2/11/2015. Valarie Petersen, DNP, FNP-BC, GCNS-BC

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1 Valarie Petersen, DNP, FNP-BC, GCNS-BC Physiological changes decreased brain weight and cortical cell count, loss of myelin from fibers Short term memory difficulty Lengthened reaction time Sleeping patterns wake frequently, less REM, may awaken less refreshed That s it. All other cognitive changes are related to delirium or dementia. 1

2 Delirium definition acute confusional change OR loss of consciousness and perceptual disturbance AND is usually resolved when the underlying cause is treated Jarvis, C. (2012). Physical examination & health assessment. St. Louis: Elsevier Saunders. state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Harding, M. (2014). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis: Elsevier Mosby. most frequent complication of hospitalization in older adults 15-53% of hospitalized patients experience postoperative delirium Up to 80% of ICU patients experience delirium Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., & Harding, M. (2014). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis: Elsevier Mosby. 2

3 Poorly understood hypothesized to be reversible impairment of cerebral oxidative metabolism and multiple neurotransmitter abnormalities Rarely caused by single factor Cholinergic deficiency Excess release of dopamine Both increased/decreased serotonergic activity Proinflammatory cytokines (interleukin-1, 2, 6, and TNF-α, and interferon) Stress and sleep deprivation Confusion is NEVER a normal sign of aging. 3

4 Increased confusion, over a short period of time, is NEVER a part of dementia. Was onset recent or insidious? Get specific time frame: few days? weeks? months? Remember that there are delirium causes that may take weeks to months to manifest: Has patient fallen in past few days/weeks? New medications past few days/weeks? Thyroid checked recently? Does the patient hurt anywhere? What symptoms is the patient having? Symptoms in elderly may not have typical presentation confusion usually first sign of any problem (no crushing chest pain, no high fever, etc.) Does the patient know medications and how to take them? 4

5 Inability to concentrate Irritability Insomnia Loss of appetite Restlessness Confusion Hypoactivity/lethargy to hyperactivity Agitation Hallucinations Misperception Misinterpretation Acknowledgment: Adapted from: Inouye SK, vandyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium. Ann Intern Med. 1990; 113: Confusion Assessment Method: Training Manual and Coding Guide, Copyright 2003, Hospital Elder Life Program, LLC. 5

6 (1) Acute onset and fluctuating course (2) Inattention (3) Disorganized thinking (4) Altered level of consciousness Delirium diagnosed with 1 and 2, and either 3 or 4 List of diagnostics Assess diagnostics with normal aging in mind Lithium levels Pneumonia might not always show on CXR Urinalysis might be negative (should culture) 6

7 INFECTION UTI, pneumonia, skin MEDICATIONS ENDOCRINE PROBLEMS OXYGENATION PROBLEMS Coronary artery disease Chronic obstructive pulmonary disease Diabetes II Chronic renal or hepatic disease Neurologic disease; hx of stroke Terminal illness Ask patient to list medications and dosages Look at bottles if available Correct medications? Any repeats? Last date filled? Inpatient consideration: may take med from home Herbals and supplements 7

8 Sedative-hypnotics Opioids Anticholinergic drugs Aminoglycosides (tobramycin, amikacin, etc.) Tx with multiple drugs (does this exclude anyone???? ) Instead of Do you drink?, ask How much do you drink? Never believe their first answer Patients may start drinking in old age History of drug abuse or current usage? Sexual habits potential for neurosyphyllis? Environmental Admission to ICU Physical restraints Pain (especially untreated duh!) Emotional stress Sleep deprivation 8

9 Sensory deprivation or overload Visual or hearing impairment Dehydration or malnutrition Surgery Delirium Onset acute, days to weeks Prognosis reversible Course fluctuating Attention cannot sustain Sleep patterns disordered Dementia Onset gradual, months to years Prognosis irreversible Course constant deterioration Attention may be able to sustain Sleep patterns usually unchanged 9

