Delirium:  Recognition  Assessment  Prevention  Management WRHA Surgical Program Delirium Guidelines

Delirium Definition: A disturbance of consciousness with inattention that develops over a short time & fluctuates

What is Delirium? An acute confusional state Usually has a reversible cause Characterized by: Inattention Sudden onset ………………..

Why Should We Use Delirium Guidelines ? Delirium can result in:  morbidity and mortality  length of stay  rates of admission to long term care facilities 20% of patients discharged post hip # still had evidence of delirium (Journal of American Geriatric Society 2001 May;49(5):678-9).

Outcomes of Delirium Patients with pre-existing dementia are likely to not recover fully after a delirium. Having a delirium often will precede the diagnosis of a dementia. A delirium may be the thing that tips the patient over to needing LTC, however, the decision should not be made while the patient is acutely delirious. Need to give it time to clear before making a final decision. (even with complete recovery, 30% dementia within 3 years = decreased brain reserve)

Recognition of Delirium Previous studies 32%-66% of cases are unrecognized by Medical Staff Yale- New Haven study (Inouye S. Ann Intern Med 1993: 119-474) 65% unrecognized by Physicians 43% unrecognized by Nurses

Top 4 Independent Risk Factors for Delirium Vision impairment: Any severe illness: Cognitive impairment: High Urea/Creatinine ratio: Inouye S. Ann Intern Med 1993: 119-474

4 Independent Risk Factors for Nurse Under-Recognition Hypoactive Delirium Age 80 yrs and over Visual Impairment Dementia

Delirium versus Dementia? The patient’s family or friends will always say, “This is not the same persona that we usually know”. -Inattention is when they can not keep speaking on on topic. Their topic discussion is all over the place. Common Demtias with Hallucinations Lewy Body Dementia, a common dementia found with patients who have Parkinson's disease It is common for Delirium to be superimposed on Dementia!

Types of Delirium Hyperactive Hypoactive Mixed

Causes of Delirium? Anything that hurts the brain or impairs its proper functioning can provoke a delirium! Brain’s way of demonstrating “acute organ dysfunction”

Causes of Delirium: Drugs Infection System failure/events Metabolic Imbalance Dehydration/Poor Nutrition Surgery or general anaesthetic within the last 5 days

Causes of Delirium: Pain Uncorrected sensory or language impairment Fecal Impaction Urinary Retention/Catheter Restraints 12. Sleep disruption 13. No factors can be identified 20% of the time 14. Recent severe illness or event involving hypoxia

Causes of Delirium Related to Surgery The etiology of post operative delirium (POD) is most often multi-factorial and difficult to diagnose. Interactions between pt risk factors (those that are predisposing and precipitating); the pt’s own comordibities and drugs that are commonly used perioperatively and in addition those meds that the pt is normally taking, can produce a complex delirium syndrome.

Theories for Post Op Delirium Acetylcholine interaction with medications used during surgery Increase of neurotransmitters, serotonin and dopamine during surgery Previous abnormality levels of melatonin Damage to neurons by oxidative stress or inflammation caused by a surgical procedure Post op abnormal brain waves -Some researchers suggest that what is happening at the neuronal level is an imbalance of neurotransmitters, particularly with acetylcholine. Acetylcholine normally plays an important roll in attention, consciousness and memory and is critically affected in dementia. Now the strange thing is that a lot of the anesthetic drugs that are given are anticolinergic (meaning they inhibit acetycholine – atropine. So this doesn’t help the situation). -Neurotransmitters that may be affected are serotonin, norephinephrine and dopamine. These types of neurotransmitters play a part in cognition, arousal, sleep and mood. But with serotonin, norephinephrine and dopamine the researchers think there is an increase in these neurotransmittors and this increase has been implicated in hyperactive delirium. -Abnormalities (decrease) in melatonin (hormone produced by the pineal gland & responsible for regulating other body hormones such as the female reproductive ones and for maintaining our body’s Circadian Rhythm (our internal 24 clock). -Damage caused to the neurons by oxidative stress or inflammation. Pro-inflammatory cytokines have been found to be increased in POD pts as well as elevations in C reactive protein. And they think there is a link between this inflammation and the neurotransmission that causes an increase in peri-vascular cerebral edema, leading to hypoxia and a subsequent reduction in the synthesis of acetylcholine. -They have tested POD pts using EEGs and have found that brain waves are abnormal. For example, the alpha waves which are normally the fast waves, decrease in number and there is an increase in the theta waves which are the slow brain waves.

