Update - Delirium in Elders Impact Recognition Prevention, and Management Michael J. Lichtenstein, MD F. Carter Pannill, Jr. Professor of Medicine Chief, Division of Geriatrics, Gerontology and Palliative Medicine Department of Medicine UT Health Science Center San Antonio, TX
Delirium in Elders: Learning Objectives Describe the increased risks and costs associated with in-hospital delirium Recognize delirium when it occurs Identify risk factors for delirium prior to and during hospitalization Take steps to prevent delirium Appropriately manage delirium
Delirium: DEFINITION A confusional state characterized by an acute decline in: Attention Cognition In-hospital delirium is: Common Life-threatening Potentially preventable
Delirium Delirium is not good for your patients Delirium leads to increased: Length of stay in-hospital Long term care placement Mortality
Delirium: Screening Diagnosis How do you recognize delirium?
Delirium: Screening Diagnosis Confusion Assessment Method (CAM) Assesses 4 mental status features: Acute onset of change and fluctuating course Inattention Disorganized thinking Altered level of consciousness May be completed in 5 minutes Well understood by physicians, nurses, and lay interviewers Inouye SK, et.al., Ann Intern Med 1990; 113:941-948
Confusion Assessment Method (CAM) Feature 1 Acute onset of changes or Fluctuations in the course of mental status AND Feature 2 Inattention AND EITHER Feature 3 Disorganized Thinking OR Delirium Feature 4 Altered level Of Consciousness Adapted from Ely EW, et.al. JAMA 2001; 286:2703-2710
Delirium Risk Factors How can you tell if someone is at risk of developing delirium?
Delirium Risk Concepts High Large Person s underlying susceptibility to develop delirium Environmental stress or insult Adapted from: Inouye SK, Charpentier PA, JAMA 1996; 275:852-857 Low Small
Delirium Risk Factors Baseline Pre-disposing Factor Vision impairment Visual acuity < 20/70 Severe illness Apache score > 16 or Nurse Rating of severe illness Cognitive Impairment Folstein MMSE < 24/30 Adjusted RR (95% CI) 3.5 (1.2, 10.7) 3.5 (1.5, 8.2) 2.8 (1.2, 6.7) BUN/Creatinine ratio > 18 2.0 (0.9, 4.6) Adapted from: Inouye SK, et.al. Ann Intern Med 1993; 119:474-481 N.B. Factor had to be present at time of hospitalization prior to the diagnosis of delirium.
Delirium Risk Factors In-Hospital Precipitating Factor Adjusted RR (95% CI) Use of physical restraints 4.4 (2.5, 7.9) Malnutrition Albumin level < 30 g/l (3.0 g%). 3 Medications added In 24-48h prior to delirium onset. 4.0 (2.2, 7.4) 2.9 (1.6, 4.7) Use of bladder catheter 2.4 (1.2, 4.7) Any iatrogenic event Any harmful occurrence that was not a part of the patient s underlying illness. 1.9 (1.1, 3.2) Adapted from: Inouye SK, Charpentier PA, JAMA 1996; 275:852-857 N.B. Factor had to be present for 24 hours prior to the diagnosis of delirium.
Delirium Risk Factors Groups Patients then categorized into two risk groups by the number of: 1. Predisposing Factors (present at baseline), and 2. Preciptating Factors (occurred in hospital) Number of Factors Low Risk Intermediate Risk High Risk Risk Group 0 Factors 1-2 Factors 3+ Factors Adapted from: Inouye SK, Charpentier PA, JAMA 1996; 275:852-857 N.B. Factor had to be present for 24 hours prior to the diagnosis of delirium.
Delirium per 100 person-days Delirium Risk Factor Interactions Development Cohort Validation Cohort 30 30 25 25 20 20 15 15 10 10 5 0 High Intermediate Low Low High Intermediate Baseline Risk Group 5 0 High Intermediate Low Low High Intermediate Baseline Risk Group Preciptating Factor Group 196 patients 1293 hospital days Precipitating Factor Group 312 patients 2131 hospital days Adapted from: Inouye SK, Charpentier PA, JAMA 1996; 275:852-857
Prevention of In-Hospital Delirium If you recognize the risk factors, can you prevent in-hospital delirium?
