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CHAMP Incident Delirium in the Hospitalized Senior. Andrea Bial, MD Don Scott, MD, MHS University of Chicago. Goals. Facilitate learning and teaching around the topic: “Incident Delirium in Hospitalized Seniors” Reduce the Incidence of Delirium in Hospitalized Seniors
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CHAMPIncident Delirium in the Hospitalized Senior Andrea Bial, MD Don Scott, MD, MHS University of Chicago
Goals • Facilitate learning and teaching around the topic: “Incident Delirium in Hospitalized Seniors” • Reduce the Incidence of Delirium in Hospitalized Seniors • Improve the Care of Hospitalized Seniors who develop Delirium
ObjectivesSection 1 (Don) • Learn More & Teach More About Assessing Risk for Delirium • Predicting Older Patients Probability of Developing Delirium • Learn More & Teach More About Delirium Prevention Strategies • Avoiding Precipitants • Prevention Interventions • Learn More & Teach More About Diagnosing Delirium: Using the Confusion Assessment Method (CAM) • To Diagnose Delirium • To Help Distinguish from Dementia
ObjectivesSection 2 (Andrea) • Learn More and Teach More about the Systematic Approach to the Evaluation of the Hospitalized Senior with Delirium • Learn More and Teach More about the Systematic Approach for the Treatmentof the Hospitalized Senior with Agitated Delirium
HPI:Mrs. G.,87 y.o. woman from home; 4-5 days c fever, cough, malaise, appetite, po; 1 day DOE PHx: DM c neuropathy, HTN, A-Fib, OA, Glaucoma, COPD Meds: glipizide, amitriptyline qhs, lisinopril, Digoxin, Vioxx, T#3’s prn, Warfarin, Ditropan Soc / Fx Hx: Lives with husband, retired teacher, Ind. in ADLs and IADL’s PEx • Vitals 381; 155/90,HR 105, RR 20; O2 94% RA, Non-Toxic • HEENT: edentulous, dry OP • Chest: BS and Exp Wheezes • CV: Syst. M c/w SEM • Abd: Benign; g- • Ext’s: Trace Pedal Edema • Neuro: A&O X 3, Non-Lateralizing, follows commands
Labs: 145 4.6 105 22 43 1.7 10.5 70% N 10% Bds 10% L 298 185 16.7 32.0 (MCV=85) U/A: >20 WBC, +LE / N, Many Bacteria U & Bld Cx’s P CXR: + COPD Changes / ?RLL Infiltrate ECG: A-Fib @ 105 Dig = 1.4 Albumin 4.0 (LFT’s WNL)
Teaching about Delirium in Hospitalized Seniors • Teaching Opportunities for: • Evidence-Based: • Risk Factors for Delirium at Admission? • Prediction of Delirium at Admission? • Delirium-Producing Insults? • Validated Prediction Tool for Delirium? • Differentiating Delirium from Dementia? • Prevention Strategies?
Teaching Moment Alert! • Why Thinking about Delirium in Vulnerable Older Adults is as Important
Delirium in Hospitalized Seniors: Significance 1. The Prototypical Geriatric Symptom • Medical Emergency THE Cardinal Symptom • “Brain Failure” Congestive Heart Failure 2. Independent Risk Factor for: • Mortality • Functional Decline • Length of Stay • Nursing Home Placement • (? cognitive decline) 3. Common: Gen Med Wards --Incidence = 14-25% (>70)
Delirium in Hospitalized Seniors: Significance 4. Potential Iatrogenic Complication of Hospitalization (X 2) 5. Costly 6. Preventable
Learn More & Teach More About Assessing Baseline Risk for Delirium
Sharon Inouye’s Work Develop a Useable Diagnostic Tool and Validate Identify Baseline Risk Factors & Develop Predictive Model for Incident Delirium Identify Precipitating Insults Causing Incident Delirium and Develop Predictive Model Develop and Test a Prevention Strategy
Predisposing Factors/ Vulnerability Precipitating Factors/ Insults High Vulnerability Noxious Insult Low Vulnerability Less Noxious Insult Delirium:Multifactorial Model Inouye, S, et. al. JAMA. 1996; 275:852- 857.
