Delirium in the Neurologically Injured

Transcription

1 Fifth Annual Baptist Health South Florida Miami Neuro Nursing Symposium 2017 Delirium in the Neurologically Injured Financial Disclosure Financial relationships none Product endorsements none Financial gains none presented by: Vera W. Bryant DNP, ARNP, ACNP-BC, CCRN, CMC, CNRN, SCRN Neuro Critical Care Nurse Practitioner - BHM Learning Objectives Review the syndrome of delirium and the subtypes Examine some of the etilogies of delirium Learn some of the most common risks factors Focus on ways to assess, prevent and treat delirium symptoms Delirium What is it? Why is it important? What causes it? Who is at risk? Can it be prevented? How is it treated? 1

2 Common Why Delirium? Common problem Serious complications Under recognized Preventable Serious Under-recognized 2

3 Preventable Definition Delirium is a nonspecific organic syndrome which is characterized by an acute onset of altered level of consciousness with a fluctuating course in orientation, memory, thought or behavior. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5 th ed. Washington, DC: American Psychiatric Press; Terminology De liro Phrenitis Like does not mean same DSM-V criteria DSM-V Criteria Disturbance in attention Develops over a short period of time There is an additional disturbance in cognition Not explained by another disorder Evidence that the disturbance is caused by a medical condition American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5 th ed. Washington, DC: American Psychiatric Press;

4 Delirium Subtypes Hyperactive 10% Hypoactive 50% Mixed 40% Increased psychomotor activity Restlessness Easily distracted Hallucinations Agitation / Combativeness Confusion Reduced alertness Lethargic Quiet Withdrawn Sluggish Confusion Decreased motivation Features periods of both hyperactive and hypoactive symptoms Why is it important? Epidemiology Prevalent delirium 11 25% of hospitalized patients will have delirium on admission Epidemiology Incident delirium 29 31% of hospitalized patients admitted without delirium will develop delirium Intensive Care Medicine. 2007;33(1): Neurology. 2011;76: Best Practice and Research Clinical Anaesthesiology. 2012;26(3): Intensive Care Medicine. 2007;33(1): Neurology. 2011;76: Best Practice and Research Clinical Anaesthesiology. 2012;26(3):

5 Epidemiology What causes it? Consequences (economic / functional) $64 Billion annually in USA Higher associated mortality Longer hospitalizations Decreased QOL Increased risk of institutionalization Nature Reviews Neurology. 2009;5(4): Archives of Internal Medicine. 2008;168: Best Practice and Research Clinical Anaesthesiology. 2012;26(3): Critical Care Medicine. 2013;41(1): Stroke. 2012;43: Pathophysiology Neurotransmitter imbalance Inflammation Impaired oxidative metabolism Altered BBB permeability Journal of Neurology. 2004;251: Innovations in Clinical Neuroscience. 2011;8(10):25-34 Stroke. 2012;43:

6 Predisposing Risks Who is at risk? Pre-existing dementia * Age * Functional impairments * Severity of illness on admission History of ETOH abuse HTN Critical Care Nurse. 2009;29:85-87 Advanced Critical Care. 2011;22: British Medical Journal. 2014;349:g6652 Precipitating Risks Infection * Uncontrolled pain Fluid / electrolyte abnormalities Environmental influences Withdrawal conditions Medications * Critical Care Nurse. 2009;29:85-87 Advanced Critical Care. 2011;22: British Medical Journal. 2014;349:g6652 Medication Risk Anticholinergics Benzodiazepines Opiates Corticosteroids Tricyclic antidepressants H 2 blockers Critical Care Nurse. 2009;29:85-87 Advanced Critical Care. 2011;22: British Medical Journal. 2014;349:g6652 6

7 Neurologically Injured Incidence rate: 13% to 28% Hypoactive is the most common LOS is longer Increase in mortality Coma was an independent risk factor for the development of delirium Journal of Neurology. 2004;251: Age and Aging. 2009;38: Acta Neurologica Scandinavica. 2010;122:39-43 Stroke. 2012;43: Am J Respir Crit Care Med. 2013;188(11): Neurologically Injured Age Urinary retention / UTI Pneumonia Pre-existing dementia Sensory impairments Stroke. 2012;43: Am J Respir Crit Care Med. 2013;188(11): Journal of Young Pharmacists. 2017;9(2): Neuropsychiatric Disease and Treatment. 2017;13: Neurologically Injured / Stroke Large anterior circulation strokes Hemorrhagic strokes Any posterior circulation strokes Cardio-embolic strokes Left hemiparesis Journal of Neurology. 2004;251: Age and Aging. 2009;38: Stroke. 2012;43: Am J Respir Crit Care Med. 2013;188(11): Mnemonic: D Drugs E Environment L Lab abnormalities I Infection R Respiratory I Immobility O Organ failure U Unrecognized dementia S Shock / Steroid / Stroke / Sleep Adapted from: St. Louis University Geriatrics Evaluation Mnemonics Screening Tool 7

