Presentation on theme: "Duke GEC www.geriatriceducation.duke.edu Duke Geriatric Education Center (GEC) January 21, 2014 Delirium and Dementia."— Presentation transcript:
Duke GEC Duke Geriatric Education Center (GEC) January 21, 2014 Delirium and Dementia
Duke GEC Objectives Recognize that patients with dementia are at high risk of developing delirium. Differentiate dementia and delirium in the acutely ill older person Discuss strategies for preventing and managing delirium in older persons.
Duke GEC Delirium: Definition Acute disorder of attention and global cognitive function Synonyms: organic brain syndrome, acute confusional state Identifiable cause(s) Not dementia
Duke GEC A BIG Problem 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% Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009.
Duke GEC Costs of Delirium In-hospital complications 1,3 – 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
Duke GEC Clinical Features of Delirium Acute or subacute onset Fluctuating intensity of symptoms Inattention – aka “human hard drive crash” Disorganized thinking Altered level of consciousness – Hypoactive v. Hyperactive Sleep disturbance Emotional and behavioral problems
Duke GEC Common Risk Factors for Delirium Predisposing Advanced age Preexisting dementia History of stroke Parkinson disease Multiple comorbid conditions Impaired vision Impaired hearing Functional impairment Male sex History of alcohol abuse Precipitating New acute medical problem Exacerbation of chronic medical problem Surgery/anesthesia New psychoactive medication Acute stroke Pain Environmental change Urine retention/fecal impaction Electrolyte disturbances Dehydration Sepsis Marcantonio, 2011.
Duke GEC Why Delirium Prevention and Treatment Matters in Persons with Dementia Increased risk of delayed recognition and treatment in persons with dementia 2 times Increased risk in rate of cognitive decline for persons with dementia who develop delirium Increased risks of hospital complications and delayed discharge, especially if left alone
Duke GEC What Dementia Families Tell Us I thought it was just her dementia progressing, but she was dehydrated and really sick. The Emergency Room was like an exhausting time capsule – when he finally got a room, we thought it was safe to go home and sleep. Why do we have to pay a sitter, given all that hospital charges? The hospital staff either asked him impossible questions he couldn’t hear anyway or talked about him like he wasn’t there.
Duke GEC Prevention of Delirium in Hospitalized Patients with Dementia Constant presence of familiar transitional person Reassuring communication: Identity props, reminders, something to do, sensory aids Eliminate wandering triggers – suitcase, coat, EXIT Adjust noise, temperature, view, TV risks Limit tethering, hide or use decoy Label and unclutter hospital room Increase mobility Nutrition and hydration
Duke GEC Resources for Families Try this: Communication Difficulties: Assessment and Interventions in Hospitalized Older Adults with Dementia (2013) 2pp. Try this: Assessing and Managing Delirium in Older Adults with Dementia (2013) 2pp. Hospitalization Happens (2009) REASSURE for DELIRIUM (Poer, 2011) Delirium: Unique to Older Adults (2012) Next Step in Care Family Caregiver Guide (2012): Emergency Room (ER) Visits: A Family Caregiver’s Guide from the United Hospital Fund.