Physical restraint use during delirium. C.L.I.P.S. Description a temporary, fluctuating disturbance of consciousness characterized by inattention, disorientation, disordered thinking, and/or other cognitive and behavioral impairments typically caused by an interaction of predisposing and precipitating factors (the latter possibilities are numerous and varied) A.K.A.: acute brain failure; metabolic, septic or toxic encephalopathy; post-op or ICU psychosis. How common is it on general medicine and geriatric wards? 29-64% of patients (18-35% on admission + 11-29% new onset) Why do we care? Associated with increased risks of mortality, falls, functional decline, and institutionalization. Diagnosis may be missed >60% of time without screening with a validated screening tool at least once a day for patients at risk. Should trigger evaluation and treatment for reversible causes. Common precipitating factors on general medicine wards psychoactive meds, use of physical restraints, multiple meds added, abnormal laboratory values, use of bladder catheter Common predisposing factors on general medicine wards Elder abuse, dementia or cognitive impairment, functional impairment, vision impairment, age > 65 years, depression, comorbidity burden What as the only hospital-related factor found to be a significant predictor of persistent delirium on discharge? Physical restraint use during delirium. Updated 1/18 Stromberg

What ages have the highest risk of delirium? C.L.I.P.S. Clinical presentation pearls Change in LOC often first clue May have psychomotor changes (hyper, hypo, or mixed), sleep-wake disturbances, or emotional disturbance and lability Evaluation highlights Consider medical emergencies (hypoglycemia, CVA, ACS…) Determine mental baseline, acute changes and fluctuations Brief cognitive screening, consider Confusion Assessment Method (CAM tool, a Brief CAM was recently included for nursing in Powerchart) CBC, chem10, UA. Add’l labs & imaging based on H&P Differential Preexisting cognitive impairment (delirium often superimposed) Depression (delirium often misdiagnosed as depression) Sundowning, focal neurological syndrome, nonconvulsive status epilepticus Treatment Address medical issues Med mgmt. - including reduce or d/c psychoactive meds -> use non-pharm alternatives for sleep and anxiety Reorient patient – environment (Clear Minds Protocol), family/friends, eyeglasses… Normalize sleep/wake cycle. Safe mobility – avoid physical restraints, d/c foley, ambulate TID, active ROM For severe agitation and psychosis, avoid benzos, can use short course of lowest dose of Haldol or atypical antipsychotics (equally effective to Haldol) What ages have the highest risk of delirium? Both the young and the old.