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Delirium: The Confusion Conundrum

Delirium: The Confusion Conundrum. February 4, 2011 Mitchell T. Heflin, MD Barbara Kamholz MD Juliessa Pavon, MD Yvette West, RN. Case Presentation. Mr. A 82 year old white male post-op day #18 from AAA repair Consult for agitation and altered mental status HPI:

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Delirium: The Confusion Conundrum

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  1. Delirium:The Confusion Conundrum February 4, 2011 Mitchell T. Heflin, MD Barbara Kamholz MD Juliessa Pavon, MD Yvette West, RN

  2. Case Presentation Mr. A • 82 year old white male post-op day #18 from AAA repair • Consult for agitation and altered mental status HPI: • Pulsatile mass found by PCP on routine exam • Confirmed as 8.2 cm infrarenal AAA on CT • Referred for elective surgical repair

  3. Case: History • Past Medical History: • Hypertension • Hyperlipidemia • Smoked 1ppd until quit 1995 • s/p finger amputation on left hand from work accident • Home Medications: • Simvastatin 40 mg daily • Bisoprolol 5 mg bid • ASA 81 mg daily • ROS: • Denied abd pain, back pain, chest pain, sob, claudication

  4. Case: History • Family History: • Alzheimer’s disease in both parents • Social History: • Lives at home alone, widower for 5 years • Independent in ADLs and IADLs • Physically active, playing golf daily • Son and daughter do not live locally

  5. Case: Hospital Course • Elective AAA repair on 12/15/10 • Returned to OR on POD #0 for bleeding from aneurysm • Following surgery: • Mental status did not return to baseline despite weaning off sedation • Failed trial of extubation due to AMS • POD #3: atrial fibrillation and tachycardia • Amiodarone started • POD #7: Trach and PEG

  6. Case: Hospital Course • POD #7-14: Restless and agitated • Pulling at trach and PEG • Attempts to treat with haldol, risperidone and ativan • POD # 16: Adynamic ileus and aspiration • Vancomycin and ciprofloxacin • POD # 18: Geriatrics consulted • Assist with management of agitation and altered mental status

  7. Case: Medications • Aspirin • Amiodarone • Metoprolol • Vancomycin • Ciprofloxacin • Ativan 1 mg IV q6hrs • Risperidone 0.5 mg VT qhs • Haldol 0.5 – 1.5 mg IV PRN (5 mg in last 24 hrs) • Dilaudid 0.5 mg IV q6hrs PRN (0 mg in last 24 hrs)

  8. Case: Exam T 36.4 HR 100s BP 90s/60s Pulse ox 97% on 40 % FiO2 Gen: Somnolent but easily arousable and anxious Grimacing and tachypneic during exam Trach in place on ventilation CV: Tachycardic, irregular Pulm: Coarse breath sounds Abd: Mildly tender, + BS, healing midline wound and PEG Ext: Restraints on hands, edema in LE Neuro: Opens eyes to loud voice and tracks but does not follow simple commands, moves all extremities, no Babinski or clonus

  9. Case: Diagnostic Testing Head CT: No focal lesions CXR: Small bilateral effusions KUB: Mildly distended loops of small bowel WBC 12K, Hct 28% Creatinine 1.0, Albumin 2.3, LFT’s and TSH normal UA: 2+ blood, 1+ LE, 6 WBC, > 50 bacteria EKG: Afib 100, no ischemia or conduction problems Cardiac enzymes: normal

  10. Case: Daughter’s input • Very physically and socially active • Had problems with forgetfulness, repeating and perseverations in the prior year • Very hard of hearing and wears glasses for distance vision • Drank at least two glasses of wine each night

  11. Delirium: Definitions • Acute disorder of attention and global cognitive function • DSM IV: • Acute and fluctuating • Change in consciousness and cognition • Evidence of causation • Synonyms: organic brain syndrome, acute confusional state • Not dementia

  12. So what’s the conundrum? • Highly prevalent • Associated with much suffering and poor outcomes • Complex and often multifactorial • Preventable but…. Better care requires a shift in paradigm

  13. Objectives • Describe the prevalence of delirium and its impact on the health of older patients • Identify pathophysiology, risk factors and key presenting features • Describe strategies for prevention and management • Find opportunities to improve current practice

  14. 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%

  15. 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

  16. The experience…

  17. Grade for Recognition: D- Inouye, J Ger Psy and Neurol., 11(3) 1998 ;Bair, Psy Clin N Amer 21(4)1998 • 33-95% of in hospital cases are missed or misdiagnosed as depression, psychosis or dementia • ER: 15-40% discharge rate of delirious patients • 90% of delirium missed in ED is then also missed in hospital!

