Transcript Document

Today's activity
You and your colleagues will evaluate 3 geriatric patients for delirium.
Each group will rotate to 3 patient stations. You will have 10 minutes with the
patient, 5 minutes to develop a management plan based on your diagnoses, and
5 minutes for feedback. Each group member should "take the lead" with one
patient.
Prior to "seeing" the patient:
--review the face-sheet to learn the history and presentation
--come up with a "pretest" probability of how likely it is that the patient will have or
develop delirium
--identify any predisposing or precipitating factors
Then, evaluate the patient
--use CAM to determine if the patient has delirium
--discuss your assessment and plan with the family at the bedside
Goals
1. Define delirium and understand concept of precipitating and
predisposing factors
2. Recognize that delirium is common, under-diagnosed, and
associated with significant morbidity and mortality
3.
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Regarding delirium, know ways to:
diagnose
evaluate
manage
Goals
1. Define delirium
2. Understand model that uses predisposing and
precipitating factors
Delirium Definition
Medical condition characterized by acute
onset of confusion (, i.e. not chronic)
Has following features:
• Fluctuating course
• Altered level of awareness/consciousness
• Inattention
• Disorganized thinking
• Increased or decreased psychomotor
activity
• Disturbance of sleep-wake cycle
Predisposing factors
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Dementia
Age
Male sex
Frailty
Malnutrition
Depression
Terminal illness
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Functional impairment
Immobility
Alcohol abuse
Sensory impairment
High medical
comorbidity
• Polypharmacy
Precipitating factors
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Medications
Neurologic disease
Surgery
Uncontrolled pain
Hypoxia
Metabolic
derangements
• Severe
illness/infection
• Low Hct
• Bed rest
• Indwelling devices
• Restraints
• Sleep deprivation
• Dehydration
Tipping the scale...
The greater the predisposing factors, the fewer
precipitating factors required to initiate the
delirium. Delirium is usually MULTIFACTORIAL.
Goals
2. Recognize that delirium is common, under-diagnosed,
and associated with significant morbidity and mortality
How many geriatric patients have delirium? Common but
underdiagnosed...
At presentation to the ED: 7-33%.
At hospital admission: 14-25%.
Postoperatively: 15-53%.
In the ICU: 70-87%.
In the community, ages 65-85: 1-10%, those >85: 14% .
At the end of life: Up to 83%.
Prognosis: It's a big deal!
May persist weeks, months- 44% at 1 month, 33% at 3
months.
Has a waxing and waning course.
Has been associated with a
• 10-fold increased risk of death in the hospital
• 3-5 increased risk of nosocomial complications
• prolonged length of stay
• impaired physical and cognitive recovery at 6 and 12
months
• need for post-acute nursing home placement
Has an associated one-year mortality rate of 35-40%!
Goals
3.
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Regarding delirium, know ways to:
diagnose
evaluate
manage
Diagnosis
*****CAM: Confusion Assessment Method*****
Based on the 4 cardinal elements of the DSM-3 criteria for
delirium:
1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
Must have have 1 and 2 and either 3 or 4
Sensitivity 94%-100%
Positive LR 9.6
Specificity 90-95%
Negative LR 0.16
Inouye SK et al. Clarifying confusion: The confusion assessment method. A new method for detection of
delirium. Ann Intern Med 1990: 113 (13): 941-948.
Feature 1. Acute Onset or Fluctuating
Course: Must have this one!
This feature is usually obtained from a family
member or nurse and is shown by positive
responses to the following
questions:
1.Is there evidence of an acute change in mental status
from the patient’s baseline?
2.Did the (abnormal) behavior fluctuate during the day,
that is, tend to come and go, or increase and decrease
in severity?
Feature 2. Inattention: Must have this
one!
This feature is shown by a positive response to the
following question:
1.Did the patient have difficulty focusing
attention, for example, being easily distractible, or
having difficulty keeping track of what was being
said?
Feature 3. Disorganized thinking
This feature is shown by a positive response to the
folllowing question:
1.Was the patient's thinking disorganized or
incoherent, such as rambling or irrelevant
conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject?
Feature 4. Altered Level of
Consciousness
This feature is shown by any answer other than
“alert” to the following question:
1. Overall, how would you rate this patient’s
level of consciousness?
-alert
-vigilant/hypervigilant
-lethargic
-stuporous
-comatose
Evaluation: D.E.L.I.R.I.U.M
Drugs!!
Electrolyte/endocrine disturbances (dehydration, sodium
imbalance, uremia, hypercalcemia, hypoglycemia,
thyrotoxicosis)
Lack of drugs (withdrawal from ETOH, benzos or poor pain
control, B12 deficiency)
Infection (sepsis, meningitis, encephalitis)
Reduced sensory input (can't see or can't hear)
Intracranial (infection, hemorrhage, stroke, tumor)
Urinary, fecal (urinary retention, fecal impaction--can be a
cause!)
Major organ system issues-- infarction, arrhythmia, shock,
COPD, hypoxia, hypercapnia, renal failure, liver failure,
hypertensive encephalopathy
Evaluation
Basics:
History
Physical exam
Targeted labs
Careful medication history
Alcohol, illicit drug use
Vital signs
Multiple factors likely involved rather than a single "cause"
but delirium can be the sole manifestation of serious
underlying disease.
If still looking...
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LP
Blood cultures
UA/Urine culture
Urine toxicology
Cardiac enzymes and EKG
Arterial blood gas
Blood alcohol
Head CT
EEG
Management of delirium
• First, try to remove/treat precipitants of delirium.
• Provide frequent orientation and therapeutic activities.
• Provide glasses and hearing aids.
• Avoid constipation/urinary retention/dehydration/electrolyte
imbalances.
• Avoid complete bed rest.
• Educate family and nursing support staff of ways to comfort patient.
• Try scheduled tylenol, ice/heat packs, warm milk in place of meds.
Medications to reduce or
eliminate...particularly if they are not needed or are not
working or there are other alternatives!
Anticholinergics
Diuretics
Antidepressants
Benzos
Opioids**
Anticonvulsants
Antiparkinsonian
agents
Nonbenzodiazepine
hypnotics (zolpidem)
Fluroquinolones
(levaquin)
Muscle relaxants
Antiemetics
Steroids
**Don't over-treat pain but also
don't under-treat it!
About restraints...
We DO NOT recommend restraints as they can cause bad
outcomes (even death!).
Always, evaluate the patient first.
Always, try other interventions first:
--Have family stay with patient
--Use a sitter
--Demonstrate calming the patient to those involved in the
patient care.
If medically necessary to the patient, use restraints for the least
amount of time possible and always inform the family about
why they are needed.
Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4): 405-8.
Pharmacologic Therapy, ie chemical
restraints
Consider only if safety is in issue or if patient's symptoms are
very distressing to the patient
High-potency antipsychotics (haldol) usually first-line
Use low dose and go slow
ex. 0.25 mg IV haldol or 0.5 mg po haldol
Use for shortest duration possible
Can see akathisia, which can be
mistaken for worsening delirium
Take-home points
Delirium is common, under-recognized and serious (increased
risk of death)!!!!!
Use the CAM to diagnose delirium: Acute onset+Inattention
and either disorganized thinking or altered level of
consciousness
Remember D.E.L.I.R.I.U.M. for differential diagnosis.
Use your H&P to guide you evaluation and management.
Try to avoid physical and chemical restraints.
Works cited
Botts, Angela. Delirium in Hospitalized Older Patients. Clinical Geriatrics 2010: Volume 18 (10): 28-33.
Inouye, S., van Dyck, C., Alessi, C., Balkin, S., Siegal, A. & Horwitz, R.(1990). Clarifying confusion: the
confusion assessment method. Annals of Internal Medicine, 113(12), 941-948..
Inouye SK, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM
1999; 340(9): 669-676.
Inouye SK et al. A predictive model for delirium in hospitalized elderly patients based on admission
characteristics. Ann Intern Med 1993: 119 (6); 474-481.
Inouye SK. Delirium in Older Persons. NEJM 2006: 354 (11); 1157-1165.
O'Keefe ST et al. Assessing attentiveness in older hospital patients. J Am Geriatr Soc. 1997; 45(4): 470473.
Rubin et al. Asphyxial deaths due to physical restraint. A case series. Arch Fam Med 1993; 2(4): 405-8
Wong et al. Does this patient have delirium? Value of bedside instruments. JAMA Aug 18, 2010- Vol 304.
Questions?
THANK YOU!
Contact information:
Lindsay Wilson
[email protected]
919-966-5945 ext 256