Transcript Delirium XXXVII ACP Annual Chapter Meeting Panama City, Republic of Panama February 27, 2015 Thomas J.

Delirium
XXXVII ACP Annual Chapter Meeting
Panama City, Republic of Panama
February 27, 2015
Thomas J. Prendergast, MD
Clinical Professor of Medicine, OHSU
Senior Scholar, Center for Ethics in Healthcare
Section Chief, PCCM, Portland VAMC
Director, Respiratory Care and PFT Lab
Outline
Hospital & Intensive Care
 Definitions
 Assessment
 Impact
 Prevention v Management
DSM-V Diagnostic Criteria Delirium
 Rapid and abrupt onset of:
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Change in cognition (at least ONE
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Change in sleep-wake cycle
Change in emotional states
Worsening of behavioral problems
in the evening
Impairment of
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In an appropriate clinical
context
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Recent memory
Orientation
Language (i.e. rambled speech,
mumbling, difficult to understand)
Perception
domain):
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Impaired attention (ability to
direct, focus, shift, sustain)
Lack of awareness of environment
Assessment tools: CAM
Confusion assessment method (CAM) rests on four criteria:
1. Acute onset and fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness
 Dx rests on both 1 and 2 and either 3 or 4.
 Sensitivity 94-100% and specificity 90-95%.
Inouye SK et al. Ann Intern Med 1990; 113:941–948.
Applying the CAM
Is there an acute change in the patient’s mental status that varies
over the course of the day? and
Does the patient show difficulty focusing attention or lose track
of what is being said?
Are the patient’s thoughts disorganized or incoherent?
or
Is there an altered level of consciousness, ie, anything other than
normally alert. Coma voids assessment.
Inouye SK et al. Ann Intern Med 1990; 113:941–948.
The gold standard: neuropsychiatry
 Inpatients on palliative care service screened using CAM.
 100 CAM+ patients referred to consult-liason psychiatry.
 Psychiatry performed a detailed assessment using the Cognitive
Test for Delirium (5 domains) and the revised Delirium Rating
Scale (3 diagnostic items and 13 severity items)
 83 had delirium, 17 had dementia with features of delirium
Meagher DJ et al. Brit J Psych 2007;190:135
A neuropsychiatry perspective
 Inattention nearly universal, other cognitive deficits common.
 Inattention is associated with other cognitive impairments but not with
non-cognitive items such as sleep disturbance and motor abnormalities.
 Motor disturbance (hypo- or hyper-) in 94% of pts, 31 had BOTH
 Language and thought deficits less common but present in >50%.
 Attention deficits fluctuated but other cognitive/language deficits did not.
 49 patients had evidence of psychosis; 18 were floridly psychotic.
 Psychotic symptoms did not correlate with motor findings.
Meagher DJ et al. Brit J Psych 2007;190:135
Neuropsychiatry, conclusion
The psychological abnormalities that the CAM points
toward are multiple and complex.
Meagher DJ et al. Brit J Psych 2007;190:135
Why is
delirium
important?
Witlox J et al. JAMA
2010;304:443
Delirium in elderly hospitalized patients
Increased risk of
• Death (OR 1.95)
• Post-discharge institutionalization (OR 1.71)
• Subsequent development of dementia (OR 12.5).1
Once present, management has limited effect on outcomes.
Prevention may be effective.
1 Witlox
J et al. JAMA 2010;304:443-51.
Prevention of Delirium
 Patients ≥ 70 yo admitted to general medicine inpatient ward
between March 1995 and March 1998 at Yale NH Hospital.
 Not delirious on admission.
 At intermediate to high risk by predictive model: cognitive impairment, visual impairment, severity of illness and high BUN/Cr ratio.
 2,434 eligible, 1,265 excluded, 852 enrolled.
 Intervention unit with standardized protocols that targeted six
risk factors.
Inouye SK et al. NEJM 1999;340:669
Prevention of Delirium
Intervention unit with standardized protocols targeting 6 risk factors.
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Cognitive impairment
Sleep deprivation
Immobility
Visual impairment
Hearing impairment
Dehydration
Inouye SK et al. NEJM 1999;340:669
Prevention of
Delirium
Inouye SK et al. NEJM
1999;340:669
Australian Health Ministers' Advisory Council (2006). Clinical Practice Guidelines, based on work from the Hospital Elder Life
Program (HELP) developed at Yale Hospital that reduced delirium in a RCT. Inouye SK et al. NEJM 1999;340:669-76.
What
about
ICU
patients
Assessment tools: CAM-ICU
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96 patients, mean age 55
All pts mechanically ventilated on enrollment
APACHE II 23 +/- 7, est mortality 35-40%
H/O dementia or prior neurologic dz was exclusion criterion
Only 37% were able to complete the ASE
471 evaluations in 96 patients
 25% normal
 25% delirious  80/96 (83%) met criteria during their ICU stay
 21% stuporous
 29% comatose
 Evaluable pts (alert/lethargic) delirious 40% of the time
Ely EW et al. JAMA 2001; 286:2703.
