Geriatric Grand Rounds

Transcription

1 Geriatric Grand Rounds Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care Hospital Tuesday, October 27, :00 noon Dr. Bill Black Auditorium Glenrose Rehabilitation Hospital In keeping with Glenrose Rehabilitation Hospital policy, speakers participating in this event have been asked to disclose to the audience any involvement with industry or other organizations that may potentially influence the presentation of the educational material. Disclosure will be done both verbally and using a slide or handout. Dr. Lotje Wasilenko, CCFP Care of the Elderly Resident October 27, 2009 Disclosure I have no relationship that could be perceived as placing me in a real or apparent conflict of interest in the context of this presentation Outline Background Research questions Methodology Results Conclusion Limitations Recommendations/Future directions Definition Delirium (DSM-IV-TR) 1 Background on Delirium Acute alteration in consciousness Ability to focus, sustain, or shift attention Develops over hours to days Results in cognitive and perceptual disturbance

2 Definition Delirium (DSM-IV-TR) 1 Prevalence of Delirium Fluctuates throughout the day Caused by medical conditions, medication side effects, substance intoxication Delirium can be found wherever there are sick patients Prevalence in hospitalized older adults is 25% to 56% 2,3 Prevalence of Delirium Risk Factors and Precipitants 8 Highest prevalence: 4,5,6 - Older patients post-op 15-53% - ICU 70-87% - Near death 80% Unrecognized in up to 65% 7 (age, dementia, other mental disorder) Delirium is a multi-factorial disorder Risk factors that increase baseline vulnerability - Underlying brain diseases (dementia/stroke) - Advanced age - Sensory impairment Risk Factors and Precipitants 8 Precipitating Factors Precipitants are factors that precipitate the disturbance Precipitants alone do not cause delirium Precipitants interact with underlying risk factors Drugs and toxins Infections Metabolic derangements Brain disorders Systemic organ failure

3 Precipitating Factors Others: Immobility (restraint use) Dehydration Malnutrition Use of bladder catheters Constipation Urinary retention Pain Sleep deprivation Vulnerability 9 Highly vulnerable patients have many risk factors - Delirium due to relatively benign precipitant - For example: change in medication Less vulnerable patients have few risk factors - Require major insult to trigger delirium Diagnosis Most important: - Delirium is a medical emergency - Recognize that delirium is present - Uncover the cause for delirium Evaluation: history (including meds), physical exam, CAM, investigations CAM 10 Confusion Assessment Method 1) Acute onset and fluctuating course 2) Inattention 3) Disorganized thinking 4) Altered level of consciousness Diagnosis of delirium requires 1 and 2, plus either 3 or 4 CAM Scores predicting Delirium (Sensitivity of % and Specificity of 90-95%) Consequences of Delirium 11 Prolonged hospital stay Functional and cognitive decline Prevention of Delirium Managing modifiable RF/Precipitants reduces risk of delirium Risk of institutionalization Morbidity and mortality Financial burden

4 Prevention of Delirium Managing modifiable RF/Precipitants reduces risk of delirium Prevention of Delirium This study used protocols to screen and control for 6 RF: - Cognitive impairment - Visual impairment - Sleep deprivation - Hearing impairment - Immobility - Dehydration Prevention of Delirium Significant reduction in number of delirium episodes compared with usual care (62 versus 90) Significant reduction in the total number of days with delirium (105 versus 161) No effect on delirium severity or recurrence rate Seniors Delirium Protocol Implemented in August 2008 To improve identification and management of delirium in the acute care setting Early recognition and intervention of delirium to improve patient outcome Seniors Delirium Protocol Guides assessment for delirium Includes CAM, guidance of opioid use, and medication management of disturbed behaviour Research Questions 3 pages of patient care orders

5 Research Questions 1) What is the prevalence of delirium in patients 65 years of age or older, admitted to a Family Medicine unit at a community based Acute Care Hospital? 2) What are the most common risk factors and precipitants in older hospitalized patients with delirium? Research Questions 3) Is the Seniors Delirium Protocol being utilized in patients with a change in behaviour or cognition? - Delirium - Acute confusion - Agitation (new onset) Methodology Methodology Literature review Ethics and site approval Chart retrieval from medical records Patients 65 years old admitted to Family Medicine Unit in an acute care facility between November 1, 2008 and February 28, 2009 Retrospective chart review and data extraction Methodology Data Extraction

6 Age/Gender of Sample Population Results n = 250 Age Mean (yrs) SD 7.83 Range (yrs) Research Question #1 What is the prevalence of delirium in patients 65 years of age or older, admitted to a Family Medicine unit at a community based Acute Care Hospital? Prevalence of Delirium/Acute Confusion/Agitation n = 250 Prevalence of Delirium/Acute Confusion/Agitation Research Question #2 n = 78 What are the most common risk factors and precipitants in older hospitalized patients with delirium?

