Strategies to Recognize & B.E.A.T. Delirium. Amy E. Seitz Cooley, MS, RN, ACNS-BC Clinical Nurse Specialist York College of Pennsylvania DNP Student

Transcription

1 Strategies to Recognize & B.E.A.T. Delirium Amy E. Seitz Cooley, MS, RN, ACNS-BC Clinical Nurse Specialist York College of Pennsylvania DNP Student

2 The very first requirement in a hospital is that it should do the sick no harm! Florence Nightingale: Notes on Nursing SITUATION

3 Story time Have you experienced?

4 Delirium was first described more than 2500 years ago It remains poorly understood and is frequently unrecognized!

5 Nurses Are key to detecting and reporting delirium symptoms since they spend time with patients...yet many times the condition goes unrecognized and therefore is poorly managed! Baker et al., 2015

6 Delirium can be superimposed on dementia but delirium is an acute process while dementia is a slowly developing chronic process Identify the patient s pre-hospital baseline!! Talk to caregivers & family members to identify what has changed

7 Why does this happen to patients that come in with a UTI? York Hospital Tower 3 RN BACKGROUND

8 Delirium Is an acute decline of cognitive functioning Inouye et al, 2014 It is common, serious, costly, under-recognized and often fatal Inouye et al, 2014 It affects as many as 50% of hospitalized adults 65 years and older Leslie et al., 2011

9 Delirium: Background Diagnosis of delirium is highly clinical & dependent upon clinician's level of expertise, systematic screening & careful clinical observations Progression to stupor and/or coma, seizures, and death is possible. AACN Hartford-sponsored Faculty Development

10 Delirium: Background Delirium is a cardinal sign of a geropsychiatric emergency and must be promptly identified and addressed Early recognition of delirium followed by rapid management of underlying medical and environmental factors decreases the severity and can lead to improved outcomes.

11 Delirium: Definition A transient and nonspecific organic mental syndrome characterized by: Acute onset (hours to days), tending to fluctuate over the 24 hour period Reduced ability to focus, sustain or shift attention Disturbed level of consciousness, such as reduced clarity of awareness Change in cognition such as memory loss, disorientation and/or language disturbance Perceptual disturbance not accounted for by pre- existing, established or evolving dementia AACN Hartford-sponsored Faculty Development

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13 Delirium Prevalence of delirium (on admission) in general medical and old age medical units is 18-35% Overall occurrence of 29-64% in these types of units Inouye, et al., 2014 Siddiqi et al. (2006) report occurrence rate per admission of 11-42%

14 Delirium Locally Percentage of 65+ Years of Age YH Inpatients Diagnosed with a POA No Delirium Diagnosis on Discharge % of All 65+ Yrs Discharges with Delirium POA No Diagnosed on Discharged 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 2.5% 2.3% 2.1% 1.6% 1.7% 1.7% 1.5% 1.5% Q Q Q Q Q Q Q Q4 2015

15 Delirium Outcomes One of the most preventable adverse events for older patients Inouye, 2006 Longer hospital stays More hospital acquired complications--falls More likely to be admitted to long term care Increased incidence of dementia Increased mortality National Institute for Health and Care Excellence (NICE), 2010

16 Delirium Costs Estimated cost of delirium ranges from $60, 516 to $64,421 per patient with the national burden on health care ranging from $38 to $152 billion yearly Leslie et al., 2008 More than $182 billion per year in 18 European countries combined OECD, 2014; WHO, 2012 The cost to patients immeasurable

17 Causes Usually multifactorial; predictive model has been well validated and widely accepted Inouye et al., 2014 Depend on complexities of relationships with predisposing factors in vulnerable patients with precipitating factors Inouye et al., 2014

18 Delirium Risk Factors Predisposing Baseline cognitive impairment; dementia Underlying illness or co-morbidity Functional impairment Advanced age Chronic renal insufficiency Dehydration Malnutrition Sensory impairment vision or hearing Male sex Precipitating Medication Immobilization Indwelling catheters Restraints Dehydration Malnutrition Illnesses infection, electrolyte imbalances Hospitalization environmental Psychosocial factors Alcohol