Predicting Delirium:PreDisposing Risk Factors • Purpose: Develop and Validate a Predictive Model for Occurrence of Incident Delirium in persons > 70 years • Design: Prospective Cohort Study • Development Cohort • Validation Cohort • Setting: Univ-Based Teaching Hospital; Gen. Med. Service • 10 Outcome: Incident Delirium via CAM • Assessed within 24 of Admission & Daily • Analysis: ID Risk Potential Ind Risk Factors c Bivariate Stepwise Prop. Hazards Model to ID Ind Risk Factors Predictive Model Inouye SK , et al. Ann Intern Med. 1993;119:474-481
DEVELOPMENT COHORT N=107 RR 1. Vision 3.5(1.2-10.7) 2. Severe Illness 3.5(1.5-8.2) 3. Cognition 2.8(1.2-6.7) 4. BUN/Cr > 182.0 (1.1-4.6) ROC = 0.74 (0.63, 0.85) VALIDATION COHORTN=174 RR Low Risk (0) 1.0 Int. Risk (1-2) 2.5 High Risk (3-4) 9.2 ROC = 0.66 (0.55-0.77) (SEE Pocket Card) Predicting Delirium:PreDisposing Risk Factors • NOTE: COG. IMPAIRMENT (MMSE < 24); VISION IMPAIRMENT > 20/70; BUN/CR > 18/1; SEVERE ILLNESS= APACHE II > 16 OR CHARLSON ORDINAL CLINICAL = RATED AS SEVERE • ROC= 0.74 (0.63-0.85) Inouye SK , et al. Ann Intern Med. 1993;119:474-481
Teachable Moment ALERT ! Teachable Moment 1: Risk Stratification • Predicting Older Patients Probability of Developing Delirium Triggers: The Long-Call or Short Call Presentation Standing at the Bedside with an At- Risk Patient
Teachable Moment ALERT ! • Teachable Moment 1 (Cont’d) • Risk Stratification Targeting Efficiency • What do you think this patient’s risk is of developing delirium? • Was Vision Checked? Glasses? • Was a MMSE or other Cognitive Screen Performed ? • Does Patient appear Severely Ill? • BUN/Cr and Volume Status ? • ? Risky Meds ? PRN’s? • Delirium Risk Score = 2 (Vision & Azotemia) (SEE 3X5 Card)
Learn More & Teach More About Diagnosing Delirium: Using the Confusion Assessment Method (CAM) • To Diagnose Delirium • To Help Distinguish from Dementia
1. Acute Onset & Fluctuating Course 2. Inattention AND plus either 3. Disorganized Thinking 4. Altered LOC Delirium: Diagnosis--CAM DELIRIUM Inouye SK et al. Ann Intern Med 1990;113:941-948.
CAM (Confusion Assessment Method) • Feature 1: Acute Onset & Fluctuating Course • This feature is usually obtained from a family member or nurse and is shown by positive responses to the following questions: • Evidence of sudden change in mental status from baseline? • Did the abnormal behavior fluctuate during the day, that is, tend to come and go, or increase or decrease in severity? Inouye SK et al. Ann Intern Med 1990;113:941-948
Validity of CAM • Inouye S, et. al. Clarifying confusion: The confusion assessment method. Ann Intern Med. 1990; 113: 941- 948 • Comparison = DSM III-R Interview • Sens 94 & 100% Spec 90 & 95% PPV 91 & 91% NPV 90 & 100% • Ely EW., et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA. 2001;286(21):2703-10. • Comparison DSM IV Interview • Sens 93 & 100% Spec 98 & 100% inter-rater reliability = 0.96 • Monette J., et al. Evaluation of the confusion assessment method (CAM) as a screening tool for delirium in the emergency room. Gen. Hosp. Psychiatry. 2001;23(1):20-5. • Comparison: “Geriatrician Interviewer” • Sens 86% Spec 100%
Teachable Moment 2: Using the Confusion Assessment Method (CAM) • To Diagnose Delirium • As a Springboard To Help Distinguish Delirium from Dementia (see Pocket Card) BEDSIDE TEACHING TRIGGERS • Suspected Delirious Patient, Dementia Patient • DEMONSTRATE USE OF CAM TO DIAGNOSE HYPOACTIVE DELIRIUM OR • USE OF CAM TO DIAGNOSE AND DISTINGUISH HYPOACTIVE DELIRIUM VS. DEMENTIA (see Pocket Card)
Learn More & Teach More About Delirium Prevention Strategies • Precipitating Factors • A Successful Prevention Strategy