8 Can it be prevented? Management of Delirium Primary Prevention Secondary Prevention Advanced Critical Care. 2011;22(3): Annals of Internal Medicine. 2011;154(11): American Journal of Critical Care. 2015;24(1): Primary Prevention - Identify patients at risk - Prevent Secondary Prevention - Identify patients at risk - Treat - Prevent 8

9 Assessment Screening Tools CAM / CAM-ICU * IC-DSC CTD Nu-DESC DOSS Primary / Secondary Prevention Review the medication list Reduce high-risk medications Do not use medications to manage sleep, anxiety, mild agitation Reserve pharmacologic approaches for severe agitation or psychosis Intensive Care Medicine. 2001; 27(5): JAMA. 2001;286: JAMA. 2004;291: Advanced Critical Care. 2011;22(3): Annals of Internal Medicine. 2011;154(11); Critical Care Medicine. 2013;41(1): Journal of American Geriatrics Society. 2015;63(1): Primary / Secondary Prevention Enhance mobility / ROM Maintain nutrition / hydration Treat pain adequately Use functional aids Minimize risk of infection Sleep promotion How is it treated? Advanced Critical Care. 2011;22(3): Critical Care Medicine. 2013;41(1): Journal of American Geriatrics Society. 2015;63(1):

10 Delirium Practice Guidelines American College of Critical Care Medicine Institute for Health and Care Excellence American Geriatrics Society Annals of Internal Medicine. 2011;154(11); Critical Care Medicine. 2013;41(1): Journal of American Geriatrics Society. 2015;63(1): British Medical Journal. 2017;7e Guideline Recommendations Recommend to avoid medication classes that may induce delirium Recommend routine monitoring of delirium using validated assessment tools Recommend the implementation of nonpharmacological interventions Guideline Recommendations Recommend use of antipsychotics only in patients that are severely agitated or distressed and are posing substantial harm to self and others Recommend using the lowest dose of medication for the shortest period of time Guideline Recommendations Do NOT recommend the use of sedatives in the treatment of delirium, except in cases of drug and alcohol withdrawal Do NOT recommend the use of antipsychotics to prevent delirium 10

11 Guideline Recommendations Recommend early mobilization Recommend thiamine should be considered in all patients with delirium General Treatment Identify, remove and treat underlying cause(s) Non-pharmacologic measures Pharmacologic measures Antipsychotics (Neuroleptics) Sedatives Annals of Internal Medicine. 2011;154(11); Critical Care Medicine. 2013;41(1): Journal of American Geriatrics Society. 2015;63(1): Pharmacologic Treatment Typical antipsychotics Haloperidol Dose: Not specified Risks: QT prolongation, EPS, NMS Benefits: Low frequency of sedation, respiratory depression and hypotension Annals of Internal Medicine. 2011;154(11); Critical Care Medicine. 2013;41(1): Journal of American Geriatrics Society. 2015;63(1): Pharmacologic Treatment Atypical antipsychotics Olanzapine Quetiapine Risperidone Dose: Not specified Risks: Drowsiness, decreased risk of QT prolongation and EPS Benefits: As effective as haloperidol Annals of Internal Medicine. 2011;154(11); Critical Care Medicine. 2013;41(1): Journal of American Geriatrics Society. 2015;63(1):

12 Pharmacologic Treatment Sedatives Benzodiazepines Propofol In Trials Dexmedetomidine Gabapentin Annals of Internal Medicine. 2011;154(11); Critical Care Medicine. 2013;41(1): Journal of American Geriatrics Society. 2015;63(1): Key Learning Points Delirium is a multifactorial syndrome with predisposing and precipitating risk factors Delirium can be diagnosed with high sensitivity and specificity Prevention should be the goal If delirium occurs, treat the underlying cause(s) Always try non-pharmacologic approaches first, and then low dose antipsychotics Summary Nurses play an important role in the assessment, recognition, prevention and treatment of delirium in their patients. Therefore, it is important to expand the knowledge about delirium to improve identification, management -- and most importantly outcome. 12

