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Mini CHAMP Delirium in the Hospitalized Elder

Mini CHAMP Delirium in the Hospitalized Elder. Shellie Williams, M.D. Assistant Professor of Medicine Section of Geriatric Medicine University of Chicago. Objectives:. Increase recognition of delirium in hospitalized elders.

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Mini CHAMP Delirium in the Hospitalized Elder

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  1. Mini CHAMPDelirium in the Hospitalized Elder Shellie Williams, M.D. Assistant Professor of Medicine Section of Geriatric Medicine University of Chicago

  2. Objectives: • Increase recognition of delirium in hospitalized elders. • Identify a risk stratification for delirium in hospitalized elder. • Gain understanding of prevention for delirium. • Enhance ability to evaluate patients for delirium—assessment. • Develop a strategy for treatment of delirium from a non-pharmacologic and pharmacologic focus.

  3. Mrs. Fleming: • 75yo female admitted from ER with generalized weakness, UTI and pre-renal azotemia. • She is admitted to 5NE with IVF & cipro • RN calls post-admit day#1: “She pulled out her IV this morning and ordered me out of her home. She is upsetting her roommate and refused another IV. Shall I initiate a sitter?”

  4. Delirium: The Data • Prevalence: 15-70% • (20%) 12.5 million elderly admits • Admission Onset: 20-33% • Post surgical: 30-59% Rockwood 1990; Francis 1992

  5. Defining Delirium: • Disturbance of consciousness and reduced ability to focus, sustain or shift attention. • Change in cognition (decline memory, orientation, language, motor) not accounted for by preexisting dementia. • Disturbance that develops over short time and fluctuates. • Direct physiologic consequences of a specific medical condition, substance intoxication, withdrawal, or multiple causes. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)

  6. Delirium: Pathophysiology • Neurotransmitter Theory: • Cholinergic deficits: benadryl, scopalmine • Norephinephrine excess: antidepressants • Dopamine excess: Parkinson meds • Cytokines-IL1, IL2, TNF (Infection) • Cerebral Hypoxia • Stress related hormonal fluctuation

  7. Why Focus on Delirium? Risk • Increased LOS (2x) • Increased Mortality (2-7x) • 38% & 51% mortality 1yr/5yr post-hosp • Increased ADL dependence (2x) • Increased instituitionalization (2-3x) Dolan J of Ger 2000; Leslie Arch In Med 2005.

  8. Why Focus on Delirium? Cost Leslie, D.L. Arch In Med, 2008; 168: 27-32.

  9. Why Focus on Delirium?: Cognition • 60% persistent impairment from baseline • 40% Progression dementia 1yr • Premorbid Cognitive Impaired: • 4% complete resolution prior d/c • 20% complete resolution 3-6mo s/p d/c

  10. Obstacles:Under-recognition • Poor recognition: Nurse recognition <50% Physician recognition 20% Inouye 2001

  11. Hyperactive: 30% Tremor Agitation Picking/Pacing Vivid hallucinations Irritability Aggression Hyperactive: 30% Hypoactive: 70% Sedate Psychomotor retardation Poverty speech Diminished awareness Recognize Delirium Fluctuating Faces: Spiller, JA. Pall Med 2006; 20: 17-23.

  12. Delirium Prevention: Pre-hospital Risk Inouye,SK. Arch Int Med; 1993, 119: 474-81.

  13. Risk Stratification Based on Pre-hospital risk: Inouye,SK. Arch Int Med; 1993, 119: 474-81.

  14. Risk Stratification: In-Hospital Risk • Use of Physical Restraints (RR 4.4, CI 2.5-7.9) • Malnutrition (RR 4.0, CI 2.2-7.4) • >3 Medications added (RR 2.9, CI 1.2-4.7) • Use of Bladder Cath (RR 2.4, CI 1.2-4.7) • Any Iatrogenic Event (RR 1.9, CI 1.1-3.2) Inouye, SK. JAMA. 1996; 275 (11): 852-7.

  15. Risk Stratification: Delirium at Discharge Inouye, SK. Arch Intern Med 167 (13): 1406-12.

  16. Prevention: Elder Life Program • Elder Life Program • Targeted protocols: • Cognitive impairment • Sleep deprivation • Immobility • Visual impairment • Hearing impairment • Dehydration Inouye, SK. NEJM 1999; (340) 9: 669-675.

  17. Delirium Prevention • Decreased incidence of delirium (9.9% vs 15.0%) p=0.02 • Decreased days of delirium (105d vs 161d) p=0.02 • No statistically significant change in severity or recurrence of delirium Inouye, SK. NEJM 1999; (340) 9: 669-675.

