Post-operative Delirium

1. Post-operative Delirium Kyle C. Moylan, MD Assistant Professor of Clinical Medicine University of Missouri - Columbia

2. Background • Delirium is common • Delirium is often unrecognized • Delirium is life-threatening • Delirium is potentially predictable and preventable

3. Consequences • Increased morbidity • Increased mortality • Increased costs • Often a trigger of a “downward spiral” resulting in loss of independence, disability, and institutionalization

4. Delirium is Common • Complicates the course of 20% of the 12.5 million patients over age 65 hospitalized every year • Prevalence at admission – 14-24% • Incidence during hospitalization – 6-56% • Post-operative incidence – 15-53% • ICU incidence - 70-87% • Incidence in post-acute care - 60%

5. Delirium is Costly • Adds $2500 to hospitalization per patient • Accounts for $6.9 billion of Medicare hospital expenditures • Increases cost for institutionalization, rehabilitation, home health services, and informal caregiving

6. Delirium is Underdiagnosed • Diagnosis is clinical • Requires careful bedside evaluation and cognitive assessment • Fluctuating nature • Confused with dementia • Significance underappreciated • Diagnosis is not considered or sought

7. Delirium – Diagnostic Criteria • Confusion Assessment Method (CAM) • Requires - • Acute Onset and Fluctuating Course • Inattention • AND Either • Disorganized thinking OR • Altered Level of Consciousness • Sensitivity: 94%-100% • Specificity: 90%-95% • Used as gold standard in almost every study • Only + or – so does not distinguish levels of severity • CAM-ICU has also been developed Inouye SK. Ann Intern Med 1990

8. Confusion Assessment Method • CAM positive IF 1 and 2, plus 3a or 3b • 1. Acute Onset and Fluctuating Course • Is there evidence of an acute change in mental status from the patient’s baseline? • Did the (abnormal) behavior fluctuate during the day (tend to come and go, or increase and decrease in severity)? • 2. Inattention • Did the patient have difficulty focusing attention (e.g. being easily distractible) or have difficulty keeping track of what was being said? • 3a. Disorganized Thinking • 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? • 3b. Altered Level of Consciousness • Overall, how would you rate this patient’s level of consciousness? (alert [normal], vigilant [hyper-alert], lethargic [drowsy, easily aroused], stupor [difficult to arouse], or coma [un-arousable]). Positive for any answer other than “alert”.

9. Delirium subtypes • Hyperactive • More easily recognized • Tends to be more severe and associated with worse outcomes • Hypoactive • Less recognized but more common • up to 70% of cases in post-hip fracture repair • Can coexist in a single patient over time

10. Etiology • Complex interaction of the patient, predisposing and precipitating factors • More susceptible patients may require minimal insult • Less susceptible patients will require more substantial insults • Often multifactorial • Pathophysiology poorly understood

11. Risk Factors for Post-Op Delirium • Older age • Cognitive impairment • Functional impairment • Decreased post-op hemoglobin • Markedly abnormal Na, K, glucose • BUN/Cr >18 • Alcohol abuse • Noncardiac thoracic surgery • Aortic aneurysm surgery • History of delirium • Preoperative use of narcotics • Low postoperative oxygen saturation • History of cerebrovascular disease • Untreated pain Marcantonio JAMA 1994; Kalisvaart J Am Geriatr Soc 2006

12. Drugs Implicated in Post-Op Delirium • Anticholinergic medications • Diphenhydramine, antispasmodics, TCA’s, antiemetics • Opiates • Meperidine • Benzodiazepines • Antiparkinsonian drugs

13. Evaluation • Physical Exam • Blood sugar, pulse oximetry • Targeted evaluation for underlying causes • Exclude focal neurologic process • Electrolytes, CBC, LFT’s, urinalysis, ECG, PCXR, ABG • Non-constrast head CT in select patients • Patients with trauma, anticoagulants, metastatic disease, focal neuro findings or unable to complete adequate neuro exam • EEG rarely helpful

14. Quick Mental Status Screen

15. Questions What year is this? What month is this? What day of the week is this? Three item recall (1 minute)  Apple Table  Penny Total possible Point Value 1 1 1 1 1 1 6 Six Item Screener

16. Delirium Management • Treat underlying causes • Don’t stop looking after finding one potential cause • Supportive Care and Environment • Targeted symptom-based treatment • First have to make the diagnosis

17. Supportive Measures • Remove unnecessary intrusions • Indwelling urinary catheters, telemetry, IV’s • Avoid interrupting sleep • Are the 3am vitals really needed for this patient? • Sensory Aids (hearing aids, glasses) • Family support • Early mobilization, avoid restraints • Provide reorientation (view of clock, calendars, familiar objects) • Adequate lighting and temperature • Include Fall Prevention protocols

18. Interventions • Numerous studies showing successful multifactorial interventions to prevent and reduce the severity of delirium (Inouye et al. NEJM 1999) • Generally address non-pharmacologic factors • Sensory enhancement, hydration, mobilization, improved sleep, avoiding problem medications • Difficult for a single person to implement • Often led by teams of geriatricians, nurse partners, others • May be part of an ACE unit

19. Pharmacologic Management • Usually NOT indicated • Reserve for patients whose symptoms threaten their own safety or that of others • May be a substitute for physical restraints • Oral therapy is preferred when possible • Stopping medications may be more effective • Outcomes of intervention studies are disappointing

20. DR. NO Approach • D – Describe the behavior, Document • R – Reason for the behavior • N – Non-pharmacologic management • O – Order medications last • Assess the effect

