Strategies to minimize delirium for hip fracture patients

Transcription

1 Strategies to minimize delirium for hip fracture patients Stephen L Kates, M.D. Professor and Chairman Department Date of Orthopaedic Surgery

2 Delirium incidence Up to 61% of hip fracture patients get delirium Often not recognized* * Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet

3 Delirium- Definition DSM-V A disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and awareness (ie, reduced orientation to the environment) (A) The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day (B) An additional disturbance in cognition (eg, memory deficit, disorientation, language, visuospatial ability, or perception) (C) The disturbances in criteria A and C are not better explained by another preexisting, established, or evolving neurocognitive disorder. 3

4 Delirium Major cause of complications Hyperactive type Hypoactive type Dementia is a permanent disorder that may be present in the setting of delirium as well but is long-standing 4

5 Consequences of delirium Increased length of stay Reduced functional status Complications including urinary incontinence, falls and pressure ulcers Increase in admission to nursing homes Increased mortality (as much as fivefold) Significant cognitive impairment in > 50%, and impairment may persist for more than one year Only one third of hospitalized older adults fully recover from delirium Inouye SK. Delirium in older persons. N Engl J Med Mar 16;354(11): Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet

6 Risk factors for delirium Preexisting dementia Previous delirium Older age Significant comorbidities Polypharmacy Visual and/or hearing impairment Major fractures: hip fracture 6

7 Common causes of delirium Poorly controlled pain Medication effects Infections Metabolic derangements, Systemic organ failure Urinary obstruction and constipation Physical restraints and tethers Impaired perception of the environment: missing glasses, hearing aids Withdrawal of benzodiazepines or alcohol 7

8 Recognizing delirium Hyperactive state easier to recognize Hypoactive delirium may be missed Standard tools can be used: Confusion Assessment Method CAM Delirium Observation Screening Scale DOSS Wei LA, Fearing MA, Sternberg EJ, et al. The Confusion Assessment Method: a systematic review of current usage. J Am Geriatr Soc May;56(5): Schuurmans MJ, Shortridge-Baggett LM, Duursma SA. The Delirium Observation Screening Scale: a screening instrument for delirium. Res Theory Nurs Pract Spring;17(1):

9 Delirium avoidance Early surgery-< 24 hours is best ERAS organized program Retain glasses and hearing aids Avoid tethers Encourage family presence and involvement Early mobilization Good pain control with minimal opioids consider nerve block 9

10 Delirium avoidance Medication review: Avoidance of anticholinergic (diphenhydramine, H2 blockers) and sedative medications, particularly new introduction of benzodiazepines Avoidance of acute medication or substance withdrawal, eg, continuation of chronic opiate or benzodiazepine therapy, management of alcohol withdrawal Monitor high-risk patients with DOSS or CAM 10

11 Recommendations Anticipate post op delirium Fix reversible causes- O2, fever, pain, BG, urinary retention, constipation Supportive environment Get rid of tethers Avoid restraints No neuroimaging Patience 11

12 Recommendations contd. Remove offending medications Typically anticholinergics Continue pre op chronic psych meds and chronic opiates Medications if needed (Haloperidol 0.5 mg) Be patient, revaluate often, treat pain American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults. Postoperative delirium in older adults: J Am Coll Surg Feb Young J, Murthy L, Westby M, et al. Diagnosis, prevention, and management of delirium: summary of NICE guidance. BMJ Jul 12

13 Delirium- Summary Avoidance is best Retain glasses and hearing aids Avoid bad meds- Benadryl, H2 blockers, Benzo s Avoid tethers Family input helps Good pain control Early Surgery ERAS Delirium may become chronic 13

14 Thank you for your attention! 14

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