19 Predictive Model Inouye et al, 2014

20 Delirium: Medication-Related (Precipitating Factors) Anticholinergics (dyphenhydramine benedryl; tri-cyclic antidepressants) Opiates Benzodiazepines (ativan) Corticosteriods (prednisone) Alcohol withdrawal Sedative-hypnotic drug withdrawal Any newly prescribed medication--investigate Over the counter (OTC) home remedies, especially those with anticholinergic effects (NSAIDS, nasal sprays, cold and flu meds) Addition of 3 newly prescribed medications - AACN Hartford-sponsored Faculty Development

21 ASSESSMENT

22 Unrecognized by Nurses Continues to be attributed to normal aging process lack of understanding differences between delirium, dementia, and delirium superimposed on dementia (DSD) Fluctuating nature of delirium hyper to hypo Impact of delirium education on recognition Communication barriers Inadequate use of delirium assessment tools El Hussein et al., 2014

23 Delirium

24 Delirium: Clinical Presentation Clinical subtype Hyperactive Hypoactive Mixed Increased psychomotor activity, such as rapid speech, irritability, and restlessness Lethargy Slowed speech Decreased alertness Apathy Shift between hyperactive and hypoactive states - AACN Hartford-sponsored Faculty Development

25 RECOMMENDATIONS

26 Here is where the B.E.A.T. Comes into Play B=Establish the Patient s Baseline E=Evaluate current cognition and screen A=Assess for delirium risk factors T=Treat the risk!!

27 Prevention of Delirium in Older Adults Early identification & modification of predisposing factors Early recognition & treatment of cognitive impairment Rapid identification & treatment of acute illness Assessment & appropriate management of pain Maintenance of normal sleepwake cycle Avoidance of deliriogenic medications & polypharmacy Assurance of adequate hydration & nutrition AACN Hartford-sponsored Faculty Development

28 Prevention of Delirium in Older Adults Enhancement of sensory status by use of sensory aids & appropriate levels of light & sound Enhancement of cognitive reserve Provision for family presence Avoidance of urinary catheterization Avoidance of physical restraint use Assessment & management of drug and alcohol withdrawal AACN Hartford-sponsored Faculty Development

29 Delirium: History When did the change in mental status begin? Does the condition change over a 24-hour period? Is there a change in the person s sleep patterns? What specific thought problems have been noticed? Is there a history of mental illness or similar thought disturbance? Has there been a sudden decline in physical function or a new onset of falls? Query family or collateral source from prior setting as to what is normal for this patient. AACN Hartford-sponsored Faculty Development

30 Delirium: Change in Mental Status An abnormal mental status exam that is a change from baseline for the person is the hallmark of delirium Abnormalities may include inattention, fluctuations in level of consciousness, new short term memory impairment, altered speech patterns, disorganized speech and (possibly) delusions or hallucinations Mental status screening tests are helpful in identifying cognitive deficits and should be performed routinely in older patients: on admission and at least daily during stay AACN Hartford-sponsored Faculty Development

31 Delirium Assessment: Direct Observation Routine and periodic observation of the older adult s level of: Alertness (alert, hyper-alert or hypo-alert) General behavior Mood & affect Speech disturbance/verbalizations Motor behavior AACN Hartford-sponsored Faculty Development

32 Delirium: Physical Exam Examine for signs of: Hypoxia Volume depletion/overload Cardiovascular injury Metabolic encephalopathy Alcohol withdrawal Hypo- or hyperthermia New onset incontinence Urinary retention or fecal impaction AACN Hartford-sponsored Faculty Development

33 Delirium: Diagnostic Tests Choice based on history and physical findings Baseline laboratory studies: Urinalysis Basic or Comprehensive Metabolic Panel Blood work: CBC, Thyroid function test Further diagnostic testing (based on exam): Head CT EKG Chest X-Ray AACN Hartford-sponsored Faculty Development

