Delirium Basics Jason Moss, PharmD, & Eleanor McConnell, PhD, RN, GCNS-BC October 24, 2011 Objectives Describe the prevalence of delirium and its impact on the health of older patients Discuss pathophysiology, risk factors and key presenting features Distinguish presenting features of delirium, dementia and depression Use nursing process to organize thinking about key nursing activities in preventing and managing delirium Find opportunities to improve current practice Meet Mrs. Florence 78 year old resident of Durham admitted to the hospital after a fall in her home.. Watch video clip in class Have you ever seen anyone like this? How would you describe her behavior? What do you think is wrong? 1
3. Disorganized Thinking What is Delirium? 1. Acute onset of mental status changes or a fluctuating course and 2. Inattention and or = Delirium 4. Altered level of consciousness CAM, CAM-ICU A BIG Problem Hospitalized patients over 65: 10-40% Prevalence 25-60% Incidence ICU: 70-87% ER: 10-30% Post-operative: 15-53% Post-acute care: 60% End-of-life: 83% Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009. Costs of Delirium In-hospital complications 1,3 UTI, falls, incontinence, LOS Death Persistent delirium Discharge and 6 mos. 2 1/3 Long term mortality (22.7mo) 4 HR=1.95 Institutionalization (14.6 mo) 4 OR=2.41 Long term loss of function Incident dementia (4.1 yrs) 4 OR=12.52 Excess of $2500 per hospitalization 1-O Keeffe 1997; 2-McCusker 2003; 3-Siddiqi 2006; 4-Witlox 2010 2
So If delirium such a big problem, why don t we hear more about it? 1. Acute or subacute onset 2. Fluctuating intensity of symptoms 3. Inattention 4. Disorganized thinking 5. Altered level of consciousness Hypoactive v. Hyperactive 6. Sleep disturbance 7. Emotional and behavioral problems Delirium Pathophysiology Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246 Let s go back to our case! 3
Mrs. Florence: Background 78 year old female who fell climbing into attic PMH significant for Knee Osteoarthritis Hypertension, Restless legs, Stroke Married, lives with husband of 52 years 4 beers a day On admission to the hospital: BAL=80 Na=128 Pain score 9/10 Medications Outpatient clonazepam ropinirole lisinopril aspirin furosemide amlodipine oxycodone oxybutynin OTC benadryl as needed for allergies Inpatient ropinirole lisinopril aspirin furosemide amlodipine oxycodone prn oxybutynin sliding scale insulin ranitidine Risk Factors Baseline Vulnerability (Predisposing) -Risk factors r/t person s baseline - Often we cannot modify these Precipitating These are things that happen to the patient Insults Often Iatrogenic Baseline + Precipitating = Delirium 4
Risk Factors- General Baseline Vulnerability Underlying Brain Disease (Dementia, Stroke, Parkinson s Disease) Increased Age Institutionalization Chronic disease (HIV, ETOH dependency, diabetes, etc) Visual/Hearing deficits Precipitating Medications Infection Dehydration Immobility/restraints Malnutrition Tubes/catheters Medications Electrolyte imbalance Sleep Deprivation Framework for Risk Baseline Vulnerability High Precipitating Stimulus Noxious Low Mild/None Anticholinergic Medication Side Effects CNS sedation Constipation Abrupt withdrawal of chronic psychotropic medications 5
Concerning Medications Anticholinergic Antihistamines Anticonvulsants Antiparkinsonian Antipsychotics Benzodiazepines Hypnotics Opioid analgesics Oxybutynin Amitriptyline (**furosemide, ranitidine) Diphenhydramine (Benadryl) Chlorpheniramine Primidone Phenobarbital Levodopa-carbidopa Dopamine agonists Clozapine and other atypicals Diazepam, clonazepam Zolpidem (Ambien) Meperidine, morphine, oxycodone Medications Outpatient clonazepam ropinirole lisinopril aspirin furosemide amlodipine oxycodone oxybutynin OTC benadryl as needed for allergies Inpatient ropinirole lisinopril aspirin furosemide amlodipine oxycodone prn oxybutynin sliding scale insulin ranitidine What Predisposing Factors Did She Have? Predisposing Advanced age Preexisting dementia History of stroke Parkinson disease Multiple comorbid conditions Impaired vision Impaired hearing Functional impairment Male sex History of alcohol abuse Baseline Vulnerability High Low Precipitating Stimulus Noxious Mild/None Marcantonio, 2011. 6
Common Risk Factors for Delirium Predisposing Advanced age Preexisting dementia History of stroke Parkinson disease Multiple comorbid conditions Impaired vision Impaired hearing Functional impairment Male sex History of alcohol abuse Precipitating New acute medical problem Exacerbation of chronic medical problem Surgery/anesthesia New psychoactive medication Acute stroke Pain Environmental change Urine retention/fecal impaction Electrolyte disturbances Dehydration Sepsis Marcantonio, 2011. What Predisposing Factors Did She Have? Precipitating New acute medical problem Exacerbation of chronic medical problem Surgery/anesthesia New psychoactive medication Acute stroke Pain Environmental change Urine retention/fecal impaction Electrolyte disturbances Dehydration Sepsis Baseline Vulnerability High Low Precipitating Stimulus Noxious Mild/None Marcantonio, 2011. 3. Disorganized Thinking What is Delirium? 1. Acute onset of mental status changes or a fluctuating course and 2. Inattention and or = Delirium 4. Altered level of consciousness CAM, CAM-ICU 7
Improving The Odds of Recognition Prediction by risk Predisposing and precipitating factors Team observations Nursing notes Clinical examination CAM Team Input Nursing recognition of high risk medications for delirium Ask Observe Be suspicious Communicate Kamholz, AAGP 1999 Assessment: Standardized Tool Confusion Assessment Method (CAM-ICU) Puts definition into action! 1.Change in cognitive status in past 24 hours? 2.Inattention? 3.Altered Consciousness? 4.Content of consciousness http://www.mc.vanderbilt.edu/icudelirium/ 8
http://www.mc.vanderbilt.edu/icudelirium/ Richmond Agitation-Sedation Score (RAAS) Prevention 1 st! Intervention Management 2 nd 9
Nursing Interventions & Evaluation Yale Delirium Prevention Program : multi-component interventions Cognitive impairment with Reality Orientation Sleep enhancement protocol Sensory impairment with therapeutic activities protocol Sensory deprivation Dehydration Reduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodes Inouye 2004 Post op multi-factorial intervention educational program Teamwork and care planning on prevention and treatment of delirium Targeted delirium risk factors Post op delirium compared to controls (56/102 and 73/97) Lundrtrom, et al. 2007 Delirium: Nursing Strategies Kristin Nomides RN Grace Kwon RN Samantha Badgley RN Duke NICHE Geriatric Resource Nurse Initiative Duke Hospital 2100 Duke NICHE: Nursing Interventions: Delirium & Risk Factors Staff Education Activity Cart / Busy Apron Stimulate cognitive and motor skills All About Me Poster Orientation Information Me File Orientation information provided by patient / family for high risk patients Question Mark Identification of patients with AMS?Altered Mental Status 10
Other Management Medications Low doses of certain antipsychotics Short-acting benzodiazepines Older adults may require lower doses Symptom triggered therapy Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-A) Supportive therapy Comorbidities Hydration and nutrition Team care Back to Mrs. Florence Hospital Course and beyond: Pain management Sitters and family Activity Clonazepam Geriatrics consultation Summary RESPECT delirium. Its common and caustic. PREDICT delirium. Assess for common predisposing and precipitating factors. RECOGNIZE delirium. It can be diagnosed with simple tools (e.g. CAM). PREVENT delirium. It can be averted with multicomponent strategies. RECRUIT team members to improve care. 11
Summary Maintain a high level of suspicion Document findings in the chart Discuss with other members of the team Inform/educate patients and families A better way. Medicine NP s PA s Psychosocial Physiologic Nursing Social work Patients and Caregivers Pharmacologic Environmental Pharmacy Nutrition Administrators PT/OT Supplemental Resources GRECC 5-D Card Delirium brochure for direct caregivers Vanderbilt University www.icudelirium.org RASS pocket cards Videos for CAM administration (2 minutes!) Vancouver Health Authority http://www.viha.ca/mhas/resources/delirium/too ls.htm 12
Delirium Teaching Rounds Itching for a Fight! November 4, 2011 GEC crew Eleanor McConnell, RN, MSN, PhD Anthony Galanos, MD Jason Moss, PharmD Julie Pruitt, RD Cornelia Poer, MSW Gwendolen Buhr, MD Mamata Yanamadala, MD S. Nicole Hastings, MD Jennie De Gagné, PhD, MSN, MS, RN-BC Katja Elbert-Avila, MD Sandro Pinheiro, PhD Robert Konrad, PhD Emily Egerton, PhD Heidi White, MD Kathy Shipp, PT, PhD Deirdre Thornlow, RN, PhD Lisa Shock, MHS, PA-C Michelle Mitchell, LMBT Michele Burgess, MCRP Joan Pelletier, MPH Sujaya Devarayasamudram, RN, MSN Loretta Matters, RN, MSN Acknowledgements Mitchell Heflin, MD & Cornelia Poer, MSW Duke University Geriatrics Division for case material & slides adapted from Medicine Grand Rounds February, 2011 Brenda Pun, RN, MSN, ACNP slides adapted from Delirium II Module prepared for Duke University School of Nursing Geriatric Innovations in Nursing Education (GNIE) Project Duke-NICHE Geriatric Resource Nurses: Kristin Nomides, RN Grace Kwon RN Samantha Badgley, RN Yvette West, RN, C MSN, Director, Duke-NICHE 13