7 Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care Hospital RF/Precipitants for Delirium in Sample Population n = 250 RF/Precipitants in Delirium versus Non-Delirium Group Age Difference Between Delirium and Non-Delirium Group n Delirium 78 Mean Age (yrs) 84.6 No Delirium SD Gender Difference Between Delirium and Non-Delirium Group Male p-value 0.03 Delirium No Delirium Female n % n % Differences Not Statistically Significant Breakdown of Sample Population by Number of RF for Delirium Geriatric Grand Rounds Breakdown of Delirium and NonDelirium Group by Number of RF Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009

8 Breakdown of Sample Population into Low Risk or High Risk Groups Prevalence of Delirium in the Low and High Risk Groups n = 250 p < Age Difference Between High and Low Risk Groups Gender Difference High and Low Risk Groups n Mean Age (yrs) SD p-value Low ( 3 RF) High ( 4 RF) Male Female n % n % Low ( 3 RF) High ( 4 RF) Differences Not Statistically Significant Difference in # Medications Between Low and High Risk Groups n Mean (# meds) SD p-value Low ( 3 RF) <0.001 High ( 4 RF) Examining the Most Predictive Risk Factors for Delirium Logistic regression used to determine the most predictive risk factors for delirium First step was to look at correlations between risk factors ( n = 15) and delirium Those risk factors found to be positively correlated with delirium were selected for use in the regression equation (10 of the 15 were significant)

9 Most predictive Risk Factors for Delirium Research Question #3 Risk Factors p-value Hx Dementia Immobility Dehydration 0.02 Physical Restraints # Medications <0.001 Bladder Catheter 0.06 Is the Seniors Delirium Protocol being utilized in patients with a change in behaviour or cognition? - Delirium - Acute confusion - Agitation (new onset) Seniors Delirium Protocol Use Conclusions Delirium is very common in our sample population (31%) Acute Confusion is documented more often in the chart than the diagnosis of delirium Significant predictors of delirium are a history of dementia, immobility, dehydration, use of physical restraints, and # of medications Seniors Delirium Protocol is underused Conclusions Limitations Patients with 4 RF/Precipitants develop delirium 3 times more often then patients with 3 RF/Precipitants Not all RF/Precipitants for delirium were included in data extraction Some RF/Precipitants were difficult to assess with retrospective chart review and might have been missed Unsure if all delirium diagnosis were correct since CAM score not mentioned in chart

10 Recommendations Since delirium is common and affects patient outcome we should anticipate it in certain patients (hx of dementia/stroke, older age) If there is change in behaviour/cognition use Seniors Delirium Protocol which addresses most RF and precipitants Recommendations At least address the most predictive RF/Precipitants: Hx of dementia Immobility Dehydration Use of physical restraints Medications that can cause delirium Recommendations If delirium is confirmed use this as diagnosis (instead of Acute Confusion) Document delirium in discharge summary Future Directions Staff surveys to find out why Seniors Delirium Protocol is not being used Regular inservices regarding Seniors Delirium Protocol with follow up in 1 year (focus on physicians, residents, students) Possibly develop an intervention protocol based on the most predictive RF/Precipitants Thank You! Dr. Bonnie Dobbs and Rhianne McKay Dr. Jennifer Stickney-Lee and Dr. Namita Rao Medical Records Staff Bonnie Launhardt References 1. American Psychiatric Association, Diagnostic and Statistical Manual, 4 th ed, Text Revision, APA Press, Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med 1998; 14(4): Siddiqi N et al. Occurence and outcome of delirium in medical in-patients; a systematic literature review. Age Ageing 2006;35: Inouye SK. Delirium in older persons. N Engl J Med Pisani MA et al. Cognitive impairment in the intensive care unit. Clin Chest Med 2003;24: Casarett D et al. Diagnosis and management of delirium near the end of life. Ann Intern Med 2001;135: Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97 (3): Inouye SK, Charpentier PA. Precipitating risk factors for delirium in hospitalized elderly persons: predictive model and inter-relationship with baseline vulnerability. JAMA 1996; 275: Young J, Inouye SK. Delirium in older people. BMJ 2007;334; Inouye SK et al. Clarifying confusion: The Confusion Assessment Method, a new method for detection of delirium. Ann Intern Med 1990; 113: McCusker J, Cole M et al. Delirium predicts 12- month Mortality. Arch Intern Med 2002;162: