, 2013 Together, we can prevent delirium

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1 (inter professional prevention of delirium) What you can do on your NEXT SHIFT to Prevent Delirium Geriatric Refresher Day April, 2013 Together, we can prevent delirium Acknowledgments: Ministry of Health and Long-Term Care University of Toronto Office of Interprofessional Education IMPLC Steering Committee Conflicts of Interest: None to Declare Acknowledgments: RGP David Ryan PhD Betty Matheson MSW Rory Fisher ChB Who Did the Work: Barb Jonathan RN Sharon Ramagnano RN Johanna Pak A-EMCA Emergency Care Committee: Deb Carew Lois Fillion Deb Brown- RN RN Farrell RN Paul Hawkins MD Jeff Tyberg MD 1

2 Learning Objectives At the end of the session, to better understand: Why PREVENTING delirium is important (some facts about delirium) What you can do on your NEXT SHIFT to prevent delirium What was special about New Years 2011? Hint: VE Day May 9 th, 1945 First Baby Boomer born Jan 1 st, =? 2

3 Why focus on the ED Care of Elders?? Demographics Age pyramid of the population of Canada, 1956 to 2006.mht Why focus on the ED Care of Elders?? Demographics Big Picture Solution? Compression of Morbidity Need to keep the population healthier, longer Jared Timmerman, Masters Class Swimmer at 100 Sets new world records 3

4 What is Delirium? = Acute Brain Failure Why is Delirium Important? Delirium is COMMON - 1% in community, % in ED, 5, % at Discharge 7 Delirium is LETHAL Independent risk factor 2x mortality 8-9 (1 year = 35-40%) Delirium is NOT ALWAYS REVERSIBLE - Average 6-12 months to return to baseline Why Focus on Delirium in the ED? Delirium may be iatrogenic ED LOS > 12 hrs doubles risk of new delirium 9 Delirious patients are hard to care for Because delirium is PREVENTABLE Inouye et al. Hospital Elder Life Program (HELP) 9 4

5 Why Prevent Delirium in the ED? 852 patients 70 years of age or older Randomized to Tx. ward vs. usual care Delirium in Treatment Group: 9.9% Delirium in Control Group: 15% 50% Relative Reduction Streptokinase 1% 10% RR TPA 0.9% Why Prevent Delirium? Duration Delirium Control: 161 Days Duration Intervention Group: 105 Days = 56 days ( >2 months) per patient!! (have we got your attention now?) Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med Mar 4;340(9):

6 What causes delirium: Inouye Delirium Model 7 Fit 65 y.o. who plays senior s hockey Strong or repeated precipitant needed Frail 89 y.o. with baseline dementia Minimal precipitant needed Things that Cause Delirium Risk Factor Rel. Risk 95% CI Physical Restraints Malnutrition > 3 New Medications Foley Catheter Out of Bed < 1 /day Iatrogenic, including Long ED Stay (>12hrs) All the News That You Knew Already The Obvious Times If It Ain t Obvious, It Ain t Here Doctors: Older people do better if we don t make them worse Full Storey Page 2 New York - According to Scientists Bob Loblaw, Bob Loblaw,& Bob Loblaw, by avoiding things known to make you worse, you can prevent becoming worse. This remarkable finding was recently published in the reputed to be reputable Medical Journal, NEJM (New Estonian Journal of Maladies). This stunning revelation was added to a litany of similar findings coming to light on a similar theme: running with scissors is indeed dangerous, drinking extremely hot coffee can cause intra-oral burns, and public-private partnerships have not saved money in any country they have been tried, because they to make a profit somehow. Furthermore, Bob Loblaw, Bob Loblaw, & Bob Loblaw added, by saying the same thing over and over again, eventually it becomes accepted as a proven fact. Furthermore, Bob Loblaw, Bob Loblaw,& Bob Loblaw added, by saying the same thing over and over again, eventually it becomes accepted as a proven fact. By saying the same thing over and over again, eventually it becomes accepted as a proven fact. By saying the same thing over and over again, eventually it becomes accepted as a proven fact. By saying the same thing over and over again, eventually it becomes accepted as a proven fact. According to Bob Loblaw, Bob Loblaw,& Bob Loblaw, by avoiding things known to make you worse, you can prevent becoming worse. This remarkable finding was recently published in the reputed to be reputable Medical Journal, NEJM (New Estonian Journal of Maladies). According to Bob Loblaw, Bob Loblaw,& Bob Loblaw, by avoiding things known to make you worse, you can prevent becoming worse. This remarkable finding was recently published in the reputed to be reputable Medical Journal, NEJM (New Estonian Journal of Maladies). 6

7 Avoiding things that cause Delirium: What you can do on your NEXT SHIFT The Low-Hanging Fruit 1) Restraints, Tethers & Catheter use 2) Immobility 3) Dehydration 4) Malnutrition 5) Avoid Medical Error! Delirium Prevention on your Next Shift Restraints, Tethers & Catheters: Restraints policy? Compliant with Provincial Legislation? Tethers: - Saline lock instead of TKVO - Clinical assessment vs. unnecesary monitors - Continence garments vs. foley Delirium Prevention on your Next Shift How do Foleys Cause Delirium? Risk of infection: 5% per day 16 > 40% of all nosocomial infections 17 Impact on Mobility? 12 - Eliminates the most frequent reason for mobilizing! - = Single-point Restraint! 7

8 Delirium Prevention on your Next Shift Avoiding Foley Catheters Continence garments vs. foley In /Out cat for clean-catch specimens! Avoiding things that cause Delirium: What you can do on your NEXT SHIFT The Low-Hanging Fruit 1) Restraints, Tethers & Catheter use 2) Immobility 3) Medications 4) Dehydration 5) Malnutrition 6) Avoid Medical Error! Why Focus on MOBILITY? Mobility is an essential life-skill, but it can be easily compromised by even brief periods of immobilization It is estimated that every day of immobility results in a 5% loss of muscle mass 8

9 Delirium Prevention on your Next Shift Mobility Focus on patients that walked into your care, not delirious on presentation What practices, attitudes and policies contribute to immobility in your setting? - E.g. stay in bed and wait for the MD - Restricted access to zones in ED Delirium Prevention on your Next Shift Mobility: VIP Volunteer IPPOD Program Trained volunteers accompany & encourage mobile patients to maintain their mobility Based on Inouye HELP program VIP Components VIP Delirium Prevention IPPOD Staff Training 9

10 Avoiding things that cause Delirium: What you can do on your NEXT SHIFT The Low-Hanging Fruit 1) Restraints, Tethers & Catheter use 2) Immobility 3) Dehydration 4) Malnutrition 5) Avoid Medical Error! Delirium Prevention on your Next Shift Dehydration & Malnutrition: in urea / creatinine ratio or albumen What practices, attitudes and policies contribute to dehydration in your setting? - Access no water, tiny cups, not enough trays - Attitudes default = NPO - I m too busy 10

11 IPPOD 2.0: What we did IPPOD 2.0 Quick Wins: Ice & Water Machines More Sandwiches! Translation Service Communi-kit for hard of hearing CAM assessment tool Volunteer protocol Results: Demographics 182 Workshop participants Evaluations completed by 88% Average age of participants: 37.5 years 62.6% were female First Interprofessional Education: 86% Mean years of experience: different professions & disciplines Results: Post Test mean Pre Test Mean P value Recognize Delirium < Assess Delirium < Identify Cause < Use Interventions <

12 IPPOD Evaluations Question Likert Scale Overall evaluation of workshop 4.56 Helpful in understanding Delirium in the ED 4.75 Guidelines developed are helpful in the ED 4.69 Possible to Prevent Delirium? 4.53 Opportunity to learn from, with and about others? 4.31 IPPOD Evaluations How comfortable are you: (1 = Not at all, 5 =Completely Pre Test Post Test Recognizing Delirium * Assessing Delirium * Identify Cause of Delirium * Using IPPOD Interventions * How likely is it to succeed 1=Very unlikely 2=Unlikely 3=Likely 4=Very Likely * * P < 0.05, Wilcoxan sign ranked test Results: Impact on Delirium IPPOD 1.0 IPPOD

13 Results: VIP Impact on Practice Oct June 08, 2011 screened 2016 ptnts (54.1%) Eligible for VIP Provided water to 91% food to 97% Orienting conversations with 100% of subjects 499 Patients ambulated with Volunteers (46%) Importance of Compliance Inouye et al. The Role of Adherence on the Effectiveness of Nonpharmacologic Interventions AIM 2003 If no Adherence to interventions, delirium: 38.1% If patients mobilized less than 50% of the time, new delirium rates:14% Mobilization more than 75% resulted in new delirium rate of 3% Results: Impact on Delirium IPPOD 1.0 IPPOD