  18. Evaluation of Delirium • MULTIFACTORIAL is the rule of thumb (2.8/pt) • Focused, patient-centered investigation • History guides diagnostics • Examination guides diagnostics

  19. Evaluation: Algorithm to Recall

  20. DOCUMENT DELIRIUM! Confusion Assessment Method: CAM

  21. Acute Onset & Fluctuating Course Inattention AND plus either Disorganized Thinking Altered LOC Evaluation: CAMConfusion Assessment Method DELIRIUM Inouye SK et al. Ann Intern Med 1990;113:941-948.

  22. Evaluation: R/o Dementia • Hx of dementia? • Need hx of sundowning to dx it! • Agitated dementia = delirium • Understand delirium-dementia relationship DEMENTIA DELIRIUM

  23. Distinguishing the 3 Ds:

  24. Evaluation: Physical Exam • “Head to toe” • Vitals (temp, HR, RR, BP, pulse ox) • CNS (CVA, bleed, meningitis, sz, blind, deaf) • Pulm (pneumonia, PE, CHF) • CVS (ischemia, CHF, arrhythmia) • GI (ischemia, impaction, bleed) • GU (UTI, retention) • Extrem (pain, volume status, CVA) • Skin (pressure ulcer, volume status)

  25. Evaluation: Most common causes of delirium • Medications 30% • Infections 40% • Fluid/Electrolyte imbalance 40%

  26. Evaluation: Medications (30%) • Too little (alcohol or other drug withdrawal) 6% • Too much narcotics neuroleptics anti-cholinergics anti-emetics • >3 new medications introduced Francis 1990, Schor 1999, Lawlor 2002

  27. Evaluation: Medications • Antibiotics (aminogly, PCN, ceph, sulfa) • Benadryl • Benzodiazepines (triazolam, alprazolam, diazepam) • Digoxin • GI (Reglan, Bentyl) • Lithium • Narcotics • Neuroleptics • Steroids • NSAIDs (Indocin) • H2 Blockers (Cimetidine,…) • Parkinsons drugs (Levodopa, Benztropine, Amantadine) • Tricyclics

  28. Evaluation: Anti-cholinergic Medications Fecal/urine impacted, confused, flushed, dry, low bp Elavil (amitriptyline) Flexeril (cyclobenzaprine) Cogentin (benztropine) Atarax/Vistaril(hydroxyzine) Bentyl (dicyclomine) Welbutrin/Zyban (bupropion) Ditropan (oxybutynin) Antivert (meclizine) Detrol (tolterodine) Ipratropium (atrovent) Benadryl (diphenhydramine) Phenergan (promethazine) Zyprexa (olanzapine) Atropine Levsin (hyoscyamine) Belladonna Alkoloids

  29. Evaluation: Brain CT? • Controversy on routine ordering • Low yield if lack focal neuro findings • Documented head trauma with new neuro findings or high risk bleed Francis, J. Clin Res 1991 (abstract); 39: 103.

  30. Evaluation: Additional tests • Labs • CBC, lytes, liver, renal • Consider TSH, B12 • Drug levels (digoxin, valproic, phenytoin) • Urine tox, UA/culture • CXR • EKG • EEG**

  31. Management: Plan before Pills • Prevention of delirium • Correction underlying causes • Non-pharmacologic intensify • Pharmacologic (agitation)

  32. Management: Non-pharmacologicHELP Prevention • Cognition: orientation board (carry pen!), (day) open drapes, clock, calendar, family photos • Sleep: min deprivation (d/c 2am labs & o/n BD/vitals; meds when awake); warm drink; limited pm awake • Mobility: Early OOBchair ; PT/OT; no foley/restraints • Vision: glasses • HOH: get aids; adapt environment (stethoscope!) • Dehydration: po fluids; observe at mealtime • Feeding: assist with meals • Activity: Involve family (rotate members) or get sitter; move pt to room close to RN station, current events Inouye, SK. JAGS 2006; 54: 1492-1499.

  33. Management: Non-pharmacologicRestraint Use • AVOID! • 4x increased risk protracted delirium • Increase risk of falls, injury, & delirium • Use only in emergency, for as short a duration as possible with frequent re-evaluations, and d/c asap • Absolutely no “sheeting” Inouye, SK. Arch Intern Med 167 (13): 1406-12.

  34. Management: Pharmacologic • 30/244 AIDS patients admitted to hospital with AIDS related illness, developed delirium • Double blind randomization to lorazepam, chlorpromazine or haloperidol • Early cessation of lorazepam arm due to worsening sedation, confusion & ataxia • Chlorpromazine & haldoperidol arm improvement in delirium per DRS score, limited EPS and improved MMSE in chlorpromazine group @ 2d Breitbart, W. Am J. Psych, 1996; 153: 231-237.

