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Confusion about Confusion: What the orthopedic surgeon needs to know about delirium

Confusion about Confusion: What the orthopedic surgeon needs to know about delirium. Edward R. Marcantonio, M.D., S.M. Orthopedic Surgery Grand Rounds University of Massachusetts Medical School November 12, 2008. Delirium. What is it? How do you diagnose it? Why is it important?

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Confusion about Confusion: What the orthopedic surgeon needs to know about delirium

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  1. Confusion about Confusion: What the orthopedic surgeon needs to know about delirium Edward R. Marcantonio, M.D., S.M. Orthopedic Surgery Grand Rounds University of Massachusetts Medical School November 12, 2008

  2. Delirium • What is it? • How do you diagnose it? • Why is it important? • What causes it? • What is the appropriate workup? • Can it be prevented? • How do you manage the delirious patient?

  3. Delirium What is it?

  4. Delirium: early descriptions • Celsus, 1st Century • “Sick people, sometimes in a febrile paroxysm, lose their judgment and talk incoherently… when the violence of the fit is abated, the judgment presently returns… • Aurelius, 2nd Century • “mental derangement may result…from the drinking of a drug…”

  5. Acute confusional state Acute mental status change Altered mental status Organic brain syndrome Toxic/metabolic encephalopathy Dysergastic reaction Subacute befuddlement Synonyms: Peer-reviewed literature

  6. Agitated Confused Combative Crazy Lethargic Out of it Out to lunch Poor historian Seeing things Sleepy Uncooperative Wild man Synonyms: on the wards

  7. Take home point: Recognizing and naming delirium is the first step in its appropriate management.

  8. Delirium How do you diagnose it?

  9. DSM Definition • First described in DSM-III, 1980 • Changes every few years • DSM-IV: • disturbance of consciousness with inattention • develops over a short time and fluctuates • change in cognition not explained by dementia • Etiology: General Medical vs. Drug

  10. Confusion Assessment Method (CAM) • Feature 1: Acute change in mental status with a fluctuating course • Feature 2: Inattention • Feature 3: Disorganized thinking • Feature 4: Altered level of consciousness • Diagnosis of Delirium: requires presence of Features 1 and 2 and either 3 or 4.

  11. Testing Attention • One of the most basic, but neglected areas of the mental status exam • Affects all other areas of cognition • Formal methods: • MMSE: Serial 7’s, WORLD backwards • Digit Span: 5 forwards, 4 backwards • Days of Week, Months of Year backwards • Informal methods: • LOC: Are the lights on? • Attention: Is anybody home?

  12. Psychomotor variants • Hyperactive (“Wild man”): 25% • most often recognized • risk: oversedation, restraints • Hypoactive (“Out of it”): 50% • risk: failure to recognize • sometimes confused with depression • Mixed delirium: hypo alt with hyper

  13. Acute onset Inattention Sometimes abnl LOC Fluctuating: minutes to hours Reversible Gradual onset Memory disturbance Normal LOC Fluctuating: none or days to weeks Irreversible Delirium vs. Dementia Common: Delirium superimposed on Dementia

  14. Take home point When in doubt, diagnose delirium!

  15. Delirium Why is it important?

  16. Common Orthopedic patients aged 70 and older • 15-20% incidence after THR, TKR • 25% incidence after laminectomy • 50% incidence after hip fracture

  17. Morbid • Hospital complications: RR=2-5 • Hospital death: RR=2-20! • Increased nursing home placement RR=3

  18. Delirium: Central in a Cascade of Adverse Events

  19. Postop delirium: complications OutcomeDeliriumNo Delirium Major Complications 15% 2%* Before delirium 5% After delirium 10% Death 4% 0.2%* *p<.001, unadjusted and adjusted Marcantonio, et. al. JAMA. 1994, 271: 134-139

  20. Costly • Acute hospitalization: • increased LOS: 2-5 days • increased inpatient costs • common reason for “falling off” pathways • Long term: • increased short and long term NH placement • incremental cost per pt over next year: > $60K

  21. Delirium What causes it? I. Basic pathophysiology

  22. Cholinergic failure hypothesis • Acetylcholine: impt in cognitive processes • Delirium: • “caused” by anticholinergic poisoning • reversed by pro-cholinergic drugs • assoc. with “anticholinergic burden” • Pilot RCT of donepezil in hip fx pts • Cholinergic agonist used for dementia • Can it prevent/treat delirium?

