Delirium in the hospitalized patient

Transcription

1 Delirium in the hospitalized patient Jennifer A. Tarin, M.D. Department of Hospital Medicine Geriatric Health Safety Chair Colorado Permanente Medical Group UCLA Reynolds Scholar

2 Delirium Preventing delirium or recognizing it early has the potential to dramatically improve safety, decrease morbidity and mortality for our patients, as well as reduce costs.

3 Learning Goals Why should you care about Delirium Recognizing Delirium Four risk factors for Delirium What physicians are thinking/doing The Delirium Order set/bundle changes What can you do

4 So why should you care if your patient has delirium?

5 Prevalence of delirium is 14-24% at time of admission. Incidence in hospital (new cases) 6-56% Inouye, SK NEJM 2006; 354: Maldonado, JR Crit Care Clin 2008; 24:

6 Prevalence of delirium in the ICU is 70-87%. Inouye, SK NEJM 2006; 354:

7 Of the 13 million patients 65 and older hospitalized in 2002, 10% to 52% had delirium at some point during their hospital stay.

8 For 80% of patients some symptoms persist at > 6 months. McCusker. J. J Gen Int Med. 2003; 18:

9 One year mortality is 35-40% Inouye, SK NEJM 2006; 354:

10 2 year survival may be as low as 33% McCusker. J. J Gen Int Med. 2003; 18:

11 Adjusted average annual costs were 2.5 times higher for patients w/ delirium. Leslie DL, et al. Arch Intern Med 2008; 168:27-32

12 Total annual costs attributed to delirium were $16,000- $64,000 per patient. Leslie DL, et al. Arch Intern Med 2008; 168:27-32

13 We cannot diagnose delirium or manage and decrease its complications if we do not look for it.

14 Nurses play a crucial role in the recognition of delirium.

15 Nurses Recognition of Delirium Study compared nurses recognition of delirium with trained interviewer ratings Nurses recognized delirium in only 31% of patients (or 40 of the 131 patients with delirium) Inouye, SK, Arch Intern Med. 2001; 161:

16 Nurses Recognition of Delirium However the specificity of nurses rating delirium was high compared with the researchers (95.8%). This indicates the nurses did not over identify delirium. Inouye, SK, Arch Intern Med. 2001; 161:

17 Nurses Recognition of Delirium Nearly all disagreements in ratings were due to under-recognition by nurses. Pts with 3 or 4 risk factors had a 20 fold risk for unrecognized delirium. Risk factors: Age over 80 Hypoactive Delirium Vision impairment Dementia Inouye, SK, Arch Intern Med. 2001; 161:

18 Nurses Recognition of Delirium Nurses are at the front line in the process of delirium recognition. Education and training are essential for detection of the key features of delirium by nursing staff.

19 Who is at risk for developing delirium?

20 Patients at risk for developing delirium Age 65 or older Cognitive impairment (past or present) or dementia Current hip fracture Serious illness (NICE clinical guideline 103, July 2010)

21 Risk factors

22 Current screening outside of the ICU.

23 The Intensive Care Delirium Screening Checklist The ICDSC consists of 8 items based off the DSM-IV criteria for diagnosing delirium.

24 8 items RN s assess for Drowsiness or hypervigilance Inattention Disorientation Hallucinations Agitation Inappropriate speech Sleep/wake issues Symptom fluctuations

25 ICDSC The ICDSC has a 99% sensitivity and 84% specificity A score of 4 is suggestive of delirium and needs further physician assessment. Score will now show up on as a vital sign for providers.

26 Diagnosis of Delirium What providers are doing/ thinkingj

27 Confusion Assessment Method (CAM) Developed to provide a quick and accurate way for detecting delirium. For non-psychiatrist trained clinicians Translated into 12 languages and used in over 250 original publications to date 95% sensitivity and specificity Inouye, SK, et al Ann Int Med 1990; 113: Wong, et al; JAMA 2010; 304:

28 CAM 1) Acute onset and fluctuating course AND 2) Inattention And either 3 or 4 3) Disorganized thinking OR 4) Altered level of consciousness Inouye, SK, et al Ann Int Med 1990; 113:

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30 Mini-cog test Orientation: person, place (city/state, hospital), time Registration: name three objects, have them repeat until they know all three Clock drawing Recall: ask for all three words Score: 1 pt for each correct word, 2 pts for correct clock Score of 0-2 suggests cognitive dysfunction; score of 3-5 suggests no cognitive dysfunction Borson et al Geriatric Psychiatry 2000; 15:

31 Etiologies for delirium: infection (PNA, UTI, CNS), metabolic (electrolytes, AKI, dehydration) neurological (stroke, subdural) cardiac (MI, HF) pulmonary (PE, hypoxia) adequate pain control Medication side effect (antihistamines, TCA s, benzos, opiates), bowel or bladder dysfunction (constipation, retention), drug withdrawal (alcohol, benzos, opiates) sensory deficit (glasses, hearing aids) (Royal College of Physicians National Guidelines on Delirium 2006; 1-17) (NICE clinical guideline 103, July 2010)

32 Our updated delirium bundle

33 Our team is very diverse and consists of physicians from various Exempla hospitals, psychiatry, behavioral health, nurses, residents, clinical pharmacists, physical therapy and IT support. Delirium Team

34 AIM statement Through the implementation of a comprehensive delirium bundle we hope to decrease the incidence of delirium throughout our hospitals. Secondarily we hope to decrease the average length of stay for our geriatric patients, the incidence of falls and the need for institutional care post discharge.

35 Delirium Prevention All patients at risk for delirium should receive a multi-component intervention to reduce the likelihood of developing delirium. This is aided by the use of the delirium order set. (NICE clinical guideline 103, July 2010; NEJM 1999; 340(9): )

36 Yale Delirium Prevention Study Modifiable Risk factor Cognitive Impairment Sleep Deprivation Immobilization Vision Impairment Hearing Impairment Dehydration Intervention Reality Orientation Sleep enhancement protocol* Early mobilization, physical therapy Vision aids, adaptive equipment Amplifying devices Early recognition, volume repletion Inouye, SK NEJM 1999; 340: ; Viden MT, JAGS 2009; 57:

37 The multi-component intervention should address: cognitive impairment and/or disorientation dehydration and/or constipation hypoxia and optimize oxygen saturation if necessary infectious issues sensory impairment poor nutrition promote good sleep patterns and sleep hygiene. review medications that could elicit or exacerbate delirium immobility and utilize physical therapy as indicated NICE clinical guideline 103, July 2010; NEJM 1999; 340(9):

38 Current Delirium Order set

39 Delirium Order set

40 Delirium order set changes All patients at risk for delirium outside of the ICU should be screened by the nurses for delirium in the hospital on admission and at 12-hour intervals using the ICDSC The ICDSC screening should occur toward the end of the nursing shift (~6PM and 6AM). This will allow the nurses the majority of their shift to evaluate the patient. Intensive Care Med 2001; ; NICE clinical guideline 103, July 2010)

41 Delirium order set changes The ICDSC scores will populate the clinical summary and be available to clinicians as another vital sign in the accordion section of esummit. An ICDSC score of 1-3 will prompt the At risk for delirium plan for the nursing plan of care. An ICDSC score of 4 will prompt delirium to be incorporated as a problem in the nursing plan of care.

42 Delirium order set changes If a patient has a ICDSC score of 4, the provider should be notified. Patients with suspected delirium should have the dx confirmed by a physician using the Confusion Assessment Method (CAM). When available and ordered by the provider, Clinical Pharmacy will perform a one-time screen of medications within 24 hours. This review will be an option providers can choose on the delirium order set. JAMA 2010; 304 (7): ; NICE clinical guideline 103, July 2010; Annal Intern Med 1990; 113: )

43 So what can you do?

44 Call us to discuss Think about Delirium Try warm milk before po Rx sleep aids. Feel free to call us to discuss if concerned about delirium.

45 Restraint rounds

46 Quick review

47 Who is at risk for developing delirium?

48 Patients at risk for developing delirium Age 65 or older Cognitive impairment (past or present) or dementia Current hip fracture Serious illness (NICE clinical guideline 103, July 2010)

49 Summary Think about delirium. Remember those risk factors. Use the screening tool. Remember you are a very important member of the team. If concerned please discuss with the provider.

50 This man is 100 years old. On October 19th, 2011 Fauja Singh, became the world s oldest person to complete a marathon, when he crossed the finish line at 8 hours and 25 minutes.

51 Delirium Preventing delirium or recognizing it early has the potential to reduce costs, dramatically improve safety as well as decrease morbidity and mortality for our patients.

52 Thank you for your attention! Questions/comments? Feel free to contact me!