1. Duke GEC www.interprofessionalgeriatrics.duke.edu Delirium Basics Jason Moss, PharmD, & Eleanor McConnell, PhD, RN, GCNS-BC October 24, 2011

2. Duke GEC www.interprofessionalgeriatrics.duke.edu Objectives Describe the prevalence of delirium and its impact on the health of older patients Discuss pathophysiology, risk factors and key presenting features Distinguish presenting features of delirium, dementia and depression Use nursing process to organize thinking about key nursing activities in preventing and managing delirium Find opportunities to improve current practice

3. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #1 from 3-D quiz Question: A chronic, progressive loss of brain cells resulting in decline of day-to-day cognition and functioning. A.Depression B. Delirium C. Dementia D. I don’t know.

4. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #2 from 3-D quiz Question: At least 6weeks, but can last several months to years, especially if not treated. A.Depression B. Delirium C. Dementia D. I don’t know.

5. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #3 from 3-D quiz Question: Performance on mental status exam may vary from poor to good depending of time of day and fluctuation in cognition. A. Depression B. Delirium C. Dementia D. I don’t know.

6. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #4 from 3-D quiz Question: Often of a frightening or paranoid nature. A.Depression B. Delirium C. Dementia D. I don’t know.

7. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #5 from 3-D quiz Question: Treatable and reversible especially if caught early. A.Depression B. Delirium C. Dementia D. I don’t know.

8. Duke GEC www.interprofessionalgeriatrics.duke.edu Meet Mrs. Florence 78 year old resident of Durham admitted to the hospital after a fall in her home….. https://phw-lmsc.duhs.duke.edu/production/DUHS_Common/delirium/videos/hyper_clip1_101711/hyper_clip1_101711.html https://phw-lmsc.duhs.duke.edu/production/DUHS_Common/delirium/videos/hyper_clip2_101711/hyper_clip2_101711.html Have you ever seen anyone like this? How would you describe her behavior? What do you think is wrong?

9. Duke GEC www.interprofessionalgeriatrics.duke.edu What is Delirium? 1. Acute onset of mental status changes or a fluctuating course and 2. Inattention and or 3. Disorganized Thinking 4. Altered level of consciousness = Delirium CAM, CAM-ICU

10. 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.

11. Duke GEC www.interprofessionalgeriatrics.duke.edu Rudolph J et al, 2011

12. 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

13. Duke GEC www.interprofessionalgeriatrics.duke.edu So…If delirium such a big problem, why don’t we hear more about it? https://phw- lmsc.duhs.duke.edu/producti on/DUHS_Common/delirium /videos/hypo_clip1_101811/ hypo_clip1_101811.html https://phw- lmsc.duhs.duke.edu/producti on/DUHS_Common/delirium /videos/hypo_clip2_101811/ hypo_clip2_101811.html 1.Acute or subacute onset 2.Fluctuating intensity of symptoms 3.Inattention 4.Disorganized thinking 5.Altered level of consciousness Hypoactive v. Hyperactive 6.Sleep disturbance 7.Emotional and behavioral problems

14. Duke GEC www.interprofessionalgeriatrics.duke.edu Delirium Pathophysiology Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246

15. Duke GEC www.interprofessionalgeriatrics.duke.edu Let’s go back to our case!

16. Duke GEC www.interprofessionalgeriatrics.duke.edu Mrs. Florence: Background 78 year old female who fell climbing into attic PMH significant for Knee Osteoarthritis Hypertension, Restless legs, Stroke Married, lives with husband of 52 years 4 beers a day On admission to the hospital: BAL=80 Na=128 Pain score 9/10

17. Duke GEC www.interprofessionalgeriatrics.duke.edu Medications Outpatient – clonazepam – ropinirole – lisinopril – aspirin – furosemide – amlodipine – oxycodone – oxybutynin – OTC benadryl as needed for allergies Inpatient – ropinirole – lisinopril – aspirin – furosemide – amlodipine – oxycodone prn – oxybutynin – sliding scale insulin – ranitidine

