Duke GEC Delirium Teaching Rounds: Recognition September 2, 2011

Duke GEC 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

Duke GEC 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

Duke GEC 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

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 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.

Duke GEC Grade for Recognition: D % 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.

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 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 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

Duke GEC 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

Duke GEC Mrs. Smith-1

Duke GEC Improving The Odds of Recognition Prediction by risk – Predisposing and precipitating factors Team observations – Nursing notes Clinical examination – CAM – MDAS

Duke GEC 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

Duke GEC Putting it all together... Precipitating Factors Predisposing Factors Inouye 1996

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 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

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

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

Duke GEC 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.

Duke GEC Mrs. Smith- 2

Duke GEC 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

Duke GEC 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

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

Duke GEC Delirium Teaching Rounds: Insult to Injury October 7, 2011