  23. Inflammation and Delirium • Delirium: inflammatory states • Infections, cancer • Delirium: common in cytokine treatment • Inflammation: • Breakdown of BBB • Adversely impacts cholinergic transmission • Several studies show assoc. between delirium and inflammatory biomarkers in medical and surgical patients de Rooij et. al., J Psychosom Med, 2007

  24. Delirium and Inflammatory Markers

  25. Neuronal Injury Markers • Measure neuronal damage in serum • Examples: • Neuron specific enolase • S100 Beta • Neuronal tau protein • Delirium associated with release of neuronal injury markers

  26. Delirium and Neuron Injury Markers Serum Tau Protein Serum S-100β Ramlawi et. al., Ann Surg, 2006

  27. Summary: Pathophysiology • Multiple pathophysiologies: • Cholinergic failure • Inflammation • Different mechanisms may pertain in different clinical situations • Some cases of delirium may cause direct neuronal injury

  28. Delirium What causes it? II. Epidemiological Model

  29. Predisposing factors: advanced age pre-existing dementia other CNS diseases functional impairment multiple comorbidities multiple medications imp. vision/hearing Precipitating factors: new psychoactive med acute medical problem exacerbation of chronic medical problem surgery pain ?environmental change Risk Factors for Delirium

  30. Implications of Model • More baseline vulnerability, less acute precipitants needed • Acute precipitants rarely in the CNS • “Law of Parsimony” rarely applies: • effective treatment requires evaluation and correction of all reversible factors

  31. Preoperative Prediction Rule Risk Factor: Points Age 70 or older 1 Cognitive impairment 1 Severe physical impairment 1 Alcohol Abuse 1 Markedly abnl serum chemistries 1 Aortic aneurysm surgery 2 Non-cardiac thoracic surgery 1

  32. Performance of the Clinical Prediction Rule: Validation Set RiskPointsIncidence of Delirium Low 0 2% Medium 1, 2 11% High 3 or more 50% Area under the ROC curve=0.79 Marcantonio, et. al. JAMA. 1994, 271: 134-139

  33. Postop (Precipitating) Factors for Delirium • Low postoperative hematocrit (<30%) • Meperidine (highly anticholinergic) • Benzodiazepines • high dose, long acting • Pain at Rest

  34. Delirium What is appropriate workup?

  35. Workup • History: • time course of mental status changes • association with other “events” • Physical examination: • Vital signs: HR, BP, temp, oxygen sat. • General medical: cardiac, pulmonary • Neuro: new focal signs

  36. Medication Review • Include OTCs, PRNs, alcohol • Recent changes, additions, discontinuations • Biggest offenders: • sedative-hypnotics (esp. long, ultra short acting) • opioid analgesics (esp. meperidine: RR=2.5) • anti-cholinergic drugs (anti-histamines, TCAs, esp. tertiary amines, misc. others)

  37. Laboratory testing • CBC (hct, wbc), electrolytes, glucose • Infectious workup: U/A, CXR, etc. • Selected additional testing: • drug levels, toxic screen, ABG, EKG • ?role for CT/LP/EEG: • new focal sxs, high suspicion, no other dx

  38. Common reversible factors • DRUGS • E lectrolyte imbalance (dehydration) • L ack of drugs (withdrawal, uncontr. pain) • I nfection • R educed sensory input (vision, hearing) • I ntracranial (CVA, subdural, etc.--rare) • U rinary retention/fecal impaction • M yocardial/Pulmonary

  39. Correct all reversible factors Don’t stop at one!

  40. Delirium Can it be prevented?

  41. Delirium and Hip Fracture Hip Fracture: >300,000 annually in U.S. • Paradigm for acute functional decline in hospitalized elderly • Hip is easily fixed, but less than 50% recover to pre-fracture status • Delirium: affects 50% of hipfx pts • Indpt risk factor for poor functional recovery, even after adjusting for dementia

  42. Geriatrics consultation: proactive: preop, or within 24 hrs postop daily visits: targeted recommendations structured protocol 10 modules adequate CNS oxygen fluid/electrolyte pain management psychoactive meds bowel/bladder nutrition mobilization postop complications environment management delirium Intervention

  43. Geriatrics consultation • 61% pts seen preop, all 24 hrs postop • 10+4 recs, 77% adherence (32%-100%) • Recs made in >2/3 pts (%adh): • transfuse to hematocrit > 30% (79%) • d/c urinary catheter by POD 2 (89%) • d/c or adjust psychoactive meds (83%) • RTC acetaminophen for pain (72%)

  44. Impact of Geriatrics Consultation Marcantonio et. al. JAGS. 2001; 49: 516-522

  45. Implications • Delirium is not inevitable: • It is preventable using a proactive, multifactorial approach • Evolution: Geriatrics-Orthopedics Co-management service • Hip fracture • High risk elective patients

  46. How do you manage the delirious patient? Do’s and Don’ts

  47. Agitated Behavior

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