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Delirium Teaching Rounds “ Itching for a Fight!”

Delirium Teaching Rounds “ Itching for a Fight!”. November 4, 2011. Objectives. Identify risk factors and key presenting features of delirium Appreciate the role of different professions in recognition and management Identify medications that contribute to the development of delirium.

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Delirium Teaching Rounds “ Itching for a Fight!”

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  1. Delirium Teaching Rounds“Itching for a Fight!” November 4, 2011

  2. Objectives • Identify risk factors and key presenting features of delirium • Appreciate the role of different professions in recognition and management • Identify medications that contribute to the development of delirium

  3. A BIG Problem Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009. • 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%

  4. Costs of Delirium In-hospital complications1,3 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

  5. Clinical Features of Delirium • Acute or subacute onset • Fluctuating intensity of symptoms • Inattention • Disorganized thinking • Altered level of consciousness • Hypoactive v. Hyperactive • Sleep disturbance • Emotional and behavioral problems

  6. 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 Common Risk Factors for Delirium Marcantonio, 2011.

  7. Itching for a Fight! • Mr. S is an 81 year old retired Baptist minister admitted for an exploratory laparotomy….. • Gather in a group with students representing all professions • Read the case and discuss the questions • Designate a spokesperson • Have fun!

  8. 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 Common Risk Factors for Delirium Marcantonio, 2011.

  9. Anticholinergic Exposure in Geriatric Patients Smaller reserve of neurotransmitters + Increased blood brain barrier permeability = ↑ Sensitivity to adverse effects of anticholinergic medications Fundamentals of Geriatric Pharmacotherapy 2010

  10. Adverse Effects of Anticholinergics Central Peripheral Urinary retention Constipation Dry mouth Dry eyes Worsening of glaucoma Impaired sweating Tachycardia • Confusion • Memory Impairment • Cognitive Dysfunction • Drowsiness • Dizziness Contributing to: • Delirium • Unsteady gait • Increased falls risk Pharmacotherapy 2005; 25 (11):1592–1601

  11. Anticholinergic Risk Score (ARS) • Ranks medications for anticholinergic potential on a 3-point scale: • 0= no or low risk • 3 = high anticholinergic potential • To calculate the patient’s ARS score: identify anticholinergic medications and add the total points for each medication. • Anticholinergic effects are cumulative! Arch Intern Med 2008; 168: 508-513

  12. Game time: Anticholinergic Medications! The Game

  13. Anticholinergic risk scale Arch Intern Med 2008; 168: 508-513

  14. Anticholinergic Risk Scale Arch Intern Med 2008; 168: 508-513

  15. Anticholinergic Risk Scale Arch Intern Med 2008; 168: 508-513

  16. Anticholinergic Activity JAGS 2008; 56 (7): 1333-1341

  17. Non-PharmacologicManagement of Pruritus • Wearing sheer clothing • Avoiding hot baths, alcohol, spicy foods • Maintain proper humidity of rooms • Avoid contact with wool or animal fur • Prevent dry skin (moisturize and apply emollients) • Apply cold wet dressings • Keep fingernails short “Happiness is having a scratch for every itch.”–Ogden Nash Reich, 2011; Patel, 2010.

  18. PharmacologicManagement of Pruritus Reich, 2011; Patel, 2010.

  19. Summary • Maintain a high level of suspicion • Watch out for precipitating medications • Discuss with other members of the team • Involve pharmacists • Consider non-pharmacologic strategies for treating common problems (e.g. pruritis) • Inform/educate patients and families

  20. A better way…. NP’s Physiologic PA’s Psychosocial Medicine Nursing Environmental Social work Pharmacologic Patients and Caregivers Pharmacy Nutrition Administrators PT/OT

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