14 Find out more? Website Questions? 14

15 References 1. Statistics Canada. Population projections for Canada, provinces and territories, Ottawa: Supply and Services Canada, 1990; Cat Evans, R. G., K. M. McGrail, et al. (2001). "Apocalypse no: Population aging and the future of health care systems." Can J Aging 20(Suppl. 1): Rueben, D., K. Herr, et al. (2006). Introduction. New York, The American Geriatrics Society. 4. Lipowski Z. Delirium (Acute confusional states). JAMA, 1987;258: Taylor D, Lewis S. Delirium. J Neurol Neurosurg Psych, 1993;56: Gaudreau JD, Gagnon P. Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypotheses. 2005;64(3): Inouye SK, Viscoli CM, Horwitz RI, Hurst LD, Tinetti ME. A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics. Ann Int Med Sep 15;119(6): Inouye SK, Baker DI, Fugal P, Bradley EH; for the HELP Dissemination Project. J Am Geriatr Soc Oct;54(10): Dissemination of the hospital elder life program: implementation, adaptation, and successes. 9. Inouye SK, Bogardus ST Jr, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM Jr. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med Mar 4;340(9): References 10. Lewis LM, Miller DK, Morley JE, Nork MJ, Lasater LC. Unrecognized delirium in ED geriatric patients. Am J Emerg Med Mar;13(2): Elie M, Rousseau F, Cole M, Primeau F, McCusker J, Bellavance F. Prevalence and detection of delirium in elderly emergency department patients. CMAJ, 2000;163: Hustey FM, Meldon SW, Smith MD, Lex CK. The effect of mental status screening on the care of elderly emergency department patients. Ann Emerg Med. 2003;41(5): Kakuma R, du Fort GG, Arsenault L, Perrault A, Platt RW, Monette J, MorideY, Wolfson C. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4): Liptzin, B. and S. E. Levkoff (1992). "An empirical study of delirium subtypes." Br J Psychiatry 161: Singal BM, Hedges JR, Rousseau EW, Sanders AB, Berstein E, McNamara RM, Hogan TM. Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients. Ann Emerg Med ;21(7): McConnel CE, Wilson RW. The demand for prehospital emergency services in an aging society. Soc Sci Med. Apr 1998;46(8): Grief CL. Patterns of ED use and perceptions of the elderly regarding their emergency care: a synthesis of recent research. J Emerg Nurs. Apr 2003;29(2): Additional Reading Alagiakrishnan K, Wiens CA. An approach to drug induced delirium in the elderly.postgrad Med J Jul;80(945): Gaudreau JD, Gagnon P. Psychotogenic drugs and delirium pathogenesis: the central role of the thalamus. Med Hypotheses. 2005;64(3): Weber JB, Coverdale JH, Kunik ME. Delirium: current trends in prevention and treatment. Int Med J 2004;34: Cole MG, McCusker J, Bellavance F, Primeau FJ, Bailey RF, Bonnycastle MJ, Laplante J. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. Cmaj 2002;167(7): McCusker J,Cole M, Abrhamowicz M, Han L, Poboda JE, Ramman-Haddad L. Environmental risk factors for delirium in Hospitalized older people. J Am Ger Soc, 2001;49: Duggleby W, Lander J. Cognitive status and postoperative pain: older adults. J Pain Symptom Manage 1994;9:

16 Additional Reading Tune LE. Anticholinergic effects of medication in elderly patients. J Clin Psychiatry 2001;62 Suppl 21:11-4. Folstein M, Bassett S, Romanoki A, et al. The epidemiology of delirium in the community: the Eastern Baltimore mental health survey. Int Psychogeriatrics, 1991;3:169. Naughton BJ, Moran MB, Kadah H, Heman-Ackah Y, Longano J. Delirium and other cognitive impairment in older adults in an emergency department. Ann Emerg Med Jun;25(6): Additional Reading Kakuma R, du Fort GG, Arsenault L, Perrault A, Platt RW, Monette J, MorideY, Wolfson C. Delirium in older emergency department patients discharged home: effect on survival. J Am Geriatr Soc. 2003;51(4): Morrison RS, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58: Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg 1998;86: