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

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

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

4. 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).

5. 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)

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

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

8. 4 Independent Risk Factors for Nurse Under-Recognition
Hypoactive Delirium
Age 80 yrs and over
Visual Impairment
Dementia

9. 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!

10. Types of Delirium
Hyperactive
Hypoactive
Mixed

11. 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”

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

13. 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

14. 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.

15. 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.

16. 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

17. 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

18. 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:

19. 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.

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

21. Assessing for Delirium

22. Pre-Admission Assessment
Decision Tree

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. What About Prevention?

30. 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 ;340:
Mobilization: 1 day a patient is left un mobilized in their bed adds on 3 days of hospital stay.

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

32. What about Management?

33. 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.

34. 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

35. 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

36. 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

37. Pre-Admission Clinic Forms

38. Questions ??????