21. Benzodiazepines • NOT first line therapy • May paradoxically worsen delirium • Implicated as etiology of delirium in many patients • Benzo use predicts development of delirium in post-op and ICU patients • Can cause oversedation or respiratory depression • Lorazepam – 0.5-1.0mg orally, repeated every 4H as needed

22. Trazadone • No controlled studies • Preferred by some experts • May cause oversedation • 25-50mg orally at bedtime, plus every 4-6H as needed

23. “Typical” Antipsychotics • Haloperidol is the drug of choice • Effective in RCT’s • 0.5-1.0mg oral BID or at bedtime • Repeat Q4H PRN • Peak effect 4-6H • Same dose can be given IM with peak effect in 20-40 minutes • IV not FDA approved and should be avoided • EPS, prolonged QT. Contraindicated in PD pts

24. “Haloperidol Prophylaxis for Elderly Hip-Surgery Patients at Risk for Delirium: A Randomized Placebo-Controlled Study” (Kalisvaart KJ et al. J Am Geriatr Soc. 2005;53:1658-1666) • Patients - 430 pts. in the Netherlands • Aged 70 and older at risk for delirium • Mostly elective hip replacements (75%) • Intervention – Haloperidol 1.5mg/daily or placebo. • Started on admit and continued to POD #3. • All patients with geriatrics consult. • Results – No difference in rate of delirium (15.1vs. 16.5%) • Decreased severity and duration (5.4 vs 11.8 days) • Decreased LOS (17.1 vs 22.6 days) • No adverse effects of haloperidol were noted • Limitations • Lower than expected incidence of delirium (underpowered) • Cognitively intact elective surgery patients • Geriatrics consultation may have benefited both groups • LOS longer than most US hospitals for this surgery

25. Atypical Antipsychotics • Little data available but frequently used • No evidence of superiority to haloperidol • Concerns about increased risk of death in studies of dementia related behavioral problems (Schneider et al, JAMA 2005) • Typical doses • Risperidone 0.5 mg BID • Olanzapine 2.5-5.0 mg daily • Quetiapine 25 mg twice daily

26. Post-Discharge Care • Delirium may persists for weeks or even months • Should have regular follow-up of mental status until back to baseline • Diagnosis and current mental status needs to be communicated to post-acute physician (and nursing) • Poorer rehab outcomes • 30% Rehospitalized from post-acute facilities (Marcantonio JAGS 2005) • Risk of new diagnosis of dementia increased at least threefold • 18% at one year (vs 5%) (Rockwood Age Ageing 1999) • 69 % at five years (vs 20%) (Lundstrom JAGS 2003) • Likely to have substantial long term needs • Only 1/3 will still live independently at 2 years (McCusker CMAJ 2001)

27. Prevention – Elective Surgery • Add to pre-op evaluation for elderly pts • Baseline MMSE • Get family and caregivers involved • Bring glasses, hearing aids to hospital • Medication review • Discuss with anesthesia

28. Conclusions • If you aren’t making the diagnosis frequently, look harder • Try using a simple screen for cognitive impairment for the next month • Set an example for learners by evaluating for delirium and cognitive impairment • Include delirium in the perioperative management of your patients • Document and communicate the problem with other providers

29. References • Inouye SK. “Current Concepts: Delirium in Older Persons.” N Engl J Med. 2006;354;1157-1165a. • Amador LF, Goodwin JS. “Postoperative Delirium in the Older Patient.” J Am Coll Surg. 2004;200:767-773. • Inouye SK, et al. “Clarifying confusion: The Confusion Assessment Method. A new method for detection of delirium.” Ann Intern Med. 1990;113: 941-948. • Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care. 2002;40: 771-781. • Marcantonio ER, Goldman L, Mangione C, et al. “A Clinical Prediction Rule for Delirium After Elective Noncardiac Surgery.” JAMA. 1994;271:134-139. • Kalisvaart KJ, Vreeswijk R, deJonghe JF et al. “Risk Factors and Prediction of Postoperative Delirium in Elderly Hip-Surgery Patients: Implementation and Validation of a Medical Risk Factor Model.” J Am Geriatr Soc. 2006;54:817-822. • Marcantonio ER, Juarez G, Goldman L, et al. “The Relationship of Postoperative Delirium with Psychoactive Medications.” JAMA. 1994;272:1518-1522. • Inouye SK, Bogardus ST, Charpentier PA, et al. “A Multicomponent Intervention to Prevent Delirium in Hospitalized Older Patients.” N Engl J Med. 1999;340:669-676. • Kalisvaart KJ et al. “Haloperidol Prophylaxis for Elderly Hip-Surgery Patients at Risk for Delirium: A Randomized Placebo-Controlled Study.” J Am Geriatr Soc. 2005;53:1658-1666. • Rockwood K, Cosway S, Carver D, et al. “The Risk of Dementia and Death after Delirium.” Age Ageing. 1999;28:551-556. • Lundstrom M, Edlund A, Bucht G, et al. “Dementia after Delirium in Patients with Femoral Neck Fractures.” J Am Geriatr Soc. 2003;51:1002-1006. • McCusker J, Cole M, Dendukuri N, et al. “Delirium in Older Medical Inpatients and Subsequent Cognitive and Functional Status: a Prospective Study.” CMAJ 2001;165:575-593. • Marcantonio ER, Kiely DK, Simon SE, et al. “Outcomes of Older People Admitted to Postacute Facilities with Delirium.” J Am Geriatr Soc. 2005;53:963-969.