2. Duke GEC www.interprofessionalgeriatrics.duke.edu Delirium Teaching Rounds: Recognition September 2, 2011

3. Duke GEC www.interprofessionalgeriatrics.duke.edu 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

4. Duke GEC www.interprofessionalgeriatrics.duke.edu So what’s the conundrum? Highly prevalent Associated with much suffering and poor outcomes Complex and often multifactorial Preventable but…. Requires a shift in paradigm

5. Duke GEC www.interprofessionalgeriatrics.duke.edu Objectives Describe the prevalence of delirium and its impact on the health of older patients Identify risk factors and key presenting features Find opportunities to improve communication about delirium

6. Duke GEC www.interprofessionalgeriatrics.duke.edu 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.

7. Duke GEC www.interprofessionalgeriatrics.duke.edu 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

8. Duke GEC www.interprofessionalgeriatrics.duke.edu The experience… Difficult for everyone: – 101 terminally ill cancer patients—54% recalled the experience – Distress scale 1 (least severe)  4 (most severe) Patients 3.20 Family member 3.75 Nurses 3.10 Brietbart 2002.

9. Duke GEC www.interprofessionalgeriatrics.duke.edu Grade for Recognition: D- 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! Inouye 1998 ;Bair 1998.

10. Duke GEC www.interprofessionalgeriatrics.duke.edu 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

11. Duke GEC www.interprofessionalgeriatrics.duke.edu 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

12. Duke GEC www.interprofessionalgeriatrics.duke.edu In-attention Cognitive state DOES NOT meet environmental demands 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

13. Duke GEC www.interprofessionalgeriatrics.duke.edu 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 1995

14. Duke GEC www.interprofessionalgeriatrics.duke.edu Mrs. Smith-1 https://www.youtube.com/watch?v=XWWs5h5dmVg

15. Duke GEC www.interprofessionalgeriatrics.duke.edu Improving The Odds of Recognition Prediction by risk – Predisposing and precipitating factors Team observations – Nursing notes Clinical examination – CAM – MDAS

16. Duke GEC www.interprofessionalgeriatrics.duke.edu Risk Factors Predisposing factors: Adjusted RR – Vision impairment3.5 – Severe illness (>APACHE 2)3.5 – Cognitive impairment (MMSE<24)2.8 – BUN/Cr >182.0 Precipitating factors: Adjusted RR – Physical restraints4.4 – Malnutrition (wt loss, alb)4.0 – >3 meds added2.9 – Bladder catheter2.4 – Any iatrogenic event1.9 Inouye 1996

17. Duke GEC www.interprofessionalgeriatrics.duke.edu Putting it all together... Precipitating Factors Predisposing Factors Inouye 1996

18. Duke GEC www.interprofessionalgeriatrics.duke.edu 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.

19. Duke GEC www.interprofessionalgeriatrics.duke.edu Nursing Input 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 Kamholz, AAGP 1999

20. Duke GEC www.interprofessionalgeriatrics.duke.edu Confusion Assessment Method (CAM) 1.Acute onset and fluctuating course 2.Inattention 3.Disorganized thinking 4.Altered level of consciousness Or Inouye 1994

21. Duke GEC www.interprofessionalgeriatrics.duke.edu CAM Recent systematic review 2 – Sensitivity 86% (74-93) – Specificity 93% (87-96) – LR + 9.4 (5.8-16) – LR – 0.16 (0.09-0.29) Other tools: – CAM-ICU – Delirium Rating Scale (DRS) 1 Inouye 1996; 2 Wong 2010.

22. Duke GEC www.interprofessionalgeriatrics.duke.edu Memorial Delirium Assessment Scale (MDAS) Rates severity of delirium Validated in palliative care 10 item, 4 point clinician-rated scale (0-30) – Awareness, orientation, memory, digit span, attention, organization, perception, delusions, psychomotor activity, sleep-wake cycle Cut-off of 13 for diagnosis of delirium Sensitivity 71%, Specificity 94% Brietbart 2007.

23. Duke GEC www.interprofessionalgeriatrics.duke.edu Mrs. Smith- 2 https://www.youtube.com/watch?v=su3ndXA_LSE

24. Duke GEC www.interprofessionalgeriatrics.duke.edu Summary Maintain a high level of suspicion Screen for delirium using a validated tool Document findings in the chart Discuss with other members of the team Inform/educate patients and families

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

26. Duke GEC www.interprofessionalgeriatrics.duke.edu A better way…. Medicine Nursing PT/OT Pharmacy Social work Nutrition PA’s Patients and Caregivers Administrators NP’s

27. Duke GEC www.interprofessionalgeriatrics.duke.edu Delirium Teaching Rounds: Insult to Injury October 7, 2011