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POSTOPERATIVE DELIRIUM Geriatrics for Surgeons Teaching Conference

POSTOPERATIVE DELIRIUM Geriatrics for Surgeons Teaching Conference. AGS. THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults. What is the incidence of delirium in the Denver VA surgical intensive care unit?. 8% 23% 44% 65%.

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POSTOPERATIVE DELIRIUM Geriatrics for Surgeons Teaching Conference

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  1. POSTOPERATIVE DELIRIUMGeriatrics for SurgeonsTeaching Conference AGS THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals. Leading change. Improving care for older adults.

  2. What is the incidence of delirium in the Denver VA surgical intensive care unit? • 8% • 23% • 44% • 65%

  3. What is the incidence of delirium in the Denver VA surgical intensive care unit? • 8% • 23% • 44% • 65%

  4. What is Delirium? Delirium is an acute, fluctuating change in mental status, with inattention and altered levels of consciousness Pandharipande et al. CurrOpinCrit Care (2005) 11:360.

  5. Diagnostic Criteria for Delirium • Disturbance of consciousness 2. Change in cognition 3. Acute onset 4. Coexisting physiologic disturbance Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (1994).

  6. Threshold Theoryof Cognitive Decline • Older age → diminished brain reserve capacity • Older patients are on a “functional cliff” for developing delirium when undergoing a major physiologic stress

  7. Changing Cognitive Functionin the Elderly Dementia 100 80 Cognitive function, % 60 40 20 0 50 60 70 80 90 100 Age, years

  8. Threshold Theoryof Cognitive Decline Dementia 100 80 Cognitive function, % 60 40 20 0 50 60 70 80 90 100 Age, years

  9. Threshold Theoryof Cognitive Decline Dementia Delirium 100 80 Cognitive function, % 60 40 20 0 50 60 70 80 90 100 Age, years

  10. PostOperativeDelirium and Age 50 50 40 40 30 30 Incidence of delirium, % 20 20 10 10 0 0 < 50 < 50 50-59 50-59 60-69 60-69 > 70 > 70 Age, years

  11. RISK FACTORS FORPostOperative Delirium (1 of 2) a – Mini-Cog Test c – Barthel Index b – Charlson Index

  12. Age Male sex Cognitive impairment Depression Psychiatric diagnosis Psychotropic drug use Alcohol abuse History of prior delirium ASA score Smoking history Comorbidity Institutional residence Functional impairment Hearing impairment Visual impairment RISK FACTORS FORPOSTOPERATIVE DELIRIUM (2 of 2) Dasgupta et al. JAGS (2006) 54:1578.

  13. What risk factor is the best for determining who will develop delirium in the Denver VA surgical intensive care unit? • Older age • Pre-existing dementia • Functional impairment • Hypoalbuminemia

  14. What risk factor is the best for determining who will develop delirium in the Denver VA surgical intensive care unit? • Older age • Pre-existing dementia • Functional impairment • Hypoalbuminemia

  15. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Slide 15

  16. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed Operation Slide 16

  17. CONFUSION ASSESSMENT METHOD — ICU FEATURE 1: Acute onset of mental status changes or a fluctuating course AND FEATURE 2: Inattention AND FEATURE 3: Disorganized thinking FEATURE 4: Altered level of consciousness OR Ely et al. JAMA (2001) 286:2703.

  18. MOTOR SUBTYPES OF DELIRIUM • A spectrum of psychomotor behavior is found in delirium • Delirium motor subtypes • Hypoactive —40% • Hyperactive —5% • Mixed type —55% Meagher et al. J of Neuropsych and ClinNeurosci(2000) 12:51.

  19. DELIRIUM ISA DIAGNOSTIC CHALLENGE • Fluctuating course • Hypoactive motor subtype • Delirium not recognized by clinical team in 32% of cases Francis et al. ClinRes (1988) 36:711A.

  20. Risk Factors: Age >65 Dementia Functional Impairment Co-Morbidities Low Albumin Assess sedation CAM-ICU evaluation Motor Subtypes: - Hypoactive - Hyperactive - Mixed Operation

  21. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed POST-OP DELIRIUM Operation Slide 21

  22. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Evaluation for an organic cause: Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed POST-OP DELIRIUM Operation Slide 22

  23. TREAT ORGANIC CAUSE • Sepsis • Hypoxemia • Hypoglycemia • Electrolyte abnormality • Dehydration • Stroke • Medications

  24. MEDICAL EVALUATION OF DELIRIUM H&P Evaluation • Mental status • Neuro exam • History of substance abuse • Vital signs Laboratory Tests • CBC • Glucose • Electrolytes • BUN / Cr • UA • O2saturation Potter et al. Clin Med (2006) 6:303.