Predicting Delirium:Precipitating Risk Factors • Purpose: To prospectively Develop and Validate a Model for Incident Delirium based on Precipitating Factors During Hospitalization • Design: Prospective Cohort Study • Setting: Univ-Based Teaching Hospital; Gen. Med. Patients • 10 Outcome: Incident Delirium via CAM (precipitating factor must proceed > 240) • Analysis: Group Risk Factors on 4 Axes (a priori assumption) Reduce variables on each axis using Multivariable Binomial Regression Models (ID’s Ind Risk Factors from each Axis) Predictive Model Inouye SK , et al. Ann Intern Med. 1993;119:474-481
DEVELOPMENT COHORT N=196 RR 1 Phys. Restraints4.4 (2.5-7.9) 2 Malnutrition4.0 (2.2-7.4) 3 3 meds added2.9 (1.2-4.7) 4 Bladder Catheter2.4 (1.2-4.7) 5Iatrogenic Event1.9 (1.1-3.2) (SEE Pocket Card) VALIDATION COHORT N=312 (RR) 1. Low Risk (0 Points)1.0 2. Intermed Risk (1-2)7.1(3.2-15.7) 3. High Risk (3-5)17.5(8.1-27.4) Predicting DeliriumPrecipitating Risk Factors Inouye SK, et. al. JAMA 1996: 275; 852- 857
Learn More & Teach More About Delirium Prevention Strategies • Precipitating Factors • A Successful Prevention Strategy
A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Adult Patients. NEJM. 1999. • Design: Prospective, Matched, 852 patients, Medicine Service • Inclusion: Age > 70, Not delirious at admit, Intermed. or High Risk • Intervention --Focused on 6 risk factors for delirium: Cognitive Impairment, Sleep Deprivation, Immobility, Visual impairment, Hearing impairment, Dehydration • 1o End Point = Incident Delirium Assessed daily until discharge Inouye SK, et al. NEJM. 1999;340:669-676
Targeted Interventions Cognitive Impairment Sleep Deprivation Immobility Orientation/ Activities Early Mobilization Non-drug; sleep enhancement
Targeted Interventions Visual Impairment Hearing Impairment Dehydration Visual Aids, Devices Hearing devices, Remove earwax Early recognition & po repletion
Prevention Protocols Inouye SK, et al. NEJM. 1999;340:669-676 SEE CHALK
Results • USUAL CARE = 15.0% • PREVENTION GROUP = 9.9% • OR 0.60 (CI 0.39- 0.92) • RRR= 40% ARR= 5.1% • NNT = 20 • NO BENEFIT ONCE DELIRIUM OCCURED Inouye SK, et al. NEJM. 1999;340:669-676.
Back to Case HPI: Mrs. S., 87 y.o. woman from home; 4-5 days c lethargy, appetite, po; 1 day n/v, no po DX:Cystitis and Possible Pyelonephritis A/P • IV Abx and NS; Clear Liquid, ADA Diet; Foley to Gravity; Bed Rest • Continue Out-Patient Medicines • SSI & FS qac & qhs • PRN’s: MOM, Compazine, Prosom, T#3’s • DVT Prophylaxis • AM lABS • Abd/Renal U/S & AM Labs
Teachable Moment ALERT ! • Teachable Moment 3: “Preventing” Delirium • Potential Triggers • Post-Call or Short Call Presentation • Bedside • Room Dark, TV Blaring, Tethered to Bed, No Glasses, No Hearing Aids, Dry Board with Wrong Day and Other Info • Ask re Out of Bed, Diet (and ?eating / drinking), BM’s? • Why is the Patient in Bed • Where’s the Geri-/Cardiac Chair ? • What is Happening Overnight ? • MAR Review
Teachable Moment 3: Preventing DeliriumAvoiding Precipitants & Prevention Interventions • ? Pt’s Baseline Risk ? • What Meds have we Added? What psychoactive medications are on the MAR? (Time for MAR Review?) (SEE 3X5 Card) • ?Any “regular Meds” that could have been temp. D/C’s? • ? Vision and Hearing ? Are Glasses and Hearing Aids Present; Is a “Pocket Talker” Needed (?Available) • Is a Foley Present and if so what is the indication? • What are the plans for getting the Patient out of Bed? Can we find a Cardiac / Geri Chair? Has PT been Ordered? Family and Pt encouraged? Are IV Fluids Really Needed • Does the patient really need to be awakened for am labs and vitals ? Really need FS qac and qhs? • Is the patient eating? Has the Diet been Advanced? Is the patient pooping?