The Chicken or the Egg: Delirium and TBI in the Elderly

1. The Chicken or the Egg: Delirium and TBI in the Elderly BreckenHentz MS CCC-SLP Lindsay Dutko MA CCC-SLP

2. Chicken or Egg?

3. Traumatic Brain Injury in the Elderly • “A blow or jolt to the head or a penetrating head injury that disrupts normal function of the brain” • TBI can occur in absence of positive Head CT • Unintentional Falls are #1 cause (51%) with MVC next (9%) • Older age is associated with higher mortality after severe TBI • Recovery after TBI is more limited for older than younger survivors • Less capacity for compensation • Reduced cognitive reserves

6. Differences in the Aging Brain • Older adults who experience an apparently trivial event in which there has been a minor trauma to the head….often present with more insidious and delayed symptom onset of undiagnosed TBI • Unique pathophysiology of the older brain • Slowly expanding SDH • “late onset TBI” • May be easily confused with delirium • Flanagan, et al., 2006

7. TBI vs. Delirium TBI Delirium -Onset is generally not until after pt arrives at hospital; can occur as early as in the ED or even prior to hospitalization, though - Attention Orientation Memory of recent events Difficulty speaking Rambling, nonsense speech Visual hallucinations Withdrawn behavior Restlessness/agitation Disturbed sleep patterns Extreme emotions • Onset immediately following accident USUALLY – except in the elderly when a SDH is slowly expanding • Attention • Orientation • Awareness • Memory • Judgment • Reasoning • Problem Solving • Executive Functioning • Initiation/Impulsivity • Behavior (agitation)

8. Case Study • 92 yo male s/p fall down carport stairs • +LOC (?LOC prior to fall d/t dehydration from stomach virus); GCS 13 in ED • Brain CT: L parieto-occipital SDH; L subarachnoid hemorrhange; L anterior temporal lobe cerebral contusion • PMH: DM II, HTN, h/o multiple TIAs, chronic dysphagia secondary to esophageal strictures last dilated 7/2012, GERD, recently diagnosed follicular lymphoma, hearing loss • NPO for several days prior to placement of NG tube with eventual placement of PEG tube secondary to very high aspiration risk and poor secretion management • D/c’d to SNF after a 9-day hospitalization with re-admission for AMS suspected for metabolic changes after 17 days • D/c’d back to SNF

9. Mental Status on First Admission • Baseline: • Mostly independent but does not drive • Primary caregiver for wife with dementia • Supportive family • In ED: • Nonverbal • Not following commands • Minimal eye opening • Throughout hospitalization • Gradual improvement (Rancho Level 3 – 5) across hospitalization but with significant variability in LOA/MS throughout each day • No agitation • Mental status on d/c was still confused, but appropriate with deficits in recall, processing, and attention.

10. Mental Status on 2nd Admission • Per family report, at SNF improved to at least a Rancho Level 6 • Increased impairments from prior hospitalization • Poor orientation • Limited auditory comprehension • Poor topic maintenance • Tangential • Impaired safety awareness/insight (attempting to get out of bed) • Extremely agitated (grabbed granddaughter and clinician’s wrists • Calmer with no one present in the room • No changes in head CT (wanted to ensure no evolution of previous findings)

11. Discussion • What are this patient’s risk factors for delirium?

12. Common Risk Factors for Delirium Predisposing • Advanced age • Preexisting dementia • History of stroke • Parkinson’s disease • Multiple cormorbid conditions • Impaired vision • Impaired hearing • Males • History of alcohol abuse Precipitating • Acute medical problem • Exacerbation of chronic medical problem • Surgery/anesthesia • New phsychoactive medication • Acute stroke • Pain • Environmental change • Urine retention/ fecal impaction • Electrolyte disturbances • Dehydration • Sepsis

13. Discussion • Does this patient have delirium? • If so, on which admission (s)?

14. Criteria for Delirium • Disturbance of consciousness with attentional impairment • Change in cognition or development of a perceptual disturbance not attributable to dementia • Disturbance develops over a short time and fluctuates during the course of the day • Disturbance is caused by a general medical condition

15. Discussion • What could have been done to prevent this patient’s delirium? • Now that he has delirium, what can we do to manage it?

16. Prevention/Management • TBI • Limit stimulation (no tv, radio, limit visitors) • Calm environment (lights low, door closed) • Brief periods of appropriate stimulation with majority of the day/night for rest • Both • Frequent orientation • Allow movement as physically able and safe • Appropriately address vision/hearing impairments • Call PVR 681-2020 • Engage pt in appropriate cognitive stimulation • Allow for uninterrupted sleep at night • Hydration • Bring personal items from home • Have a routine • Minimize restraint use • Delirium • Lights on during the day (allow for TV and radio per pt’s preference) • Frequent engagement by visitors/staff • Therapeutic activities (i.e. word searches, newspapers, conversations, etc)

17. Strategies • Orientation: • Verbal re-orientation • Written re-orientation • Safety Awareness: • Active bedside attendant • Verbal cues • Written cues

18. More Strategies • Attention/Receptive Language • Eliminate distractions • Close the door • Turn off the TV, radio, etc • Limit # of people in the room when having conversations • For delirium, even though you want family present and familiar background noise to keep pt oriented and awake, when you are communicating with pt, environment needs to be quiet • Sit directly across from the pt • Sit pt upright and comfortably • Provide multimodal communication as able • i.e. Use gestures, pictures, and written key words to supplement verbal information

19. More Strategies • Expressive Language • Simplify language; ask 1 question at a time • i.e. say “Do you hurt?” instead of “Are you ready for more pain medicine?” • i.e. say “You fell and hit your head. You are at Duke Hospital” instead of “You fell and sustained a brain hemorrhage, so your family brought you into Duke Hospital.” • If not verbal or minimally verbal attempt to elicit nonverbal yes/no responses • Verify responses with opposite question • i.e. Ask both “Are you hot?” and “Are you cold?” • i.e. Ask both “Are you in pain?” and “Are you comfortable?” • Provide tangible choices • i.e. show the pt both orange juice and apple juice • Provide written choices

20. In Conclusion… • Delirium can co-occur with other cognitive and communication impairments, like TBI. • Management of delirium in these patients may have to be modified to best fit the patient.