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POSTOPERATIVE DELIRIUM
Geriatrics for SurgeonsTeaching Conference
THE AMERICAN GERIATRICS SOCIETYGeriatrics Health Professionals.
Leading change. Improving care for older adults.
AGS
What is the incidence of delirium in the Denver VA surgical intensive care unit?
a) 8%
b) 23%
c) 44%
d) 65%
Slide 2
What is the incidence of delirium in the Denver VA surgical intensive care unit?
a) 8%
b) 23%
c) 44%
d) 65%
Slide 3
WHAT IS DELIRIUM?
Pandharipande et al. Curr Opin Crit Care (2005) 11:360.
Delirium is an acute, fluctuating change in mental status, with inattention and altered levels of consciousness
Slide 4
DIAGNOSTIC CRITERIA FOR DELIRIUM
1. Disturbance of consciousness
2. Change in cognition
3. Acute onset
4. Coexisting physiologic disturbance
Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (1994).Slide 5
THRESHOLD THEORYOF COGNITIVE DECLINE
• Older age → diminished brain reserve capacity
• Older patients are on a “functional cliff” for developing delirium when undergoing a major physiologic stress
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CHANGING COGNITIVE FUNCTIONIN THE ELDERLY
0
20
40
60
80
100
50 60 70 80 90 100
Age, years
Cognitive function, %
Dementia
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THRESHOLD THEORYOF COGNITIVE DECLINE
0
20
40
60
80
100
50 60 70 80 90 100
Age, years
Cognitive function, %
Dementia
Slide 8
THRESHOLD THEORYOF COGNITIVE DECLINE
0
20
40
60
80
100
50 60 70 80 90 100
Dementia
Delirium
Age, years
Cognitive function, %
Slide 9
POSTOPERATIVE DELIRIUM AND AGE
0
10
20
30
40
50
< 50 50-59 60-69 > 70
Incidence of delirium, %
Age, yearsSlide 10
0
10
20
30
40
50
< 50 50-59 60-69 > 70
Present Absent P
Age, years 69 ± 9 61 ± 6 <.001
Alcohol abuse 82% 18% .009Albumin 3.3 ± 0.8 3.9 ± 0.4 <.001
Dementiaa 3.3 ± 1.5 4.4 ± 1.0 <.001
Comorbiditiesb 4.2 ± 0.5 1.9 ± 0.2 <.001
Functional statusc 91 ± 11 99 ± 3 <.001
a – Mini-Cog Test c – Barthel Index
b – Charlson Index
RISK FACTORS FORPOSTOPERATIVE DELIRIUM (1 of 2)
Slide 11
RISK FACTORS FORPOSTOPERATIVE DELIRIUM (2 of 2)
• Age• Male sex• Cognitive impairment• Depression• Psychiatric diagnosis• Psychotropic drug use• Alcohol abuse• History of prior delirium
• ASA score• Smoking history• Comorbidity• Institutional residence• Functional impairment• Hearing impairment• Visual impairment
Dasgupta et al. JAGS (2006) 54:1578.Slide 12
What risk factor is the best for determining who will develop delirium in the Denver VA
surgical intensive care unit?
a) Older age
b) Pre-existing dementia
c) Functional impairment
d) Hypoalbuminemia
Slide 13
What risk factor is the best for determining who will develop delirium in the Denver VA
surgical intensive care unit?
a) Older age
b) Pre-existing dementia
c) Functional impairment
d) Hypoalbuminemia
Slide 14
Slide 15Slide 15
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Slide 16Slide 16
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
Operation
CONFUSION ASSESSMENT METHOD — ICU
Ely et al. JAMA (2001) 286:2703.
