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Delirium

Delirium. Literature Update 10/2011 N.J. O’Dorisio. Clinical case. Mrs. Johnson is 76 yo female with diabetes, heart failure and urosepsis. Her exam reveals HR 96, BP 100/62, rr 20 and 94% on 2l nc Labs-include wbc 14000, UA-+LE, + bacteria, +nitrites You admit her to the step down unit.

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Delirium

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  1. Delirium Literature Update 10/2011 N.J. O’Dorisio

  2. Clinical case Mrs. Johnson is 76 yo female with diabetes, heart failure and urosepsis. Her exam reveals HR 96, BP 100/62, rr 20 and 94% on 2l nc Labs-include wbc 14000, UA-+LE, + bacteria, +nitrites You admit her to the step down unit

  3. Clinical case Hosp day # 2 your partner is called at 0100 to evaluate Mrs. Johnson She is pulling at her IV, pulls off her telemetry leads and is talking about her deceased husband You evaluate her that morning and she is oriented to name and answers questions Is this Delirium?

  4. What do you do? A. Formal testing? B. Psychiatry consult? C. Family History/input? D. “I know it when I see it”?

  5. Review of Literature Wong, C.L, Holroyd-Leduc, J. Does this Patient have Delirium. JAMA 2011; 304 (779-786) O’Mahony, R, Murthy, L, et.al. Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of delirium. Annals of Internal Medicine 2011; 154 (746-752) Witlox, J, Eurlings, L, et al. Delirium in Elderly Patients and the Risk of Postdischarge Martality, Institutionalization, and Dementia. JAMA 2010. 304; (443-451) Wald, H, Galsheen, J, et al. Evaluation of a Hospitalist-Run Acute Care for the Elderly Service. Journal of Hospital Medicine 2011. 6; (313-321)

  6. Is this Delirium Wong, C.L, Holroyd-Leduc, J. Does this Patient have Delirium. JAMA 2011; 304 (779-786) What is the appropriate test?

  7. Background Delirium is often mistaken for dementia, mental illness, withdrawl There is no pathognemonic sign or lab to indicate the onset Delirium adds to the M/M and cost of a Hospital stay

  8. Clinical scenario Diagnosed by sudden onset (v. dementia) Careful observation Inattention Altered consciousness Sleep disturbance

  9. Who to test? Age greater than 65 Oncology/Palliative care unit ICU Multiple co-morbidities Surgical intervention

  10. How to test? Multiple different bedside tests MMSE Global Attentiveness Rating (GAR) Memorial Delirium Assesment Scale (MDAS) Clinical assesment of Confusion (CAC) Delirium Observation Screening Scale (DOSS) Based on DSM-IV criterion

  11. Which is best? • CAM • has been widely adopted • translated in 10 languages • requires training and 5 min • GAR • Based on 2 min of conversation • Based on analog scale

  12. CAM

  13. GAR

  14. Clinical scenerio Mrs. Johnson improves She’s on cipro for sens E.coli PT/OT are on board No further Hospitlization needed Is widowed, lives alone and dghtr lives “down the road” What should we do and can we do?

  15. Now what? How do you d/c? A. D/C to home and ask her to call the PCP? B. Social work consult for placement? C. Arrange home health and nursing? D. Schedule appt for PCP within 1 week? E. Combination of discharge strategies?

  16. What happens? Witlox, J, Eurlings, L, et al. Delirium in Elderly Patients and the Risk of Postdischarge Martality, Institutionalization, and Dementia. JAMA 2010. 304; (443-451) Assoc. with prolonged hosp. stay Poor-outcomes Increased cost Mortality

  17. Delirium sequelae Pts. (esp. older) have high rates of post discharge complications May lead to long term cognitive deficit Higher rate of institutionalzation Harbinger of dementia?

  18. What to do? O’Mahony, R, Murthy, L, et.al. Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of delirium. Annals of Internal Medicine 2011; 154 (746-752) Get ‘em mobile (PT/OT) Treat pain (trade off) Reconcile meds Max. nutrition

  19. What to do? Coordinated care team-min. hand offs Screen at admission Max. circadian rhythm/familiarity Assure hydration Fix hypoxia Don’t forget infection!

  20. Question # 1 What do you do? A. Formal testing? B. Psychiatry consult? C. Family History/input? D. “I know it when I see it”?

  21. Question # 2 How do you discharge Mrs. Johnson? A. D/C to home and ask her to call the PCP? B. Social work consult for placement? C. Arrange home health and nursing? D. Schedule appt for PCP within 1 week? E. Combination of discharge strategies?

  22. Take home points Delirium is a clinical diagnosis Multifactorial-but predisposing factors Has patient centered and health system costs Is important to identify and treat Don’t forget longitudinal care

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