  18. Clinical Features of Delirium • Acute or subacute onset • Fluctuating intensity of symptoms • ALL SYMPTOMS FLUCTUATE…not just level of consciousness • Clinical presentation can vary within seconds to minutes • Inattention – aka “human hard drive crash”

  19. In-attention • Cognitive state DOES NOT meet environmental requirements • Result= global disconnect • Inability to fix, focus, or sustain attention to most salient concern • Hypoattentiveness or hyperattentiveness • Bedside tests • Days of week backward • Immediate recall

  20. This Can Look Very Much Like… • ….depression • 60% dysphoric • 52% thoughts of death or suicide • 68% feel “worthless” • Up to 42% of cases referred for psychiatry consult services for depression are delirious • Farrell Arch Intern Med. 1995 155:22

  21. Improving The Odds of Recognition • Clinical examination • CAM • Team observations • Nursing notes • Prediction by risk • Predisposing and precipitating factors

  22. Diagnosis: Confusion Assessment Method • Geropsychiatry assessment gold standard • Recent systematic review2 • Sensitivity 86% (74-93) • Specificity 93% (87-96) • LR + 9.4 (5.8-16) • LR – 0.16 (0.09-0.29) 1 Inouye 1996; 2 Wong 2010.

  23. CAM • Acute onset and fluctuating course • Inattention • Disorganized thinking • Altered level of consciousness Or Inouye 1994

  24. Nursing Input Kamholz, AAGP 1999 • Chart Screening Checklist • Nurses’ commonly charted behavioral signs (Sensitivity= 93.33%, Specificity =90.82% vs CAM) • Pulling at tubes, verbal abuse, odd behavior, “confusion”, etc • 97.3% of diagnoses of delirium can be made by nurses’ notes alone using CSC • 42.1% of diagnoses made by physicians’ notes alone using CSC

  25. Risk Factors Predisposing factors: Adjusted RR • Vision impairment 3.5 • Severe illness (>APACHE 2) 3.5 • Cognitive impairment (MMSE<24) 2.8 • BUN/Cr >18 2.0 Precipitating factors: Adjusted RR • Physical restraints 4.4 • Malnutrition (wt loss, alb) 4.0 • >3 meds added 2.9 • Bladder catheter 2.4 • Any iatrogenic event 1.9 Inouye SK 1998

  26. Putting it all together... Precipitating Factors Predisposing Factors Inouye SK 1998

  27. Oxidative StressModel: ARDS • ANY source of ischemia • Low cardiac output • Impaired pulmonary function/oxygenation • Low Hgb/Hct • Mechanisms: • Dysfunction of CAC • Rapid depletion of ATP • Depolarization of cell membrane • Ca++ influx, imbalance of neurotransmitters • Remodeling at all neuronal levels, including decreased synaptic transmission, cell death

  28. Inflammatory ProcessModel: Sepsis • Peripheral interleukins (IL6,TNFa, IL1B) induce symptoms of delirium • Direct neural pathways (primary autonomic afferents) • Transport across BBB • Circumventricular region/BBB non-continuous • TNFa can persist for months in CNS • Gradient from dementia to delirium of TNFa (amount, rate of cognitive decline)

  29. Neurotransmitter Dysfunction • Dopamine • Hypoxiamitochondrial dysfunctioncellular instabilityCa++influx: • Increases in production of DOPA due to upregulated tyrosine hydroxylase • Decreased activity of COMT • Acetylcholine • Synthesis very sensitive to hypoxia • Transmission is very sensitive to metabolic abnormalities, especially of O2 and glucose • Suppresses immune dysregulation via vagal nerve pathway

  30. Summary: Feet of Sand • Delirium in frail patients often associated with disturbances of most basic substrates and cellular functions: • Impaired oxygenation (blood loss, pulmonary disease) • Metabolic disturbances, commonly Na, Calcium • Infection/inflammation (UTI, Pneumonia) • Medications, especially those that affect vital, basic pathways • Helps with prediction • Primary CNS causes are in the distinct minority

  31. Multicomponent Intervention to Prevent Delirium • 852 patients over 70 on Gen Med • IM risk (1-2 RF’s) or High risk (3-4 RF’s) • Randomized by units with prospective matching • Standardized protocols for 6 risk factors • ID Team: Nurse specialist, PT, RT, MD and volunteers • Outcomes assessed daily by CAM Inouye 1999.

