5 older patients become. What is delirium? (Acute confusional state) Where We ve Been and

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1 Update on Delirium: Where We ve Been and Where We re Going Sharon K. Inouye, M.D., M.P.H. M PH Professor of Medicine Beth Israel Deaconess Medical Center Harvard Medical School Milton and Shirley F. Levy Family Chair Director, Aging Brain Center Hebrew SeniorLife Acknowledging contributions by: Edward Marcantonio, MD, SM MD 1 DSM5 CRITERIA FOR DELIRIUM DELIRIUM What is delirium? (Acute confusional state) Disturbance in attention and awareness (reduced orientation to the environment) Disturbance develops acutely and tends to fluctuate An additional disturbance in cognition, (e.g., memory i di i i i deficit, language, visuoperceptual) Not better explained by a preexisting dementia explained by a preexisting dementia Not in face of severely reduced level of arousal or coma Evidence of an underlying organic etiology or multiple organic etiology or etiologies 3 Used with permission. American Psychiatric Association, In U.S. hospitals today today 5 older patients become t delirious every minuteevery 2.6 million older adults develop delirium each year older develop delirium each What do we know about delirium? about delirium? Common problem Serious complications Often unrecognized Typically multifactorial etiology Up to 40% cases preventable Effective multicomponent strategies for prevention U.S. Dept HHS, AoA Report, Profile of Older Americans

2 Delirium is common Delirium Rates Hospital: Prevalence (on admission) 14-24% Incidence (in hospital) 6-56% Postoperative: 15-53% Intensive care unit: 70-87% Nursing home/post-acute care: 20-60% Palliative care: up to 80% Mortality Hospital mortality: 22-76% One-year mortality: 35-40% Delirium has serious complications Delirium associated with: Increased morbidity and mortality Functional and cognitive decline Increased rates of dementia Institutionalization Increased LOS and healthcare costs Post-traumatic t ti stress disorder d Caregiver burden Ref: Inouye SK, NEJM 2006;354: ; Lancet 2014; 383: Outcome Adverse Outcomes with Delirium i Mortality 217/714 (30%) Rate When Delirium: Present Absent n/n (%) n/n (%) 616/2243 (27%) No. Studies Risk (95% CI) 7 HR= 2.0 ( ) Institutionalization 176/ / OR=2.4 (33%) (11%) ( ) Dementia 35/56 (63%) 15/185 (8%) 2 OR = 12.5 (1.9-84) 984) Delirium is expensive Hospital costs (> $8 billion/year) Post-hospital costs (>$150 billion/year) Rehospitalization Institutionalization Rehabilitation Home care Caregiver burden Ref: Witlox J et al. JAMA 2010;304: et JAMA 9 Ref: Leslie DL, et al. Arch Intern Med 2008;168: RECOGNITION OF DELIRIUM Previous studies: 32-66% cases unrecognized by physicians i and nurses Pearl: We cannot manage delirium or decrease its complications unless we recognize it Delirium measurement is complex Reasons for complexity include: Fluctuating course Different forms hypoactive/hyperactive Concurrence with dementia Easily overlooked Requires bedside diagnosis and cognitive testingti 11 12

3 CAM measurement approaches CAM will be covered later today 3D CAM CAM-S (for delirium severity) FAM-CAM proxy based approach [Tools and training videos available without charge at: Copyright approval required for any publication] Chart-based approaches Validated chart review approach (Inouye, 2005) Combination of once daily CAM and chart review most sensitive approach and provides 24 hour perspective (Saczynski 2014) [All available without charge at: Copyright approval required for publication] Delirium is typically multifactorial Predictive Models for Delirium and many, many more 15 Ref: Inouye SK et al. JAMA 1996; 275: Predisposing Factors from Predictive e Models General Surgery Predisposing Factors Medicine Non- Cardiac cardiac ICU Relative Risks Dementia Cognitive impairment History of delirium 3.0 Functional impairment Vision Vso impairment Hearing impairment 1.3 Comorbidity/severity of illness Depression History of transient ischemia/ stroke 1.6 Alcohol abuse Older age Inouye SK et al. Lancet 2014; 383: Precipitating Factors from Predictive Models Precipitating Factors Medicine Surgery ICU Non-cardiac Cardiac Medications Multiple li l medications i added d Psychoactive medication use 4.5 Sedative-hypnotics 4.5 Use of physical restraints Use of bladder catheter 2.4 Physiologic Elevated BUN/creatinine ratio Abnormal sodium, glucose, potassium 3.4 Metabolic acidosis 1.4 Infection 3.1 Any iatrogenic event 1.9 Surgery Inouye SK et al. Lancet 2014; 383:

4 Who is at risk for delirium? Identifies who we need to be extra cautious about during hospitalization Allows us to proactively put into place prevention strategies Some targeted t vulnerability factors are amenable to intervention Conceptualization of Cognitive Aging Rather than a smooth longitudinal progression, the actual process is more likely to be one of punctuated acute decline and recovery The summated curve may represent the accumulation of declines and improvements over time Impact of Delirium Impact of Delirium (cont) Saczynski JS et al. N Engl J Med. 2012; 367: Delirium occurred in 46% patients following in cardiac surgery Cognitive trajectory characterized by abrupt trajectory characterized abrupt initial decline followed by gradual recovery over 6 months Patients did not get fully back to baseline even at 1 year Delirium potentially preventable in 30 40% cases. 22 Preliminary Findings: SAGES Study Study Delirium occurred in 24% patients following ed %pate ts o o major elective surgery In both groups, acute cognitive decline at 1 g month Non delirium group, recovers above baseline at 2 months, then gradual decline out to 36 mos (above baseline) Dlii Delirium group, recovers above baseline at 2 b t2 months, then gradual decline out to 36 months substantially below baseline (equal to MCI). below baseline to 23 BRAIN-USA: Impact of Delirium after ICU stay [N=821 ICU survivors] Pandharipande PP et. al, NEJM 2013;369:

