Delirium Pilot Project

Transcription

1 CCU Nurses: Delirium Pilot Project Our unit has been selected to develop and implement a delirium assessment and intervention program. We are beginning Phase 1 with education and assessing for our baseline incidence of delirium. Phase 2 will come in 2014 and include the intervention component. As we learn together we ll begin to see the significance and impact this will have on patient outcomes. To begin: Complete all aspects of this module including the QUIA quiz. You will be paid 1 hr of education time if this education is completed outside of work time. More details will be coming regarding a class Dr. Baum will be teaching with dates/times to be announced but we re planning the third/fourth week of October. Please complete this Delirium QUIA module prior to class so you are ready to participate in case studies and perform a delirium assessment! Please see Rhonda with questions.

2 Delirium Education Part 1: Diagnosis and Consequences Dr. Betsy Baum M.D, CMD Associate Professor Medicine, NEOMED Geriatric Consultant, Aultman Hospital Medical Director, Bethany Nursing Facility Clinical Faculty, CMEF, Aultman FP Residency

3 Objectives 1. Define delirium and its subtypes 2. Describe the significance of delirium and its impact on patient outcomes 3. Identify patients who are at risk for delirium and the precipitating factors 4. Demonstrate proficiency on using the CAM and Mini-cog

4 Synonyms of Delirium: Peer Reviewed Literature Acute confusional state Acute mental status change Metabolic encephalopathy Organic brain syndrome Subacute befuddlement Brain Failure

5 What is Delirium? American Psychiatric Association, 2000: Disturbance of consciousness with impaired attention and disorganized thinking that develops rapidly and with evidence of an underlying physiologic or medical condition

6 Difficult diagnosis FAILURE TO RECOGNIZE DELIRIUM Only 20% cases ID by Drs. Only 50% cases ID by Nurses Epidemiology of delirium Prevalence on admit:14-24% Incidence in hospital: 6-56% ICU incidence: 70-87% 1/3 hospitalize patients over the age of 70

7 Types of Delirium 1. Hyperactive you recognize this! Agitated, Climbing out of bed, wandering, restless, pulling out their IV/Foley Catheter 2. Hypoactive the good patient Unawareness, lethargy, decreased alertness, staring, sparse/slow speech, apathy, decreased motor activity; often delayed diagnosis, mistaken for depression 3. Mixed Fluctuates between hyperactive, hypoactive, and normal behavior 4. Delirium Superimposed on Dementia

8 Consequences of Delirium Increases Hospital LOS Functional decline Nursing home placement Nurse surveillance & care time Risk for other Geriatric syndromes (falls, urinary incontinence, skin) Family stress Mortality as high as MI or sepsis

9 Newly Recognized Consequences of Delirium Recent studies have shown that delirium persists through hospital discharge in 25%-50% of those affected [JAMA. 2010; 304(4): ] Among those discharged with delirium persistence rates of up to 50% have been reported at 1 month Delirium accelerates cognitive decline in Alzheimer s Disease [Neurology. 2009; 72: ] Delirium is associated with an 8x increased risk for incident dementia [Brain. 2012; 135: ]

10 What are the risk factors for Delirium? Interaction between 1. Predisposing factors (chronic factors that increase a patient s vulnerability) and 2. Precipitating factors (acute conditions that initiate delirium) Annals,

11 Delirium: Predisposing Factors Advanced age ( > age 80) Preexisting dementia History of stroke Parkinson disease Multiple co-morbid conditions Impaired vision and/or hearing Functional impairment History of alcohol abuse

12 PRECIPITATING FACTORS Acute cardiac events Acute pulmonary events Bed rest Drug withdrawal (sedatives, alcohol) Fecal impaction Fluid or electrolyte disturbances Indwelling devices Infections (esp. respiratory, urinary, sepsis) Medications Restraints Severe anemia Uncontrolled pain Urinary retention