FEATURE 1: Acute onset of mental status
changes or a fluctuating course
AND
FEATURE 2:Inattention
AND
FEATURE 3: Disorganized thinking
FEATURE 4:Altered level of consciousness
OR
Slide 17
MOTOR SUBTYPES OF DELIRIUM
• A spectrum of psychomotor behavior is found in delirium
• Delirium motor subtypes Hypoactive — 40% Hyperactive — 5% Mixed type — 55%
Meagher et al. J of Neuropsych and Clin Neurosci (2000) 12:51.Slide 18
• Fluctuating course
• Hypoactive motor subtype
• Delirium not recognized by clinical team in 32% of cases
DELIRIUM ISA DIAGNOSTIC CHALLENGE
Francis et al. Clin Res (1988) 36:711A. Slide 19
Slide 20
Risk Factors:Age >65DementiaFunctional ImpairmentCo-MorbiditiesLow Albumin
Operation
Assess sedationCAM-ICU evaluationMotor Subtypes:- Hypoactive- Hyperactive- Mixed
Slide 21Slide 21
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
Slide 22Slide 22
Evaluation for an organic cause:
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
• Sepsis• Hypoxemia• Hypoglycemia• Electrolyte abnormality• Dehydration• Stroke• Medications
TREAT ORGANIC CAUSE
Slide 23
H&P Evaluation• Mental status• Neuro exam• History of substance
abuse• Vital signs
Laboratory Tests• CBC• Glucose• Electrolytes• BUN / Cr• UA• O2 saturation
MEDICAL EVALUATION OF DELIRIUM
Potter et al. Clin Med (2006) 6:303.Slide 24
Slide 25Slide 25
Evaluation for an organic cause: Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance withdrawalReview medications
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
Slide 26Slide 26
Organic cause:Treat appropriately
Evaluation for an organic cause: Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance withdrawalReview medications
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
Slide 27Slide 27
Multi-component treatment plan
Organic cause:Treat appropriately
Evaluation for an organic cause: Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance withdrawalReview medications
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
Pharmacologic treatment:
Slide 28
Supportive measures:
Slide 28
Multi-component treatment plan
Organic cause:Treat appropriately
Evaluation for an organic cause: Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance withdrawalReview medications
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY
• HypothesisReducing the number of risk factors for delirium will prevent delirium in hospitalized elderly patients
• Methods 852 hospitalized medical patients
Older than 70 years
Compare effectiveness of reducing the risk factors for delirium to standard of care
Inouye et al. N Engl J Med (1999) 340:669.Slide 29
MULTI-COMPONENT INTERVENTION TO PREVENT DELIRIUM
Risk Factor InterventionCognitive impairment Orientation protocol
Sleep deprivation Sleep enhancement
Immobility Early mobilization
Visual impairment Early vision correction
Hearing impairment Hearing protocol
Dehydration Change BUN/Cr ratio
Inouye et al. N Engl J Med (1999) 340:669.Slide 30
PREVENTING DELIRIUM IN THE HOSPITALIZED ELDERLY
Inouye et al. N Engl J Med (1999) 340:669.
Intervention Usual Care P
Incidence of delirium 9.9% 15.0% .02
Total days of delirium 105 161 .02
Episodes of delirium 62 90 .03
Slide 31
Pharmacologic treatment:
Slide 32
Supportive measures:ReorientationSleep enhancementVision/hearing protocolRemove Foley Medication choices
Slide 32
Multi-component treatment plan
Organic cause:Treat appropriately
Evaluation for an organic cause: Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance withdrawalReview medications
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
Pharmacologic treatment:
Screen high-risk patients in preoperative clinic
Slide 33
Supportive measures:ReorientationSleep enhancementVision/hearing protocolRemove Foley Medication choices
Slide 33
Multi-component treatment plan
Organic cause:Treat appropriately
Evaluation for an organic cause: Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance withdrawalReview medications
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
Haloperidol 2 mg q20 min (while agitation persists)
OR
Degree of agitation Initial dose of haloperidolPO, IM or IV
Mild 0.252 mg
Moderate 24 mg
Severe 48 mg
PHARMACOLOGIC TREATMENT: ICU
Jacobi et al. Crit Care Med (2002) 30:119. Slide 34
PHARMACOLOGIC TREATMENT: ICU
• Maintenance dose 50% of total loading dose is the maintenance
dose, divided every 68 hours daily Continue maintenance dose for 2448 hours
before tapering
• Taper maintenance dose by 20%30% daily until off
Slide 35
PHARMACOLOGIC TREATMENT: ICU
Haloperidol AdministrationControl Moderate agitation
2:00 AM – 2 mg IV2:30 AM – 2 mg IV3:00 AM – 2 mg IV3:30 AM – Agitation controlled
Maintain 1 mg TID IV or PO 24 hoursKeep daily dose for 24–48 hours
Taper 0.5 mg PO BID for 24 hr, then DC
Slide 36
• General recommendation Haloperidol 12 mg q24 hr PRN May be administered PO, IM, or IV
• For elderly patients Haloperidol 0.250.5 mg q4 hr PRN
PHARMACOLOGIC TREATMENT: WARD
American Psychiatric Association. Practice Guideline for Treatment of Patients with Delirium (1999). Slide 37
Pharmacologic treatment:1. ICU Haloperidol 12 mg IV Repeat every 20 min until resolution of agitation Taper over several days2. Surgical ward Haloperidol 1 mg PO/IM/IV Maintenance dose 0.250.5 mg Q4h Taper over several days
Screen high-risk patients in preoperative clinic
Slide 38
Supportive measures:ReorientationSleep enhancementVision/hearing protocolRemove Foley Medication choices
Slide 38
Multi-component treatment plan
Organic cause:Treat appropriately
Evaluation for an organic cause: Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance withdrawalReview medications
Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin
Assess sedationCAM-ICU evaluationMotor subtypes:- Hypoactive- Hyperactive- Mixed
POST-OPDELIRIUM
Operation
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