ICU delirium as seen by Nashville*
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Increased ICU length of stay (8 vs 5 days)
Increased hospital length of stay (21 vs 11 days)
Increased time on ventilator (9 vs 4 days)
Higher ICU costs ($22,000 vs $13,000)
Higher ICU mortality (19.7% vs 10.3%)
Higher hospital mortality (26.7% vs 21.4%)
3-fold increased risk of death at 6 months
Ely, et al. ICM 2001; 27, 1892-1900
Ely, et al, JAMA 2004; 291: 1753-1762
Lin, SM CCM 2004; 32: 2254-2259
Milbrandt E, et al, Crit Care Med 2004; 32:955-962.
Ouimet, et al, ICM 2007: 33: 66-73
*www.ICUdelirium.org
5 questions for a new epidemic
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Is delirium incidence really this high?
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Can sedation cause false positive CAM?
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Is mortality relationship an association or causal?
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Have we underestimated CNS effects of critical illness?
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What do prevention and mgmt look like in the ICU?
1. Is delirium incidence this high?
Devlin JW et al. Intensive Care Med. 2013 Dec;39(12):2196-9.
2. Can sedation cause a false+ CAM?
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CAM-ICU performed before and after daily sedation
interruptions in 102 intubated ICU patients.
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Delirium much more common before than after
sedation interruption – OR 11.05
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12% of patients had sedation-related delirium ONLY.
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Outcomes in this 12% identical to patients w/o delirium
Patel SB et al. AJRCCM 2014;189:658
Sedation affects the CAM
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Delirium assessments should be standardized with
respect to timing and intensity of sedation.
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The bulk of the CAM-ICU literature does not explicitly
assess for effects of sedation.
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Different sedatives with different pharmacokinetics
may lead to more (or less) sedation-related delirium.
Patel SB et al. AJRCCM 2014;189:658
Is delirium an independent mortality RF?
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1112 consecutive adult patients admitted to a mixed ICU
over 2.5 years from Jan 2011- July 2013.
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50.2% developed at least one episode of delirium
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Crude mortality with and w/o delirium: 17% v 7% (p<.oo1)
BMJ. 2014 Nov 24;349:g6652. doi: 10.1136/bmj.g6652.
3. Is mortality causal or an association?
BMJ. 2014 Nov 24;349:g6652. doi: 10.1136/bmj.g6652.
Delirium-associated ICU mortality
Whole cohort (n=1112)
1 Logistic regression
2 Competing risks survival regression
3 Marginal structural model
1.77 (1.15-2.72)
2.08 (1.40-3.09)
1.19 (0.75-1.89)
Observed delirium for at least 2 consecutive days (n=1095)
1 Logistic regression
2.02 (1.34-3.03)
2 Competing risks survival regression
2.15 (1.50-3.09)
3 Marginal structural model
1.67 (1.13-2.47)
BMJ. 2014 Nov 24;349:g6652. doi: 10.1136/bmj.g6652.
The attributable mortality of delirium
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Delirium had no effect on the daily risk of death
Delirium reduced the daily probability of d/c from the ICU
Adjusting for evolution of disease severity, delirium not associated with mortality
In patients with delirium for ≥2 consecutive days, there was a positive association
with increased mortality (HR 1.67 [1.13-2.47]), mediated by prolonged stay rather
than increased daily risk of death.
BMJ. 2014 Nov 24;349:g6652. doi:
10.1136/bmj.g6652.
4. Do we underestimate CNS effects of critical illness?
FVC
6 minute walk
Return to work
Bernard GR. AJRCCM 2005;172:798,
data from Herridge MS et al. NEJM 2004;348:683
Sequelae of Critical Illness, I
 106 ARDS patients (P/f ratio < 150) admitted to LDS Hospital in Salt
Lake City enrolled in a 1 year QOL & neuropsych outcomes study.
 39 (37%) died in hospital, 3 died within 1 year, 4 lost to f/u, 5
pending 1 yr eval, leaving 55 evaluable patients.
 Survivors intubated an average of 29 +/- 20 days
 Two assessments:
• Q15m pulse oximetry measured on all patients
• Neuropsychiatric testing performed at hospital d/c and at oneyear follow up
Hopkins RO et al. AJRCCM 1999;160:50
Sequelae of Critical Illness, I
 At the time of hospital d/c, 55/55 (100%) had demonstrable
cognitive impairment on neuropsychiatric testing
 There was significant improvement at one year f/u, although 78%
continued to demonstrate cognitive impairment.
