Delirium in Hospital Care Dr John Puxty 1 Learning Objectives By the end of the workshop participants will be able to: Appreciate the main diagnostic criteria for delirium. Describe common risk factors, causes and main differential diagnoses. Describe the immediate and long term impact of delirium on prognosis and outcome. Appreciate key components of strategies to both prevent and manage delirium within a hospital setting Definition and Epidemiology of Delirium 3 1
Definition Delirium is a disturbance of consciousness with reduced ability to focus, sustain, or shift attention. It is a change in cognition that occurs over a short period of time and tends to fluctuate over the course of the day. (Milisen et al. 2001). It s common! Estimated prevalence of delirium: 10-30 % ER attendees over 65 years of age 10-18% on admission to hospital increases to 20-40% during hospital stay 5-10% after elective general surgery 20-30% elective orthopedic but >50% post hip fracture surgery 40% of patients admitted to ICU rising to 70-87% during ICU stay 40% of transfers between acute care and LTC As many as 80% of patients develop delirium near death Under-Recognition Up to 66% deliriums are unrecognized (Inouye, 1998) Specific factors linked to under-recognition: Clinical presentation: hypoactive delirium, age 80+, vision impairment, and dementia Caregiver knowledge or attitudes: unaware that delirium is a potential medical emergency attribute changes to dementia older patients are expected to get confused System/processes: lack of continuity of care lack of use of standard measures 2
Common causes of Delirium 7 Possible mechanisms EEG, neuro-imaging and neuropsychology studies have suggested generalized disruptions of cortex, subcortical, basal ganglia, limbic and thalamic structures Cholinergic deficiency Dopamine-acetylcholine imbalance Some evidence for abnormalities other neurotransmitters Cytokines influence Hyperactivity sympathetic nervous system Predisposing Factors Dementia - fivefold increase of risk (Cole, 2004) Increased relative risk during hospitalization due to: vision impairment (RR = 3.5) severe illness (RR = 3.5) cognitive impairment (RR = 2.8) and high urea/creatinine (RR = 2.0) (Inouye (Inouye,1998) Other predisposing risk factors: dependence in activities of daily living history of depression use of anticholinergic medications medical co-morbidities (Dolan et al., 2000; Marcantonio et al., 2000) 3
Precipitating Factors Often multiple predisposing and precipitating factors Use an acronym to screen for precipitants: I WATCH DEATH DELIRIUMS I WATCH DEATH Infection Withdrawal (benzodiazepines/alcohol) Acute metabolic (fluids/electrolytes) Trauma (pain) CNS pathology Hypoxia Deficiencies Endocrine Acute vascular Toxin/Drugs Heavy metal DELIRIUMS 4
Or go for the Money! Drugs, drugs, drugs, drugs Prescription, OTC, using someone else s, illicit, alcohol, withdrawal Infection Pulmonary, Urinary, Skin (PUS) Metabolic Cardio/respiratory Pain including discomfort from retention and constipation Impact of Delirium 14 Personal Experience 5
Personal Experience Delirious patients post surgery experienced being trapped in incomprehensible experiences and turmoil of past, present and here and there, which were all regarded as real and at the same time as changing and unreal (Anderson et al). Hospitalized cancer patients with delirium recalled their experience as highly distressing. It was also a highly distressing experience for spouses/caregivers and nurses who were caring for the delirious patients (Breitbart et al, 2002). Poor Prognosis Mortality rates in hospital: 10-26% for those admitted with delirium 22-76% of those who develop delirium during hospitalization have increased chance of death during the months following discharge) Independent predictor of sustained poor cognitive and functional status during the year after medical admission to hospital Increases the length of stay and likelihood of admission to long-term care facilities Average increase in cost of care $2,500 per case Differential Diagnosis 18 6
Delirium and Dementia Is a frequent complication of dementia May unmask an early dementia May present as new or worsening behaviour or psychological symptom of dementia Has a negative impact on the prognosis of dementia Delirium may occur in the absence of any overt cognitive impairment i and does not mean dementia is present Should not be mis-termed as a worsening of dementia or BPSD just because it fails to resolve after a few days or weeks, especially if the use of chemical and/or physical restraints persists Differentiating Delirium and Dementia Approach and Management of Delirium 21 7
Important Principles in the Approach to Delirium Consider possibility of delirium with altered level of consciousness/attention and fluctuating course Often need multiple short assessments over period of time Clarify pre-morbid status and sequence of events Exclude important differential diagnosis (e.g. postictal state, language deficit post CVA, depression, psychosis, dementia) Identify all predisposing and precipitating factors (often multiple) May persist weeks-months Monitoring is Crucial The Confusion Assessment Method (CAM): screen for delirium relatively high sensitivity and specificity (Inouye et al, 1990) Neecham Confusion Scale used by nursing to monitor delirium Confusion Assessment Method Sensitivity 94-100% Specificity 90-95% (Inouye et al, 1990) Acute change in mental status AND Inattention/fluctuation PLUS Disorganized thinking OR Altered level of consciousness 8
Useful simple tests of attention Days of the week backwards Months of the year backwards Counting backwards from 20 Random digit span Recited list of digits it with Raise i your hand everytime I say 3 MoCA Interventions for preventing or treating delirium in hospital Number non-randomized studies have demonstrated benefits through multi-component reduction of several risk factors through care protocols, education or systems redesign (Cole 2002; Inouye 2000; Rubin 2006 and 2011). The Hospital Elder Life Program (HELP) reduced incidence of delirium (30%), improved patient functional outcomes (30%), reduced length of stay (25%) and saved an average of $831 per intervention patient for acute hospital costs and $9,446 per patient per year in long-term nursing home costs. At a dissemination site in a large community hospital, HELP was evaluated using administrative data, and saved $1.25 million per year in 704 patients on one 40-bed unit. A follow-up study involving 7,000 patients per year on six hospital units resulted in annual net savings of $6.9 million. Interventions for preventing or treating delirium in hospital Small number of RCTs (Cochrane library 2009): Proactive geriatric consultation in # hip (30% reduction incidence of delirium) (Marcantonio 2001). Prophylactic small dose haloperidol was not effective in preventing delirium but did reduce its severity and duration, and also decreased length of hospital stay (Kalisvaart 2005). 9
Non-Pharmacological Approach Inform and educate staff and family Optimise vision clean glasses, lighting Optimise hearing hearing aids Treat all precipitating causes including pain! Optimise hydration, nutrition, sleep Early mobilization Stabilise environment and re-orientate Encourage presence of family members for reassurance Low stimulation - avoid excessive noise or frequent moves Normalize sleep Avoid restraints (physical and chemical) Pharmacological Approach Review all medications - minimize use where possible Avoid chemical restraints if possible Use sedation only if severely agitated and restless Avoid prn use of medication if possible Use a SINGLE medication rather than two to decrease the potential for side effects/drug interactions: start with a low dose choose a drug with low anticholinergic activity try to stop the medication as soon as possible, focusing on correcting the underlying cause for the delirium continue with non-pharmacological interventions Canadian Coalition for Seniors Mental Health Guidelines on the Assessment and Treatment of Delirium (2006) Haloperidol: low doses (0.25 1 mg per dose or 1-2 mg per day) as short a period of time as possible (days) during acute delirium not for delirium due to withdrawal from alcohol or benzodiazepine Acute alcohol or benzodiazepine withdrawal delirium: use a shorter acting benzodiazepine i (Lorazepam is recommended) d) Atypical antipsychotics: limited data on their use for agitation due to delirium alternate agents for those with: Parkinson s Disease Lewy Body dementia a history of severe side effects with haloperidol Cholinesterase inhibitors effects are variable 10
References Breitbart, W., Gibson, C., and Tremblay, A (2002). The Delirium experience: Delirium recall and delirium-related distress in hospitalized patients with cancer, their spouses/caregivers, and their nurses, Psychosomatics, 43(3), 183-194. Britton A, and R Russell (2005). Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment. The Cochrane Database of Systematic Reviews. Article No: CD000395.pub2. DOI: 10.1002/14651848.CD00395.pub2. Cole, M. (2004). Delirium in elderly patients. American Journal of Geriatric Psychiatry, 12, 7-21. Cole MG, McCusker J, Voyer P, Monette J, Champoux N, Ciampi A, Vu M, Belzile E. (2012) The course of delirium in older long-term care residents. Int J Geriatr Psychiatry. 27(12):1291-7 McCusker J, Cole MG, Voyer P, Monette J, Champoux N, Ciampi A, Vu M, Belzile E. (2011) Prevalence and incidence of delirium in long-term care. Int J Geriatr Psychiatry. Jan 27 Dolan, M., Hawkes, W., Zimmerman, S., & Morrison, R. (2000). Delirium on hospital admission in aged hip fracture patients: Prediction of mortality and 2 year functional outcomes. Journal of Gerontology: Medical Sciences, 55A, M527-M534. Inouye, S. K. (1998). Delirium in hospitalized older patients: Recognition and risk factors. Journal of Geriatric Psychiatry and Neurology, 11, 118-125. Milisen, K., Foreman, M. D., Abraham, I. L., De Geest, S., Godderis, J., Vandermeulen, E., et al. (2001). A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients. The Journal of the American Geriatrics Society, 49, 523-532. Other Sources: The Hospital Elder Life Program (HELP) for clinicians interested in learning more about delirium http://elderlife.med.yale.edu/public/public main.php 11