Prevention of In-Hospital Delirium Multi-component intervention to prevent delirium Randomized Controlled Trial General Medicine Service Yale Age > 70 years No delirium on admission Randomized 852 patients Inouye SK, et al. N Engl J Med 1999; 340:669-676
Prevention of In-Hospital Delirium Address risk factors for delirium Provide orienting communication Encourage early mobilization Use visual and hearing aids Prevent dehydration Provide uninterrupted sleep time Avoid psychoactive drugs Inouye SK, et al. N Engl J Med 1999; 340:669-676
Number of Cases Prevention of In-Hospital Delirium 180 160 140 120 100 161 Intervention (N=426) Odds Ratio for Risk Usual Care (N=426) Reduction for 105 Delirium: 90 80 60 40 20 0 42 64 First Epidsode of Delirium 0.60 (95% CI, 0.39-0.92) Days of Delirium Inouye SK, et al. N Engl J Med 1999; 340:669-676 62 Episodes of Delirium
Cumulative Incidence of Delirium Cumulative Incidence of Delirium According to Study Group 0.25 0.20 Inouye SK, et al. N Engl J Med 1999; 340:669-676 Usual Care 0.15 0.10 Intervention 0.05 0.00 Median length of stay 1 2 3 4 5 6 7 8 9 10 11 Days of Hospitalization
Preventing In-Hospital Delirium What works? Intervention Control P-Value Orientation Score 7.2 (N=128) 6.8 (N=125) 0.06 Sedatives 35% (N=426) 46% (N=426) 0.001 ADL Score 9.7 (N=96) 9.3 (N=98) 0.34 Vision Correction 37% (N=57) 21% (N=62) 0.27 Hearing 5.3 (N=120) 4.5 (N=98) 0.09 BUN/Cr Ratio 20.7 (N=240) 20.7 (N=254) 0.22 Inouye SK, et al. N Engl J Med 1999; 340:669-676 (N=number assessed)
Delirium Management Once you ve identified Delirium, how are you going to manage it?
Delirium Management Identify and treat precipitating problems (using the mnemonic DELIRIUM ): D rug use (especially when drug is started or the dose adjusted) E lectrolyte and physiologic abnormalities (eg, hyponatremia) L ack of drugs (withdrawal eg, benzodiazepines) I nfection (especially urinary tract or respiratory infection) R educed sensory input (eg, blindness, deafness) I ntracranial problems (eg, stroke, bleeding, post-ictal state) U rinary retention and fecal impaction M yocardial problems (eg, arrhythmia, heart failure) Almost any acute illness affecting any organ system, or an exacerbation of any chronic illness, may precipitate delirium. Merck Manual On-line: http://www.merck.com/mrkshared/mmg/sec5/ch39/ch39a.jsp
Delirium Management Delirium Present (DSM-IV or CAM) Offending Drug? Discontinue Review Medications Perform Focused H&P Obtain Basic Labs CBC Glucose Electrolytes BUN/CR Urinalysis Pulse Oximetry EKG Adapted from J Frances UpToDate 2006 Trauma/Focal Finding? Focus of Infection? Nuchal Rigidity? No Obvious Etiology? CT Brain Antibiotic LP Consider: - B12/folate - MRI - Thyroid - Drug Levels - EEG - Toxin Screen
Delirium Management Delirium Present (DSM-IV or CAM) Institute Supportive Measures - Maintain Hydration - Avoid Restraints - Mobilize Patient - Reduce Noise - Orienting Stimuli - Reassurance - Bedside Sitters Adapted from J Frances UpToDate 2006 Does Patient Behavior Interfere With Care or Safety? Yes Low Dose Neuroleptic (Haloperidol, Risperidone, Quetiapine) THIS IS CONTROVERSIAL Continue Evaluation And Treatment No
Delirium Unresolved Problems Lots more work to be done to understand the underlying biology for the pathophysiology of delirium Once delirium has developed, need more effective means of management