1. Concept Mapping Caroline Harada, MD

2. Concept Map A concept map is a diagram showing the relationships among concepts. It is a graphical tool for organizing and representing knowledge. We plan to use them here to: – Provide an initial conceptual frame for subsequent information and learning – Increase meaningful learning – Enhancing metacognition (thinking about what you know and what you need to learn) Wikipedia, “Concept map” Accessed Sept 4, 2009

3. Becomes a geriatrician Example of a Concept Map Applies to geriatrics fellowship Accepted to geriatrics fellowship Spends a year learning geriatrics

4. Example Concept Map Tired person Skips exercise Eats muffins Drinks lots of coffee Gains weight Doesn’t sleep well at night

5. Patient: Mrs. T 75 year old woman with a history of hemorrhoids and depression admitted for blood in stools on Monday evening She is very weak and there is concern she will fall, so she is put on bedrest and a foley is placed She is made NPO, IVF are started, she gets prepped for colonoscopy by drinking a gallon of GoLytely She has a colonoscopy on Tuesday afternoon Tuesday evening she becomes very agitated, she starts fighting caregivers, pulling out her IV and foley She is placed in restraints She is now extremely confused. How did this happen?

6. Is this confusion delirium?

7. Delirium & the Hospitalized Older Patient

8. Learning Objectives Recognize delirium in hospitalized older adults Describe hospitalized older adults who are at risk for delirium Identify common causes of delirium in the hospitalized older adult Develop strategies to prevent or manage delirium

9. What is Delirium?

10. Acute confusional state Acute decline in attention and cognition Usually there is evidence of an underlying physiologic or medical condition Inouye SK, NEJM 2006

11. A. Disturbance in level of awareness and reduced attention B. A change in cognition C. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiologic consequences of a general medical condition D. The disturbance develops over a short period of time (usually hours to a few days) and tends to fluctuate in severity DSM V criteria http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=32

12. Common Symptoms Thinking is slow and muddled but content can be complex Hallucinations/delusions (30%) Sleep wake reversal Labile affect Psychomotor disturbances: 2 characteristic forms – Hyperactive- agitation, picking behaviors – Hypoactive- lethargy Inouye SK. NEJM 2006

13. Confusion Assessment Method (CAM) Does your patient have: 1. Acute change in mental status with fluctuating course 2. Inattention PLUS, either 3. Disorganized thinking 4. Altered level of consciousness Inouye SK et al. Ann Int Med 1990

14. Do you hear the term “DELIRIUM” used often? Delirium is often called something else: – Altered mental status – Dementia – Confusion – Agitation – Sundowning – Loopy

15. Delirium recognition is particularly poor in patients with dementia If person has dementia it is assumed they are “at baseline” Delirium gets confused with dementia – Dementia patients are at HIGH risk for delirium when in the hospital – Anyone can get delirious (even if they don’t have dementia) Fick, DM et al JAGS 2002

16. Delirium OR Dementia? Confused, inattentive New, acute onset Fluctuating course Reversible Caused by MANY triggers Altered level of consciousness (sleepy, hyperalert) Sometimes preventable Confused but attentive No different from baseline Minimal fluctuations Irreversible Caused by one disease Normal level of consciousness (alert) Not preventable

17. Epidemiology

18. How common is it? One fifth of hospitalized patients over 65 One third of hospitalized patients over 70 One third of older ER patients 70-87% of older ICU patients Geriatrics Review Syllabus 6 th Ed; Inouye SK. NEJM 2006

19. Impact of Delirium

20. Cost Adds $2,500 to the hospital cost per patient $6.9 billion of Medicare expenditures due to delirium Inouye SK. NEJM 2006

21. Patient Outcomes Patients with it die often and quickly – Mortality for hospitalized patients with delirium is 22-76% (similar to AMI or sepsis) – One year mortality 35-40% Deconditioning Longer hospital stays 3-5 times risk for nosocomial complications Increased risk of nursing home placement after discharge Inouye SK. NEJM 2006; Geriatrics Review Syllabus 6th Ed

22. What causes delirium?

23. Vulnerable patient: a house of cards Old age Male Dementia Functional dependence Visual/Hearing impairment Dehydration Multiple drugs or coexisting conditions Depression, alcoholism Inouye SK. NEJM 2006

24. A trigger: the fan gets turned on your house of cards… Drugs Neurologic disorders Illness Surgery Environmental triggers (hospitalization, ICU, restraints, Foley, sleep deprivation) Pain, malnutrition/dehydration Constipation, urinary retention Inouye SK. NEJM 2006

25. What can we do to prevent delirium?

26. Prevention Yale Delirium Prevention Trial Targeted common risk factors: – Cognitive impairment – Immobilization – Psychoactive drugs – Sleep deprivation – Vision/hearing impairment – Dehydration Inouye SK, NEJM 1999

27. Yale Delirium Prevention Trial: Interventions – Cognitive impairment – Immobilization – Psychoactive drugs Inouye SK, NEJM 1999 Frequent reorientation- white boards, volunteers Out of bed early- chair is better than bed Nonpharmacologic approaches to agitation

28. – Sleep deprivation – Dehydration – Vision/hearing impairment Inouye SK, NEJM 1999 Herbal tea, massage, music Hearing aids, magnifying glasses Feeding volunteers, early IV fluids Yale Delirium Prevention Trial: Interventions

29. Results Delirium developed in: – 9.9% of patients in the intervention group – 15% in the normal care group Delirious episodes were shorter in the intervention group But… the intervention did not affect severity of delirium or recurrence rates Inouye SK, NEJM 1999

30. Case Ms. Z is 87 years old with mild stage Alzheimer’s disease She is in the hospital after a fall down the stairs with C-2 and humerus fracture She is mildly confused, but alert and pleasant. She is able to pay attention to you when you ask her questions, but her answers usually don’t make sense. Is this delirium or just her underlying dementia?