  25. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Evaluation for an organic cause: Electrolyte imbalance Hypoglycemia Hypoxemia Sepsis Substance withdrawal Review medications Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed POST-OP DELIRIUM Operation Slide 25

  26. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Evaluation for an organic cause: Electrolyte imbalance Hypoglycemia Hypoxemia Sepsis Substance withdrawal Review medications Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed POST-OP DELIRIUM Operation Organic cause: Treat appropriately Slide 26

  27. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Evaluation for an organic cause: Electrolyte imbalance Hypoglycemia Hypoxemia Sepsis Substance withdrawal Review medications Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed Multi-component treatment plan POST-OP DELIRIUM Operation Organic cause: Treat appropriately Slide 27

  28. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Supportive measures: Evaluation for an organic cause: Electrolyte imbalance Hypoglycemia Hypoxemia Sepsis Substance withdrawal Review medications Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed Multi-component treatment plan POST-OP DELIRIUM Pharmacologic treatment: Operation Organic cause: Treat appropriately Slide 28

  29. PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY • Hypothesis Reducing the number of risk factors for delirium will prevent delirium in hospitalized elderly patients • Methods • 852 hospitalized medical patients • Older than 70 years • Compare effectiveness of reducing the risk factors for delirium to standard of care Inouye et al. N Engl J Med (1999) 340:669.

  30. Multi-Component Intervention To Prevent Delirium Inouye et al. N Engl J Med (1999) 340:669.

  31. PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY Inouye et al. N Engl J Med (1999) 340:669.

  32. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Supportive measures: Reorientation Sleep enhancement Vision/hearing protocol Remove Foley Medication choices Evaluation for an organic cause: Electrolyte imbalance Hypoglycemia Hypoxemia Sepsis Substance withdrawal Review medications Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed Multi-component treatment plan POST-OP DELIRIUM Pharmacologic treatment: Operation Organic cause: Treat appropriately Slide 32

  33. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Supportive measures: Reorientation Sleep enhancement Vision/hearing protocol Remove Foley Medication choices Screen high-risk patients in preoperative clinic Evaluation for an organic cause: Electrolyte imbalance Hypoglycemia Hypoxemia Sepsis Substance withdrawal Review medications Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed Multi-component treatment plan POST-OP DELIRIUM Pharmacologic treatment: Operation Organic cause: Treat appropriately Slide 33

  34. PHARMACOLOGIC TREATMENT: ICU Haloperidol 2 mg q20 min (while agitation persists) OR Jacobi et al. CritCare Med (2002) 30:119.

  35. PHARMACOLOGIC TREATMENT: ICU • Maintenance dose • 50% of total loading dose is the maintenance dose, divided every 68 hours daily • Continue maintenance dose for 2448 hours before tapering • Tapermaintenance dose by 20%30% daily until off

  36. PHARMACOLOGIC TREATMENT: ICU

  37. PHARMACOLOGIC TREATMENT: WARD • General recommendation • Haloperidol 12 mg q24 hr PRN • May be administered PO, IM, or IV • For elderly patients • Haloperidol 0.250.5 mg q4 hr PRN American Psychiatric Association. Practice Guideline for Treatment of Patients with Delirium (1999).

  38. Risk factors: Age >65 Dementia Functional impairment Comorbidities Low albumin Supportive measures: Reorientation Sleep enhancement Vision/hearing protocol Remove Foley Medication choices Screen high-risk patients in preoperative clinic Evaluation for an organic cause: Electrolyte imbalance Hypoglycemia Hypoxemia Sepsis Substance withdrawal Review medications Assess sedation CAM-ICUevaluation Motor subtypes: - Hypoactive - Hyperactive - Mixed Multi-component treatment plan POST-OP DELIRIUM Pharmacologic treatment: 1. ICU Haloperidol 12 mg IV Repeat every 20 min until resolution of agitation Taper over several days 2. Surgical ward Haloperidol 1 mg PO/IM/IV Maintenance dose 0.250.5 mg Q4h Taper over several days Operation Organic cause: Treat appropriately Slide 38

  39. Thank you for your time! Visit us at: www.americangeriatrics.org Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics linkedin.com/company/american-geriatrics-society

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