13 References Abdalla A, Alomar MJ. Subdural hematoma and delirium case evaluation in elderly patients. Journal of Young Pharmacists. 2017;9(2): Ali S, Patel M, Jabeen S, Bailey RK, Patel T, Shahid M. Insight into delirium. Innovations in Clinical Neuroscience. 2011;8(10): American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5 th ed. Washington, DC: American Psychiatric Association, Andrews L, Silva SG, Kaplan S, Zimbro K. Delirium monitoring and patient outcomes in a general intensive care unit. American Journal of Critical Care. 2015;24(1): Barr J, Fraser GL, Puntillo K, et al. Clinical practice guidelines for the management of pain, agitation and delirium in adult patients in the intensive care unit. Critical Care Medicine. 2013;41(1): References Bergeron N, Dubois MJ, Dumont M, Dial S, Skobik Y. Intensive care delirium screening checklist: Evaluation of a new screening tool. Intensive Care Medicine. 2001;27(5): Bush SH, Marchington KL, Meera A, Davis DH, Sikora L, Tsang TW. Quality of clinical practice guidelines in delirium: a systematic appraisal. British Medical Journal Open. 2017;7:e Caeiro L, Ferro JM, Albuquerque R, Figueira ML. Delirium in the first days of stroke. Journal of Neurology. 2004;251: Dahl MH, Ronning OM, Thommessen B. Delirium in acute stroke prevalence and risk factors. Acta Neurologica Scandinavica. 2010;122(190): Ely EW, Inouye SK, Bernard GR, et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). Journal of the American Medical Association. 2001;286: References Ely EW, Shintani A, Truman B. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. Journal of the American Medical Association. 2004;291: Fong TG, Tulebaev SR, Inouye SK. Delirium in elderly adults: diagnosis, prevention and treatment. Nature Reviews Neurology. 2009;5(4): Inouye SK, Westendorp RG, Saczynski JS. Delirium in elderly people. Lancet. 2014;383: Inouye SK, Robinson T, Blaum C, Busby-Whitehead J, Boustani M, Chalian A, et al. American Geriatrics Society abstracted clinical practice guideline for postoperative delirium in older adults. Journal of the American Geriatric Society. 2015;63(1): References Klouwenberg PM, Zaal IJ, Spitoni C, Ong DS, van der Kooi AW, Bonten MJ, et al. The attributable mortality of delirium in critically ill patients: prospective cohort study. British Medical Journal Open. 2014;349:g6652. Leslie DL, Marcantonio ER, Zhang Y, Leo-Summers L, Inouye SK. Oneyear healthcare costs associated with delirium in the elderly population. Archives of Internal Medicine. 2008;168: Maneeworg J, Maneeton B, Maneeton N, Vaniyapong T, Traisacathit P, Sricharoen N, et al. Delirium after a traumatic brain injury: Predictors and symptom patterns. Neuropsychiatric Disease and Treatment. 2017;13: McManus J, Pathansali R, Hassan H, Ouldred E, Cooper D, Stewart R, et al. The course of delirium in acute stroke. Age and Aging. 2009;38:

14 References Naidech AM, Beaumont JL, Rosenberg NF, Mass MB, Kosteva AR, Ault ML, et al. Intracerebral hemorrhage and delirium symptoms. American Journal of Respiratory and Critical Care Medicine. 2013;188(11): Nydahl P, Bartoszek G, Binder A, Paschen L, Margraf NG, Witt K, Ewers A. Prevalence for delirium in stroke patients: A prospective controlled study. Brain and Behavior. 2017;7:e Oldenbeuving AW, de Kort PL, Jansen BP, Algra A, Kappelle LJ, Roks G. Delirium in the acute phase after stroke: incidence, risk factors, and outcome. Neurology. 2011;76: O'Mahony R, Murthy L, Akunne A, Young J. Synopsis of the National Institute for Health and Clinical Excellence guideline for prevention of delirium. Annals of Internal Medicine. 2011;154(11): References Ouimet S, Kavanagh BP, Gottfried SB, Skobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Medicine. 2007;33(1): Pun BT, Boehm L. Delirium in the intensive care unit. AACN Advanced Critical Care. 2011;22(3): Shi Q, Presutti R, Selchen D, Saposnik G. Delirium in acute stroke. Stroke. 2012;43: Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Practice & Research Clinical Anaesthesiology. 2012;26(3):