 There was significant correlation between cumulative time of
recorded hypoxemia and multiple measures of cognitive
impairment.
Hopkins RO et al. AJRCCM 1999;160:50
Sequelae of Critical Illness, II
 Telephone administration of standardized neuropsychiatric tests
to 122 survivors previously enrolled in the ARDSnet FACTT.
 406 eligible, 213 consented, 102 tested at 12 months, 75 completed
testing in all domains.
 No history of pre-existing dementia.
 Cognitive impairment in 41/75 (55%) at 12m.
 Two risk factors independently associated with LTCI:
 Hypoxemia
 Enrollment in the conservative fluid mgmt arm (!)
Mikkelsen ME et al. AJRCCM 2012;185:1307
Sequelae of Critical Illness, III
Pandharipande PP et al. NEJM 2013;369:14
Sequelae of Critical Illness, III
 821 ICU patients with resp failure or shock, enrolled between Mar
2007 and May 2010 at 2 hospitals in Nashville TN.
 Inpatients assessed for delirium daily using the CAM-ICU.
 Psychologists conducted detailed neuropsychiatric testing of
survivors at 3 months (448/569 79% of survivors) and 12 months
(382/510 75% of survivors) .
 91% of patients mechanically ventilated for a median of 3 days
Pandharipande PP et al. NEJM 2013;369:14
Pandharipande PP et al. NEJM 2013;369:14
Pandharipande PP et al. NEJM 2013;369:14
Sequelae of Critical Illness, III
 Median global cognition scores were 1.5 SD below age-adjusted
mean at both 3 and 12 months, c/w mild cognitive impairment.
 26% and 24% at 3 and 12 months, respectively, had scores >2SD
below normal, similar to mild Alzheimer’s disease.
 LTCI was associated with increased duration of delirium.
 LTCI was not associated with
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Presence or absence of delirium
MICU v SICU
Increasing age
Co-morbid illnesses
Duration of coma
Administration of sedatives and analgesics
Pandharipande PP et al. NEJM 2013;369:14
Interim conclusions
 Critical illness is accompanied by altered states of consciousness
in the majority of patients.
 Critical illness exacerbates preexisting cognitive impairments.
 Critical illness probably causes new cognitive impairments in a
significant minority of patients that persist at one year.
 These impairments are more likely the result of illness
(hypoxemia, cerebral perfusion, inflammation) than sedation.
 Recovery from critical illness is complex, prolonged, fragile and
incomplete in many if not most patients.
5. What do
delirium
prevention
and mgmt
look like in
the ICU?
van Rompaey et al. Critical
Care 2009;13:R77
Do ICU patients require sedation?
 140 mechanically ventilated ICU patients randomly assigned to
receive sedation (propofol for 48h titrated to Ramsay 3-4 with
daily interruptions, then midazolam) or no sedation.
 Both groups treated with morphine bolus PRN for pain and
haloperidol PRN for delirium.
Strøm T et al. Lancet, 2011;375:475
Do ICU patients require sedation?
 No sedation strategy resulted in
• Fewer ventilator days
• Shorter ICU and hospital LOS
• Trend towards lower mortality (p = 0.06)
• More delirium
• More use of haloperidol
• No change in opioid administration
 Follow up psychiatric assessment of 13 patients in each group two
years after randomization showed no evidence of long-term
psychological sequelae.
Strøm T et al. Lancet, 2011;375:475
Strøm T et al. Critical Care, 2011;15:R293
Interim conclusions, II
Delirium is complex and multifactorial.
Critically ill patients are at particularly high risk.
Meticulous attention to the underlying acute illness is the first and
most important step – fluids/electrolytes, impaired perfusion,
hypoxemia, infections, drug toxicities inc drug-drug interactions.
A simplified bedside assessment scale (CAM-ICU) is useful
because it is simple, reproducible and heightens awareness (RN and
MD) of the impact of A-S-D mgmt on patients.
ABCDEF bundle of ICU measures
Assess for and manage pain
Both spontaneous awakening and spontaneous breathing trials
Choice of sedation and analgesia
Delirium monitoring and management
Early mobility
Family engagement
WHICH INTERVENTION IS ASSOCIATED WITH IMPROVED
MORTALITY?
1www.ICUdelirium.org
ABCDEF bundle of ICU measures
Assess for and manage pain
Both spontaneous awakening and spontaneous breathing trials
Choice of sedation and analgesia
Delirium monitoring and management
Early mobility
Family engagement
1www.ICUdelirium.org
Interim conclusions, III
Best practice mgmt of ICU delirium is not pharmacologic
but re-engineering:
 Reduce or eliminate sedation for most patients
 Redirection and personal contact rather than restraints
 Early mobilization, including ventilated patients
 Non-pharmacologic approaches to improving sleep
 Environmental modification to reinforce orientation, inc
visual and hearing aids
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