18. Duke GEC www.interprofessionalgeriatrics.duke.edu Risk Factors Baseline Vulnerability (Predisposing) -Risk factors r/t person’s baseline - Often we cannot modify these Precipitating – These are things that happen to the patient – Insults – Often Iatrogenic Baseline + Precipitating = Delirium

19. Duke GEC www.interprofessionalgeriatrics.duke.edu Risk Factors- General Baseline Vulnerability – Underlying Brain Disease (Dementia, Stroke, Parkinson’s Disease) – Increased Age – Institutionalization – Chronic disease (HIV, ETOH dependency, diabetes, etc) – Visual/Hearing deficits Precipitating – Medications – Infection – Dehydration – Immobility/restraints – Malnutrition – Tubes/catheters – Medications – Electrolyte imbalance – Sleep Deprivation

20. Duke GEC www.interprofessionalgeriatrics.duke.edu Framework for Risk Baseline Vulnerability Low High Mild/None Noxious Precipitating Stimulus

21. Duke GEC www.interprofessionalgeriatrics.duke.edu Medication Side Effects Anticholinergic CNS sedation Constipation Abrupt withdrawal of chronic psychotropic medications

22. Duke GEC www.interprofessionalgeriatrics.duke.edu Concerning Medications Anticholinergic Oxybutynin Amitriptyline (**furosemide, ranitidine) Antihistamines Diphenhydramine (Benadryl) Chlorpheniramine Anticonvulsants Primidone Phenobarbital Antiparkinsonian Levodopa-carbidopa Dopamine agonists Antipsychotics Clozapine and other atypicals Benzodiazepines Diazepam, clonazepam Hypnotics Zolpidem (Ambien) Opioid analgesics Meperidine, morphine, oxycodone

23. Duke GEC www.interprofessionalgeriatrics.duke.edu Medications Outpatient – clonazepam – ropinirole – lisinopril – aspirin – furosemide – amlodipine – oxycodone – oxybutynin – OTC benadryl as needed for allergies Inpatient – ropinirole – lisinopril – aspirin – furosemide – amlodipine – oxycodone prn – oxybutynin – sliding scale insulin – ranitidine

24. Duke GEC www.interprofessionalgeriatrics.duke.edu What Predisposing Factors Did She Have? 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 Marcantonio, 2011. Baseline Vulnerability Low High Mild/None Noxious Precipitating Stimulus

25. 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.

26. Duke GEC www.interprofessionalgeriatrics.duke.edu What Predisposing Factors Did She Have? Marcantonio, 2011. Baseline Vulnerability Low High Mild/None Noxious Precipitating Stimulus 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 Delirium!

27. Duke GEC www.interprofessionalgeriatrics.duke.edu What is Delirium? 1. Acute onset of mental status changes or a fluctuating course and 2. Inattention and or 3. Disorganized Thinking 4. Altered level of consciousness = Delirium CAM, CAM-ICU

28. 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

29. Duke GEC www.interprofessionalgeriatrics.duke.edu Team Input Nursing recognition of high risk medications for delirium – Ask – Observe – Be suspicious – Communicate Kamholz, AAGP 1999