10 Prevention Recognition of high-risk patients Patients with neurologic disorders Sensory impairment Advanced age Hospitalization (especially ICUs) Early recognition using CAM or otherwise Treatment eliminate precipitating factors Nursing Pharmacy Nutrition, ST Social services Medicine PT, OT help prevent immobility Protect patient from harm Calm and safe environment (some hospitals have geriatric ERs) Reduce environmental stimuli (noise, light) Family may need to be at bedside Provide familiar objects, reorientation objects 10

11 Remove unneeded tubes, catheters, and equipment Keep call bell within reach Eyeglasses and hearing aids Provide way to communicate needs Associated with: Increased risk of death Institutionalization Dementia Independent of: Age, sex, comorbid illness or illness severity Presence of dementia at baseline Patients with delirium should be considered a vulnerable population Once present, management does not improve longterm mortality Also does not improve need for institutional care 11

12 They will never be the same. Substantially more likely to die within the next 6 months (34% vs 15%) Hospital stays 5 to 10 days longer More likely to end up in nursing homes (16% vs 3%) Associated with lasting cognitive impairment and psychiatric problems SIGNS/SYMPTOMS: 1. Past year has been looking around house at night with flashlight to check for bugs 2. Acts proud that is checking for bugs like it s a man thing 3. Started 1 month later when he was alone saying oh, God, oh my God while he was alone several times a day for 6-8 months, then he just stopped 4. Started to hide from me in the house around the summertime (6 months ago); and stopped a couple of months ago; when wife found him, he had a totally blank look on face; also at this time started to have angry outbursts on phone when answering to anyone; this continues through present 5. Also having angry outbursts at minute details, such as rubber band breaking when wrapping around envelope; angry outbursts often directed at wife 12

13 6. Did apologize a week or so later for angry outburst that happened with the trash basket (this happened a week ago) 7. Has bawled out the pharmacist within the past month; now doesn t want to go back 8. Occasionally still gives empty looks and real angry looks 9. Also on sites on computer 10.Started going through the garbage every day since last summer 11.Demanding obedience in everything 12.Has been losing weight, but hasn t been eating (has lost 30 pounds in past year) 13.Has maintained 153 pounds past 3 months 14.This past week woke up dizzy and vision affected when getting up to bathroom (this only happened last year when he was on insulin, but insulin was stopped last summer); blood sugar this past week at this time when getting up to the bathroom was 70 DIAGNOSES: 1. Aortic stenosis 2. DM II 3. Dyspnea 4. Atrial fibrillation 5. Paroxysmal atrial fibrillation 6. HTN 7. Dyslipidemia 13

14 MEDS: 1. AMIODORONE 200 MG daily 2. TOPROL XL 50MG 24hr tab daily 3. LISINOPRIL 20MG daily 4. WARFARIN 2MG as directed 5. LIPITOR 10MG at HS 6. GLUCOPHAGE 1000MG bid 7. LEVOTHYROXINE 50MCG daily 8. COLACE 100MG CAPS bid 9. MIRALAX POWDER prn 10.TRAMADOL 50MG DAILY 11.SERTRALINE 25MG daily 12.TYLENOL 325MG prn 13.GLIMEPRIRIDE 2MG bid 14.PROSCAR 5MG daily 15.TAMSULOSIN 0.4 MG daily 16.LUNESTA (recently placed on this within the past month because insurance company for Elavil anymore) ALLERGIES 1. PCN (critical) 2. Macrobid (rash) SURGERIES: 1. Appendix 2. Tonsils 3. BPH (TURP?)

15 CHECK ON OR DO: 1. Last TSH? 2. Possibly order sleep study? (daytime sleepiness, some snoring, low O2 at night) 3. HGBA1C? can glimepiride 2m BID be reduced 4. Last PT/INR? Has not been going monthly to have labwork drawn 5. MRI? Possible TIAs or mini-strokes? The end. 15