13 Predisposing Factors (Risk Factors): High Vulnerability Precipitating Factors(Triggers): High Noxious Insult Low Vulnerability Low Noxious Insult Case 1: 66 y/o in good health presents with dyspnea, develops severe sepsis and respiratory failure and this triggers Delirium; Low Vulnerability but High Level of Insult Case 2: 87 y/o with dementia and renal failure develops UTI during hospitalization and this triggers Delirium; High Vulnerability but Low Level of Insult

14 Confusion Assessment Method (CAM) Gold standard for delirium diagnosis Once adequately trained can be done in 5 minutes Sensitivity of % Specificity of 89-95% Summary of CAM can be obtained at: If interested, visit this website:

15 CONFUSION ASSESSMENT METHOD (CAM) Requires features 1 and 2 and either 3 or 4: 1. Acute change in mental status and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness Inouye, Ann Intern Med. 1990; 113:941-48

16 Evaluation of Inattention: Recite days of week or month backwards Spell own name or world backwards Digit span: repeat a random sequence of numbers forward and then in reverse order Subtract serial sevens

17 Evaluation of Disorganized Thinking: Speech disorganized/incoherent Unclear or illogical flow of ideas Unpredictable switching subjects Severe disorientation, unable to follow commands

18 Delirium Diagnostic Assessment Instruments Confusion Assessment Method (CAM) Requires features (1) and (2) and either (3 or 4): 1. Acute change in mental status 2. Inattention 3. Disorganized Thinking 4. Altered level of consciousness Reference: Inouye SK, et al. Ann Intern Med. 1990; 113:941-8.

19 CAM-ICU Version of CAM for non-verbal patients Uses same 4 features as CAM Attention: Vigilance A, Attention Screening Exam Disorganized thinking: Yes/no questions Excellent in ICU/non-verbal patients Lower sensitivity in verbal patients

20 Distinguishing Characteristics of Delirium, Dementia, and Depression

21 How to differentiate normal aging from dementia? NORMAL AGING More time may be needed to learn new information Older people may need more cues to recall things Decrease reaction time and increased difficulty on timed tasks Decrease in pursuits that require multi-tasking NOT NORMAL AGING Older adults should not have a decline in their ADLs and IADLs unless there is a true physical impairment,i.e should still be able to pay bills, cook, drive etc.

22 Mini-Cog A quick screen for a possible dementia This is not a definitive diagnosis of dementia and would need confirmed with additional testing when patient improves Sensitivity for dementia = 76-99% Specificity for dementia = 89-93% Summary of Mini-cog obtained at:

23 Mini-Cog: How to Administer Give the patient 3 words to remember (i.e. apple, table, penny) Distract the patient and have them draw a clock and place the time at 2:35 Normal clock must have: All 12 numbers relatively evenly spaced in the circle 2 hands pointing to correct time

24 Mini-Cog: Scoring Patient scores 1 point for each correct word remembered for maximum possible score of 3 Any score < 3 is considered a positive screen for possible underlying dementia Clock score is either 2 (acceptable) or 0 (not acceptable) Normal clock must have all 12 numbers relatively evenly spaced in the circle and two hands pointing to the correct time Any score < 3 is considered a positive screen for possible underlying dementia Best possible score = 5/5 3/3 for recall for all 3 words 2/2 for normal clock

25 Summary for Part 1 Delirium Education Delirium is common and associated with substantial morbidity for older adults Most delirium is missed by medical staff without specific screening tests (CAM) Dementia is the greatest risk factor for delirium and can be screened by Mini-cog Knowing predisposing and precipitating risk factors for delirium can be the first step in preventing delirium

26 To complete this module: Click/open the link below and view the CAM video module. Complete the following sections: Introduction, Using the CAM, CAM Steps (1-4), Scoring, and Interpretation. You will need to manually click on the FWD key (lower right of screen) to forward the slides and sections. (This takes approx min) CAM Full Version

27 You are now ready to go to the quiz section of QUIA to complete a short delirium quiz