  35. Management: Pharmacologic Anti-psychotics Typical: Haldol Advantages: min sed Disadvantages: lower sz thrshld; more EPS (even at low dose); not FDA-app for IV; can incr QTc; Torsades Dose: 0.25-0.5mg po, IM, IV; can repeat in 30 mins x1; then dose q4h t1/2=21h (10-38) APA 1999

  36. Management:Pharmacologic Antipsychotics Atypical: Advantages: min sed, less EPS, hyperglycemia Disadvantages: take time to work, no evidence in short-term; recent Black Box warning: vascular events! Risperidone 0.25-0.5mg po bid t1/2=20-30h EPS with high dose Olanzapine (Zyprexa) 2.5-5mg po qd t1/2=30 (21-54h) more anticholinergic Quetiapine (Seroquel) 12.5-25mg po bid t ½=6h less EPS risk Van Zyl. Geriatrics 2006; 61(3): 18-21.

  37. Management: PharmacologicBenzodiazepines Used best in w/d Lorazepam 0.5-1mg po, IM, IV q6-8 (no first-pass, no renal adjustment) t1/2=12h

  38. Conclusion: • Prevent delirium. • Evaluate risk factors pre-admit, during and post hospitalization. • Adjust admit orders • It is important to develop a systematic approach for diagnosis of delirium, THEN (DOCUMENT!). • First use non-pharmacologic measures, then pharmacologic, to treat delirium.

  39. Case Revisited: • Mrs. Fleming is a 75 year old female with htn, OA, dm, cri (1.3) baseline and chronic AF. She lives alone in a 3 story home. • Meds: (Home) Lisinopril 20mg qam Asa 81 mg Celebrex 200mg qam Metformin 500mg bid Hctz 25mg qam Elavil 50 mg qhs

  40. Lisinopril 10mg qam Hctz 25mg qam Regular Insulin SS 0.9NS 150 cc/hr x 36hr Elavil 50mg qhs ASA 81mg qam Darvocet N 1 q 6hr Prosom 15mg qhs prn Benadryl 25mg q 6hr itching, sleep Vicodin 5/500mg q 4hr prn Morphine 2-4 mg iv q 4hr Zofran 4mg q 6hr prn n/v Medicines In-hospital:

  41. Case revisited: • Currently, pt is quietly sitting in chair, picking at skin. • When asked what is she doing she notes, “ It is a shame you can’t afford extermination in this place!” • She then returns to her activity. • Her daughter notes she has not slept in 3 days and was incontinent of urine 2 days PTA. • Roommate notes she was lethargic and not answering questions a few moments ago.

  42. CAM Assessment: Is she Delirious? • Acute/fluctuating? • Inattentive? • Disorganized thinking? • Decreased level of consciousness?

  43. An Algorithm to Remember!

  44. Review Dementia? • Dementia • Get further hx from family of baseline • Was dx missed or never made? • Prior hx of delirium during hospitalization? • Do serial cognitive assessment: MMSE

  45. Review Other Risks for Delirium: • Recent physical symptoms? Cough, chills, SOB • Psychiatric symptoms? None • Alcohol/Illicit drug use? 1 Highball nightly • Recent CNS trauma? No trauma other than hip • Recent stroke symptoms? No

  46. Case Revisited: Exam • Sat 88% ra, rr 28, p 100, bp 100/50, pain grimace • HEENT: Dry mucosa, no evidence cns contusion • Neck: No adenopathy or thyromegaly or jvd • Lungs: Increase fremitus and percussion dullness rt. base no use acc muscles • Heart: Irregular rhythm, rate 100, no murmur, rub or gallop • Abdomen: +bs, soft non distended, non tender • GU: +foley, no evidence retention • Neuro: Inattentive, disoriented, poor recall of hospital events, hyperalert at times, motor strength symmetric, normal sensory function, no hyper-reflexia, antalgic gait

  47. Case, cont’d • Labs: 10.5 13.2 192 33.0 148 110 56 128 5.2 30 1.8 UA: +LE, nitrite, 1.025, bacteria, rbc ECG: A. Fib rate 60s, no acute ST changes

  48. CXR:

  49. Foley Poor po intake Poor vision > 3 new medications Sensory impairment Use of restraints Bed bound status >30 bun/creatinine ratio Baseline cognitive deficits Lack of pain control Poor sleep Case Revisited: What factors predisposed this patient for delirium?

  50. Stroke UTI Pneumonia Anti-cholinergics Dehydration Hypoxia Anemia Hypotension Metabolic derangements Alcoholism Illicit drugs Cardiac ischemia Case Revisited: What factors precipitated delirium?

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