30. Duke GEC www.interprofessionalgeriatrics.duke.edu 1 month before admPCP NoteEpisode of confusion following her knee surgery. She does not feel confused presently. Presents to ED20:20EDVerbally converses and oriented 5 Day Admitted01:25Adm Data She can’t tell me how many stairs she fell down. She is a little disoriented…reports ~2 beers per day which puts her at risk for withdrawal...monitor closely for signs/symptoms of withdrawal. Day Admitted03:05PRM10:40 AM BSN Findings: Independent prior to admission: Newly dependent Hospital Day 103:10NursingPatient is very drowsy. Hospital Day 110:14OTCognition: Alert, changed to lethargic once medication had taken affect. Hospital Day 111:40PTCognition: Impaired…Oriented to self, place, time, situation, with significant prompting. Hospital Day 117:25Post Anesthesia Reports mild post-operative confusion, but per husband significantly better anesthesia recovery than the previous surgery 1 year prior. Hospital Day 118:55NursingPt a/o x 3, unaware of correct date/time…pulling at soft cast on left hand but reorients well. Hospital Day 122:22Nursing Pt is alert and orientedx4, with mild anxiety present…pulling wrap to arm…told numerous times to leave it alone…order for a hand mitt restraint…is aware if tugging again will be restrained. Hospital Day 203:03Nursing alert and orientedx2-3, with mild anxiety and occasional hallucinations… pulled out foley catheter...pulled at cast… Bilat hand mitts and wrist restraints were applied. Hospital Day 214:04NursingPt. AOx1-2, very agitated and restless at times... Pt. resting quietly at this time. Family at bedside. Hospital Day 415:00PTThe patient reports "Take this off of me (referring to restraints and mits) so I can run an errand." Hospital Day 418:52NursingPt s/p right radial fracture, right hip fracture, now with delirium r/t possible alcohol w/d. Hospital Day 505:08NursingHas been agitated…Sitter at bedside. Restraints. Pt not agitated at the time the BP taken. Hospital Day 518:32NursingA&ox4 today with some stm deficits noted. Hospital Day 515:01NursingPATIENT CAN BE IMPULSIVE AT TIMES…EMOTINOAL SUPPORT GIVEN

31. Duke GEC www.interprofessionalgeriatrics.duke.edu Assessment: Standardized Tool Confusion Assessment Method (CAM-ICU) Puts definition into action! 1.Change in cognitive status in past 24 hours? 2.Inattention? 3.Altered Consciousness? 4.Content of consciousness http://www.mc.vanderbilt.edu/icudelirium/

32. Duke GEC www.interprofessionalgeriatrics.duke.edu http://www.mc.vanderbilt.edu/icudelirium/

33. Duke GEC www.interprofessionalgeriatrics.duke.edu Richmond Agitation-Sedation Score (RAAS)

34. Duke GEC www.interprofessionalgeriatrics.duke.edu Intervention Prevention 1 st ! Management 2 nd

35. Duke GEC www.interprofessionalgeriatrics.duke.edu Nursing Interventions & Evaluation Yale Delirium Prevention Program : multi-component interventions  Cognitive impairment with Reality Orientation  Sleep enhancement protocol  Sensory impairment with therapeutic activities protocol  Sensory deprivation  Dehydration  Reduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodes Inouye 2004 Post op multi-factorial intervention educational program  Teamwork and care planning on prevention and treatment of delirium  Targeted delirium risk factors  Post op delirium compared to controls (56/102 and 73/97) Lundrtrom, et al. 2007

36. Duke GEC www.interprofessionalgeriatrics.duke.edu Delirium: Nursing Strategies Duke NICHE Geriatric Resource Nurse Initiative Kristin Nomides RN Grace Kwon RN Samantha Badgley RN Duke Hospital 2100

37. Duke GEC www.interprofessionalgeriatrics.duke.edu Duke NICHE: Nursing Interventions: Delirium & Risk Factors Staff Education Delirium & Risk Factors Staff Education Activity Cart / Busy Apron Activity Cart / Busy Apron – Stimulate cognitive and motor skills All About Me Poster All About Me Poster – Orientation Information Me File Me File – Orientation information provided by patient / family for high risk patients Question Mark Question Mark – Identification of patients with AMS ? Altered Mental Status

38. Duke GEC www.interprofessionalgeriatrics.duke.edu Other Management Medications – Low doses of certain antipsychotics – Short-acting benzodiazepines – Older adults may require lower doses Symptom triggered therapy – Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-A) Supportive therapy – Comorbidities – Hydration and nutrition Team care