34 Delirium: Diagnostic Tests cont'd When difficult to differentiate delirium from acute psychotic state Electroencephalography The electroencephalogram reveals: Diffuse slowing in most cases of delirium Fast ac:vity in cases of delirium related to drug withdrawal Normal pa=erns in pa:ents with acute func:onal psychosis AACN Hartford-sponsored Faculty Development

35 Delirium: Environmental Precipitating Factors Transfers within the hospital or unit Absence of a clock or watch Absence of reading glasses, hearing aid Absence of family members Use of physical restraints AACN Hartford-sponsored Faculty Development

36 Differentiating Delirium from Dementia & Depression Chronic cognitive impairment seen in dementia typically: Occurs gradually over time Persists greater than one month Is irreversible Most older adults with dementia are alert and able to maintain attention in the early stages of dementia AACN Hartford-sponsored Faculty Development

37 Differentiating Delirium from Dementia & Depression Depression may also present acutely with deficits in ability to sustain attention. Depression may present similar to hypo- or hyperactive delirium; therefore, it is important to screen for depression in older adults who present with a mixed picture. AACN Hartford-sponsored Faculty Development

38 Delirium: Differential Diagnosis With recent change in cognition, an older person should be presumed delirious until proven otherwise Sudden cognitive and/or functional deterioration in a patient with dementia suggests delirium superimposed on dementia Apathy, slowed speech and mood disturbance may be indicative of hypoactive delirium rather than depression AACN Hartford-sponsored Faculty Development

39 Delirium: Differential Diagnosis Functional psychosis ü Acute functional psychosis can resemble delirium ü Onset at an earlier age ü Most older patients with functional psychosis have a history of psychiatric illness ü Hallucinations tend to be auditory ü Delusions are more elaborate than those associated with delirium Dementia with Lewy Bodies includes fluctuating cognition and visual hallucinations Consultation with a psychiatrist or a neurologist may be necessary in difficult cases - AACN Hartford-sponsored Faculty Development

40 Delirium: General Management Multi-component interventions are most effective Prompt recognition & treatment of underlying cause Creation of a maximum supportive environment Immediate medical treatment as necessary Discontinuation or reduced doses of medications thought to be deliriogenic Use of environmental interventions clock, pictures, sunlight AACN Hartford-sponsored Faculty Development Ensure

41 Delirium: General Management- Nutrition & Hydration Accurate 24 hour I & O Avoidance of depletion-dehydration syndrome ü Toilet patient on a schedule ü Address any excess output issues such as polyuria or diarrhea ü Enteral tube feeding or hyperalimentation as necessary Ensure AACN Hartford-sponsored Faculty Development

42 Delirium: General Management Pulmonary care to ensure adequate oxygenation, avoid atelectasis and pneumonia Bowel and bladder protocols to prevent or treat constipation, diarrhea, and urinary incontinence Vigilence for fall risk and patient safety Use cognitive stimulation Avoid complications of immobility mobilize, mobilize, mobilize!! Minimize skin breakdown Ensure AACN Hartford-sponsored Faculty Development

43 Delirium: Managing the Environment Presence of family members Inclusion of familiar items from home Use of glasses & hearing aids Avoidance of physical restraints Delirium room for high risk patients Night-light and minimization of noise Ensure ü Interrupt sleep only when absolutely necessary AACN Hartford-sponsored Faculty Development

44 Delirium: Maximizing Cognition Ensure Re-orientating strategies ü Inclusion of orienting facts in normal conversation ü Discussion of current events ü Discussion of specific interests ü Structured reminiscence ü Word games ü Cognitive stimulation Find out what the person likes to do to occupy time! AACN Hartford-sponsored Faculty Development

45 Delirium: Medication Management Use medications when: behaviors associated with psychotic thinking and perceptual disturbances (e.g., hallucinations) pose a safety risk or are distressing to the individual. delirium interferes with needed medical therapies and behavioral interventions fail Do Not use medications as a substitute for detection, correction, or elimination of underlying causes of delirium Use low doses of medications over the shortest possible time period AACN Hartford-sponsored Faculty Development