31. Delirium OR Dementia? Confused, inattentive New, acute onset Fluctuating course Reversible Caused by MANY triggers Altered level of consciousness (sleepy, hyperalert) Sometimes preventable Confused but attentive No different from baseline Minimal fluctuations Irreversible Caused by one disease Normal level of consciousness (Alert, awake) Not preventable

32. What do you need to know to help prevent delirium in this patient? Geriatric assessment is the first step – Assess hearing, vision, cognition, mobility/fall risk, pressure ulcer risk Look for hospital hazards – Foley, restraints, O2, Telemetry

33. What was done for Ms. Z? Nursing interventions – Cognitive impairment – Immobilization Family encouraged to stay, educated on reorientation OOB to chair daily, Foley out, O2 off

34. – Vision/hearing impairment – Dehydration – Sleep deprivation Put on her glasses D/c low cholesterol diet, RN educated on signs of dehydration See next slide

35. Avoiding Sleep Deprivation Nursing interventions for daytime – Keep lights on, curtains open Nursing interventions for nighttime – Keep lights in hallway low – Keep lights low and TV off in patient rooms – Keep hallway noise down at night Stop waking the patient up – Check labs BEFORE bedtime – No vital sign checks between 11pm and 6am – No nebs at night

36. List 3 things that increase the risk of delirium where you work THAT COULD REALISTICALLY CHANGE RIGHT NOW Create an Action Plan

37. List 3 things you would like to make available to your patients to reduce delirium where you work Create a Wish List

38. Practice Audits

39. Summary: Delirium Prevention Frequent reorientation Out of bed as much as possible Keep the environment calm and non-stressful Minimize sensory impairments Avoid dehydration Promote nighttime sleep PAIN control Avoid irritants- TAKE OUT THE FOLEY, unneeded IVs, Tele, O2, braces & cervical collars Avoid constipation, look for urinary retention

40. The case continues… Mrs. Z does NOT develop delirium for the first 5 days of hospitalization. On hospital day #5, she develops a small bowel obstruction and requires surgical repair. Postoperatively, she is initially very somnolent, but then develops agitation and confusion, (much worse than her baseline). What do you think was the trigger for her delirium?

41. The doctor orders lorazepam and restraints. The patient becomes even more agitated, and she pulls out her Foley catheter.

42. Why did the delirium get worse? Restraints and benzodiazepines tend to cause or worsen delirium and agitation. What works better?

43. Management: What can we do once delirium occurs?

44. Management: 3 Components Eliminate Triggers Avoid Complications Manage Symptoms

45. Management Look for and eliminate all possible triggers – Infection, Ischemia – Metabolic disturbances – Medications – Restraints Avoid complications – Avoid DVT – Protect airway – Avoid pressure ulcers – Avoid dehydration – Avoid falls- low bed? Eliminate Triggers Avoid Complications

46. Management Manage symptoms – Nonpharmacologic Continue delirium prevention Use sitters, NOT restraints Encourage sleep at night Use music, massage, relaxation techniques for agitation Inouye SK, NEJM 2006 Manage Symptoms

47. Unclear if these modify the natural course of disease One placebo controlled RCT in the elderly showed no benefit to quetiapine Haloperidol- po if possible Atypical antipsychotics – Lowest possible doses, as infrequently as possible (0.5 mg risperidone BID, 2.5mg olanzapine QD, 25mg quetiapine qhs) Use standing doses for 2-3 days at most Pharmacologic Symptom Management Manage Symptoms Flaherty JH, et al. JAGS 2011

48. Mrs. Z You notice that although the patient just had surgery, she hasn’t asked for any pain meds. The only pain med ordered is acetaminophen prn. Haloperidol prn agitation You order scheduled acetaminophen, oxycodone prn Restraints are removed Foley is NOT replaced Mrs. Z becomes calm and comfortable (and pleasantly forgetful) the rest of her hospitalization.

49. Back to Concept Maps

50. Patient: Mrs. T 75 year old woman with a history of hemorrhoids and depression admitted for blood in stools on Monday evening She is very weak and there is concern she will fall, so she is put on bedrest and a foley is placed She is made NPO, IVF are started, she gets prepped for colonoscopy by drinking a gallon of GoLytely She has a colonoscopy on Tuesday afternoon Tuesday evening she becomes very agitated, she starts fighting caregivers, pulling out her IV and foley She is placed in restraints She is now extremely confused

51. Draw a Concept Map How did Mrs. T get so confused? Blood in stools Delirium

52. Haldol How did this patient get so confused? Bed rest Weak, fall risk Foley Pain Restraints Anesthesia Colonoscopy GIB Depression Confused patient Preexisting Alzheimer’s Lots of meds

53. Summary Delirium is an acute state of confusion Delirium is different from dementia (because it’s fixable), but dementia is a risk factor for getting delirious Delirium can sometimes be prevented All health care providers can play a role in protecting patients from getting delirious while in the hospital

54. Useful References Inouye SK. Delirium in Older Persons. NEJM 2006; 354:1157- 65 Inouye SK et al. A multicomponent intervention to prevent delirium in hospitalized older patients. NEJM 1999; 340:669- 76 Flaherty JH et al. Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. Journal of the American Geriatrics Society 2011; 59:S269-276