39. Duke GEC www.interprofessionalgeriatrics.duke.edu Back to Mrs. Florence Hospital Course and beyond: Pain management Sitters and family Activity Clonazepam Geriatrics consultation

40. Duke GEC www.interprofessionalgeriatrics.duke.edu Summary RESPECT delirium. Its common and caustic. PREDICT delirium. Assess for common predisposing and precipitating factors. RECOGNIZE delirium. It can be diagnosed with simple tools (e.g. CAM). PREVENT delirium. It can be averted with multicomponent strategies. RECRUIT team members to improve care.

41. Duke GEC www.interprofessionalgeriatrics.duke.edu Summary Maintain a high level of suspicion Document findings in the chart Discuss with other members of the team Inform/educate patients and families

42. 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

43. Duke GEC www.interprofessionalgeriatrics.duke.edu Supplemental Resources GRECC 5-D Card Delirium brochure for direct caregivers – Vanderbilt University www.icudelirium.orgwww.icudelirium.org – RASS pocket cards – Videos for CAM administration (2 minutes!) Vancouver Health Authority – http://www.viha.ca/mhas/resources/delirium/too ls.htm http://www.viha.ca/mhas/resources/delirium/too ls.htm

44. Duke GEC www.interprofessionalgeriatrics.duke.edu Delirium Teaching Rounds “Itching for a Fight!” November 4, 2011

45. Duke GEC www.interprofessionalgeriatrics.duke.edu GEC crew Eleanor McConnell, RN, MSN, PhD Anthony Galanos, MD Jason Moss, PharmD Julie Pruitt, RD Cornelia Poer, MSW Gwendolen Buhr, MD Mamata Yanamadala, MD S. Nicole Hastings, MD Jennie De Gagné, PhD, MSN, MS, RN-BC, CNE Katja Elbert-Avila, MD Mitch Heflin, MD Sandro Pinheiro, PhD Robert Konrad, PhD Emily Egerton, PhD Heidi White, MD Kathy Shipp, PT, PhD Deirdre Thornlow, RN, PhD Lisa Shock, MHS, PA-C Michelle Mitchell, LMBT Michele Burgess, MCRP Joan Pelletier, MPH Sujaya Devarayasamudram, RN, MSN Loretta Matters, RN, MSN

46. Duke GEC www.interprofessionalgeriatrics.duke.edu Acknowledgements Mitchell Heflin, MD & Cornelia Poer, MSW Duke University Geriatrics Division for case material & slides adapted from Medicine Grand Rounds February, 2011 Brenda Pun, RN, MSN, ACNP – slides adapted from Delirium II Module prepared for Duke University School of Nursing Geriatric Innovations in Nursing Education (GNIE) Project Duke-NICHE Geriatric Resource Nurses: Duke-NICHE Geriatric Resource Nurses: – Kristin Nomides, RN – Grace Kwon RN – Samantha Badgley, RN – Yvette West, RN, C MSN, Director, Duke-NICHE

47. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #1 from 3-D quiz Question: A chronic, progressive loss of brain cells resulting in decline of day-to-day cognition and functioning. A.Depression B. Delirium C. Dementia D. I don’t know.

48. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #2 from 3-D quiz Question: At least 6weeks, but can last several months to years, especially if not treated. A.Depression B. Delirium C. Dementia D. I don’t know.

49. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #3 from 3-D quiz Question: Performance on mental status exam may vary from poor to good depending of time of day and fluctuation in cognition. A. Depression B. Delirium C. Dementia D. I don’t know.

50. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #4 from 3-D quiz Question: Often of a frightening or paranoid nature. A.Depression B. Delirium C. Dementia D. I don’t know.

51. Duke GEC www.interprofessionalgeriatrics.duke.edu Item #5 from 3-D quiz Question: Treatable and reversible especially if caught early. A.Depression B. Delirium C. Dementia D. I don’t know.