Medications Associated with Delirium Any drug can potentially cause confusion Take a careful history of any new drug STARTED or any old drug STOPPED recently

Medications Associated with Delirium Over the counter drugs Cimetidine Cough/Cold Remedies Gravol/Maxeran Sleeping medications Herbal meds Sleeping medications such as any benzodiazepines. Ex Lorazepam or valium

Reference List of Drugs with Anticholinergic Effects Antidepressants Antipsychotics Antihistamines/ Antipruritics Antiparkinsonian Antispasmotics Antiemetics Opioids Anticonvulsants Antibiotics Corticosteroids Anticholinergics Antidepressants: Amitriptilline ( Elavil), Bupropion (Wellbutrin), Fluoxetine (Prozac), SSRIs (Nortriptyline) and MAOI -Antipsychotics: Chlorpromazine, olanazpine, thioixene (Navane), -Antihistamines: Benadryl, phenregan, atarax. Anticholinergics:

Studies In studies, drugs with anticholinergic side effects have been shown to: Lower cognitive scores in elderly subjects Cause/worsen severity of delirium Associated with more ADL decline in patients with dementia Associated with faster MMSE decline in patients with dementia If drugs reduced, be associated with improvements in dementia and delirium.

Full List of Safe Medications for the Older Adult Please see attachment at the end of this presentation

Assessing for Delirium

Pre-Admission Assessment Decision Tree

CAM – Confusion Assessment Method Sensitivity (94 to 100%), specificity (90 to 95%) Requirement for delirium = 1, 2 AND either 3 OR 4 Abrupt change? Inattention, can’t focus? Disorganized thinking? Incoherent, rambling, illogical? 4. Altered level of consciousness? (Hyper-alert to stupor?) AND

Trigger Questions 1. Acute change in behaviour? 2. Changes in function? 3. Changes in cognition? MMSE 4. Changes in medications? 5. Physiologically stable?

How Do We Assess for Inattention Recite the months backwards or days backwards Have the patient count backwards from 20 to 1. Use the CAM

Once You Identify Delirium, Now What? Identify the acute medical problems that could be either triggering the delirium, or prolonging it! Clarify pre-morbid functional status, sequence of events and previous admission cognitive baseline Identify all predisposing and precipitating factors, and consider the differential

Physical Exam Vitals: normal range of BP, HR, Temp and pain Good physical exam: particular emphasis on Cardiac, pulmonary and neurologic systems Hydration status Also rule out fecal impaction urinary retention Infected pressure ulcer, UTI or pneumonia

Delirium workup: Lab testing Basic labs most helpful! CBC, lytes, BUN/Cr, glucose,CO2, Ca+, Mg, PO4 TSH, B-12, LFTs & albumin Infection workup (Urinalysis, CXR) +/- blood cultures EKG O2 sat/ABG

What About Prevention?

Yale Delirium Prevention Trial Risk Factors Intervention Cognitive Impairment Reality orientation / therapeutic activities program Vision/Hearing impairment Vision / hearing aids / adaptive equipment Immobilization Early mobilization / Reduce immobilizing equipment Psychoactive medication Non pharmacologic approaches to sleep / anxiety / Restricted use of sleeping medication Dehydration Early recognition / Volume expansion Sleep deprivation Noise reduction strategies/sleep enhancement program Ref: Inouye SK, NEJM. 1999;340:669-676 Mobilization: 1 day a patient is left un mobilized in their bed adds on 3 days of hospital stay.

Prevention and Pre-Op Assessment Pre-op Clinic Form Pre- op- Questionnaire

What about Management?

Non Pharmacological Interventions Always apply non-pharmacological interventions in your Care Plan. Examples Initiate toileting routines Mobilize ASAP Quiet room, soothing music Mobilization: Also means getting the patient dangling at the beds side and upon their chair.

Pharmacological Interventions Only use medication if: Non-pharmacological interventions are not successful The patient is a danger to themselves or others You may see the physician order or a pharmacist suggest the following medications: Low dose Haloperidol or Low dose Risperidone or Low dose Olanzapine ** Avoid the use of benzodiazepines

Pharmacological Interventions It is important to remember that: Dosing is best given prn when agitation becomes a concern or becomes a safety issue Medications must be discontinued once the agitation from the delirium is resolved

Delirium Pamphlet This is to be given to Families so that they may better understand what their family member is going through. It is also recommended that it be displayed in any Pamphlet Holders for Patient and Family Education. A copy of the pamphlet is found at the back of the presentation

Pre-Admission Clinic Forms

Questions ??????