  32. Elder Life Program

  33. Results of Multicomponent Intervention Trial * * p< 0.02 for both outcomes Inouye 1999.

  34. Results • Most effective for IM risk group • No change in severity of delirium • Cost • $327/pt • $6341/case prevented • No lasting beneficial effect on functional status or resource utilization • Benefit replicated Inouye 1999; Rizzo 2001; Bogardus 2003

  35. CNS oxygen delivery Fluid and electrolytes Treatment of pain Unnecessary medications Bowel/bladder Early mobilization Prevention, early detection and treatment of complications Nutrition Environmental stimuli Agitated delirium Reducing Delirium After Hip FractureGeriatrics Consultation Marcantonio 2001.

  36. Results • No change in length of stay • Most effective in patients without • Pre-existing dementia • ADL impairment Marcantonio 2001.

  37. Pharmacotherapy • Dopamine blockade1 • Haldol (1.5 mg daily) prophylaxis in high risk hip fracture patients • No change in incidence • Decrease in severity and duration • Acetylcholinesterase inhibitor2 • Donepezil did not decrease incidence or severity of delirium 1 Kalisvaart 2005, 2 Liptzin 2005.

  38. Treating pain • Prospective cohort study >500 hip fracture patients with and without delirium • Patients receiving <10 mg IV Morphine/day were 5x more likely to become delirious • Patients reporting severe pain 10x more likely to develop delirium Morrison 2003.

  39. Delirium Management: Key Points • Early recognition of high risk patients and situations is key to effective management • Prevention is more effective than treatment • Address: • Physiologic • Environmental • Pharmacologic • Psychosocial • Enlist a team Sendelbach and Guthrie, 2009.

  40. Psychosocial Assess substance use Address stress and distress Educate patient and family Assess decision making Consider function and safety • Physiologic • O2 and BP • Food and fluids • Sleep/wake cycle • Activity and mobility • Bowel and bladder • Pain • Infections Pharmaceutical Reduce/avoid certain meds - Benadryl, Benzo’s Monitor for S.E.’s of pain meds Low dose neuroleptic Benzo’s for withdrawal • Environmental • Reorientation • Continuity in care • Family or sitters • Hearing aids, glasses • QUIET at night • No restraints • AMBULATE!

  41. What about Mr. A? • Psychosocial • Watch for w/d symptoms off Ativan • Educate patient and family • Provide reassurance and means • of communication • Physiologic • Control HR, BP improved • Increase trach size • Treat UTI and aspiration • Bowel regimen • Schedule oxycodone and acetaminophen • Advance tube feeds • Pharmaceutical • Taper Ativan • Monitor for S.E.’s of Oxycodone • Risperidone 0.5 mg bid • Environmental • Light, activity, orientation during day • QUIET at night—avoid VS, meds, etc. • Remove restraints • Glasses on, loud voice and lip reading

  42. Geriatrics • Inpatient consult service • Assistance with older adults with: • Delirium and other cognitive disorders • Multiple, complex medical problems • Medications, medications, medications • Goals of care • Pager 970-0370

  43. Old way…. D = Dehydration E = Electrolytes (including glucose, Ca) L= Low oxygen I = Infection R = Retention of urine/stool I = In pain U = Under-diagnosed withdrawal M = Medications

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

  45. 5 year, $1.2 million project funded by HRSA • Goal: Create Geriatrics Education Hub • Staffed by interprofessional faculty • Focused on improving the care of older adults with or at risk for delirium • Learning resources, clinical experiences and practice improvement projects • Part of six school consortium addressing this issue

  46. Delirium: Nursing StrategiesDuke NICHEGeriatric Resource Nurse Initiative Kristin Nomides RN Grace Kwon RN Samantha Badgley RN Duke Hospital 2100

  47. Supporting Literature: Nursing Interventions Yale Delirium Prevention Program : multi-component interventions • Cognitive impairment with Reality Orientation • Sleep enhancement protocol • Sensory impairment with therapeutic activities protocol • Sensory deprivation • Dehydration • Reduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodes Inouye, s. 2004 Delirium education for team (MD and RN) • Provided post program support and learning reinforcement • 250 acute admit patients > 70 recruited on 2 units • Delirium 12/122 intervention unit vs. 25/128 control unit Tabet N,, et al, 2005 Post op multi-factorial intervention educational program • Teamwork and care planning on prevention and treatment of delirium • Targeted delirium risk factors • Post op delirium compared to controls (56/102 and 73/97) Lundrtrom, et al. 2007

  48. Nursing Interventions: ? Altered Mental Status • Delirium & Risk Factors Staff Education • Activity Cart / Busy Apron • Stimulate cognitive and motor skills • All About Me Poster • Orientation Information • Me File • Orientation information provided by patient / family for high risk patients • Question Mark • Identification of patients with AMS

  49. Summary • Delirium is common and caustic for older adults • It can be diagnosed using validated tools (e.g. CAM) • Predisposing and precipitating factors are well established • Prevention is more effective than treatment • Management requires a team approach

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