5 Impact of Delirium Post Post ICU 74% developed delirium during ICU stay delirium during Longer duration of delirium associated with worse global cognition at 3 and 12 months at and follow up Longer duration of delirium associated with of delirium associated worse executive function at 3 and 12 months follow up >30% with deficits at 12 months No true baseline measures of cognition of Delirium is a preventable medical conditionis medical condition Previous studies documented at least 30studies documented 30 40% 40% of delirium is preventable Multiple successful strategies: strategies: Hospital Elder Life Program (Inouye 1999, 2000; Chen 2012) Proactive geriatric consultation (Marcantonio 2001) Exercise and rehabilitation interventions (Caplan 2006, Schweickert 2009) NONPHARMACOLOGIC DELIRIUM PREVENTION: HOSPITAL ELDER LIFE PROGRAM (HELP) Multicomponent intervention strategy targeted at 6 delirium risk factors Risk Factor Intervention Cognitive Impairment.Reality orientation Therapeutic activities iti protocol Sleep Deprivation.. Nonpharmacological sleep protocol Sleep enhancement protocol Immobilization Early mobilization protocol Minimizingi i i immobilizing i equipment Vision Impairment.. Vision aids Adaptive equipment Hearing Impairment.. Amplifying devices Adaptive equipment and techniques Dehydration Early recognition and volume repletion Delirium Prevention Meta Meta analysis Systematic review and meta and meta analysis of 14 studies studies with nonpharmacologic multicomponent interventions for delirium (12 HELP based) Documents substantial effectiveness for prevention of delirium and falls. Inouye SK. N Engl J Med 1999;340: Hshieh TT et al. JAMA IM. 2015; 175: Results: Delirium Incidence Results: Falls 29 30

6 Summary Provides evidence that multicomponent, nonevidence non pharmacologic delirium prevention interventions are effective Reducing incidence of delirium Preventing falls Trend towards avoiding institutionalization Trend towards decreasing length of stay One million cases of delirium in the hospital li i i h it l could be prevented Medicare cost savings of approximately $10,000 per case or $10 billion per or (US) per year $5 7 billion dollars per year saved from preventable falls 31 PHARMACOLOGIC APPROACHES Drug treatment may reduce agitation but prolong delirium and cognitive decline Conclusion reached by several systematic review and guideline panels: No recommendation for drug treatmentt t for prevention or management of delirium at this time Ref: NICE 2010, VA HSRD American Geriatrics Society Delirium Guidelines Focus on postoperative delirium, however, on systematic review was comprehensive geriatrics geriatrics society clinical practice guideline for postoperative delirium in older adults/cl018 Followed IOM Approach for Trustworthy Guidelines, with systematic literature review and adjudication by a23member a 23 member expert panel based on GRADE e panel based approach. AGS Clinical Practice Guideline: Strong Recommendations Multicomponent nonpharmacologic interventions should be implemented to prevent delirium Ongoing education for all healthcare professionals Medical evaluation to identify underlying contributors y Pain management (preferably with non opioids) should be optimized to prevent postoperative delirium Medications with high risk for delirium should be avoided high delirium should avoided Benzodiazepines should not be used for first line treatment of agitation in delirium Antipsychotics and benzodiazepines should be avoided in should avoided in hypoactive delirium Cholinesterase inhibitors should not be newly prescribed for delirium prevention or treatment or treatment IOM Report recommends: Healthcare providers should educate patients and families about delirium Patients and families and should speak to their healthcare provider to learn more about preventing delirium Delirium is an indicator of quality of careis indicator of of care Meets criteria as AHRQ quality of care as care indicator: Common and clinically relevant Preventable High risk of serious complications Integrally linked to processes of care On patient safety agenda for AHRQ, NQF, CMS Used as quality marker in many settings and health systems 35 36

7 Delirium sheds light on brain function light Delirium = Acute Brain Failure Final common pathway of many different and dff d disparate etiologies Understanding how the brain fails will shed light on many brain disorders Advance understanding of cognitive reserve Ultimately, understanding g delirium may advance the prevention and treatment of dementia 37 Hot topics in delirium research topics in research Area Recognition Epidemiology Research priorities Better measurement methods (severity, subtypes) Efficacy of screening Cost effective evaluation Long term outcomes, relationship to dementia Patient experience, post traumatic stress Genetic determinants Pathophysiology h Cellular Clll and molecular underpinnings l d i Biomarkers Neuroimaging Animal models Treatment Efficacious approaches that impact delirium outcomes: trials of targeting etiologies, drug reduction, nonpharmacologic approaches Prudent, individualized approaches to sedation, anesthesia, analgesia 38 Preventing delirium may offer the may the unprecedented opportunity to prevent or ameliorate future cognitive decline. Add life to years, not years to life