46 Delirium: Medication Management First line therapy: Low doses high-potency neuroleptics (antipsychotics--e.g. haloperidol) ü Associated with extrapyramidal symptoms (EPS) Newer antipsychotics [e.g.: olanzapine (Zyprexa) and risperidon (Resperdal)] have a lower incidence of EPS and may be better tolerated in older patients ü Neuroleptic Malignant Syndrome, a more serious side effect of antipsychotic therapy, can occur with high-potency as well as with novel anti-psychotics ü Benzodiazepines (e.g., lorazepam) are recommended with alcohol withdrawal or withdrawal from benzodiazepines. In non-alcohol withdrawal, benzodiazepines potentially worsen delirium and should be used with caution AACN Hartford-sponsored Faculty Development

47 Delirium Management: Aftercare Help the patient and family understand the bizarre and bewildering experience Comprehensive discharge planning ü ü ü Home care referral Physical and occupational therapy Psychiatric nursing home care services Psychiatric care to facilitate resolution through: ü ü ü Sensitive retrospective exploration of the experience Increasing patient s understanding and acceptance Encouraging patients to report risk of delirium for subsequent hospitalizations eslide- AACN Hartford-sponsored Faculty Development

48 Delirium: Conclusion Historically seen as: A benign and expected condition related to hospitalization Currently seen as: A serious health problem with significant negative consequences Nurses and NAs are frontline in early identification of patients most at risk for delirium and early detection of symptoms Routine and systematic assessment for confusion is key eslide - AACN Hartford-sponsored Faculty Development

49 Resources Delirium Screen NuDESC & CAM-ICU Web Consultgerirn Hartford Institute for Geriatric Care

50 B=Baseline Change? E=Evaluate Current Cognition and Screen A=Assess for Delirium Risk T=Treat the Risk using Nonpharmacological Interventions

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52 Selected References Baker, N. D., Taggert, H. M., Nivens, A., & Tillman, P. (2015). Delirium: Why are nurses confused? MedSurg Nursing, 24, El Hussein, M., Hirst, S., & Salyers, V. (2014). Factors that contribute to underrecognition of delirium by registered nurses in acute care settings: A scoping review of the literature to explain this phenomenon. Journal of Clinical Nursing, 24, doi: /jocn Hshieh, T. T., Yue, J., Oh, E., Puelle, M., Dowal, S., Travison, T., & Inouye, S. K. (2015). Effectiveness of multicomponent nonpharmacological deliriumm interventions: A meta-analysis. JAMA Internal Medicine, 175, doi: / jamainternalmed Inouye, S. K., Westerndorp, R. G. J., & Saczynske, J. S. (2014). Delirium in elderly people. The Lancet, 383, doi: Inouye, S. K. (2006). Delirium in older persons. The New England Journal of Medicine, 354, Leslie, D. L., & Inouye, S. K. (2011). The importance of delirium: economic and societal costs. Journal of the American Geriatrics Society, 59, S241-S243. doi: /j x Leslie, D. L., Marcantonio, E. R., Ahang, Y., Leo-Summers, L., & Inouye, S. K. (2008). One-year health care costs associated with delirium in the elderly population. Archives Internal Medicine, 168, National Institute For Health And Care Excellence (NICE). (2010, July). Delirium: Diagnosis, prevention and management. Retrieved February 13, 2015, from Organisation For Economic Co-Operaiton And Development (OECD). (2012). OECD health data 2012: Paris. Retrieved from Siddiqi, N., House, A. O., & Holmes, J. D. (2006). Occurrence and outcome of delirium in medical in-patients: A systematic review. Age and Ageing, 35, doi: /ageing/afl005 Tullman, D. F., Fletcher, K., & Foreman, M. D. (2012, July). Nursing standard of practice protocol:delirium. Retrieved August 3, 2015, from