Delirium in Older Patients Admitted to a Community Based...
Transcript of Delirium in Older Patients Admitted to a Community Based...
Geriatric Grand RoundsGeriatric Grand RoundsGeriatric Grand Rounds
Tuesday, October 27, 2009 12:00 noonTuesday, October 27, 2009 12:00 noon
Dr. Bill Black AuditoriumDr. Bill Black AuditoriumGlenrose Rehabilitation HospitalGlenrose Rehabilitation Hospital
In keeping with Glenrose Rehabilitation Hospital policy, speakers participating in this event have been asked to disclose to the audience any involvement with industry or other
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Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care
Hospital
Dr. Lotje Wasilenko, CCFPCare of the Elderly Resident
October 27, 2009
Disclosure
I have no relationship that could be perceived as placing me in a real or apparent conflict of
interest in the context of this presentation
Outline• Background
• Research questions
• Methodology
• Results
• Conclusion
• Limitations
• Recommendations/Future directions
Background on Delirium
Definition Delirium (DSM-IV-TR)1
• Acute alteration in consciousness
• ↓ Ability to focus, sustain, or shift attention
• Develops over hours to days
• Results in cognitive and perceptual
disturbance
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
Definition Delirium (DSM-IV-TR)1
• Fluctuates throughout the day
• Caused by medical conditions, medication
side effects, substance intoxication
Prevalence of Delirium
• Delirium can be found wherever there are sick patients
• Prevalence in hospitalized older adults is 25% to 56% 2,3
Prevalence of Delirium
• Highest prevalence: 4,5,6
- Older patients post-op 15-53%- ICU 70-87% - Near death 80%
• Unrecognized in up to 65%7 (age, dementia, other mental disorder)
Risk Factors and Precipitants8
• Delirium is a multi-factorial disorder
• Risk factors that increase baseline
vulnerability
- Underlying brain diseases (dementia/stroke)
- Advanced age
- Sensory impairment
Risk Factors and Precipitants8
• Precipitants are factors that precipitate the
disturbance
• Precipitants alone do not cause delirium
• Precipitants interact with underlying risk
factors
Precipitating Factors
• Drugs and toxins
• Infections
• Metabolic derangements
• Brain disorders
• Systemic organ failure
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
Precipitating FactorsOthers:• Immobility (restraint use)• Dehydration• Malnutrition• Use of bladder catheters• Constipation• Urinary retention• Pain• Sleep deprivation
Vulnerability9
• Highly vulnerable patients have many risk factors - Delirium due to relatively benign precipitant- For example: change in medication
• Less vulnerable patients have few risk factors- Require major insult to trigger delirium
Diagnosis
• Most important:- Delirium is a medical emergency- Recognize that delirium is present- Uncover the cause for delirium
• Evaluation: history (including meds), physical exam, CAM, investigations
CAM10
• Confusion Assessment Method1) Acute onset and fluctuating course2) Inattention3) Disorganized thinking4) Altered level of consciousness
• Diagnosis of delirium requires 1 and 2, plus either 3 or 4
• CAM Scores predicting Delirium (Sensitivity of 94-100% and Specificity of 90-95%)
Consequences of Delirium11
• Prolonged hospital stay
• Functional and cognitive decline
• ↑ Risk of institutionalization
• ↑ Morbidity and mortality
• ↑ Financial burden
Prevention of Delirium
• Managing modifiable RF/Precipitants reduces risk of delirium
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
Prevention of Delirium
• Managing modifiable RF/Precipitants reduces risk of delirium
Prevention of Delirium
• This study used protocols to screen and control for 6 RF:
- Cognitive impairment - Visual impairment- Sleep deprivation - Hearing impairment- Immobility - Dehydration
Prevention of Delirium
• Significant reduction in number of delirium episodes compared with usual care (62 versus 90)
• Significant reduction in the total number of days with delirium (105 versus 161)
• No effect on delirium severity or recurrence rate
Seniors’ Delirium Protocol
• Implemented in August 2008
• To improve identification and management of
delirium in the acute care setting
• Early recognition and intervention of delirium
to improve patient outcome
Seniors’ Delirium Protocol
• Guides assessment for delirium
• Includes CAM, guidance of opioid use, and medication management of disturbed behaviour
• 3 pages of patient care orders
Research Questions
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
Research Questions
1) What is the prevalence of delirium in patients 65 years of age or older, admitted to a Family Medicine unit at a community based Acute Care Hospital?
2) What are the most common risk factors and precipitants in older hospitalized patients with delirium?
Research Questions
3) Is the Seniors’ Delirium Protocol being utilized in patients with a change in behaviour or cognition?
- Delirium- Acute confusion- Agitation (new onset)
Methodology
Methodology
• Literature review
• Ethics and site approval
• Chart retrieval from medical records– Patients ≥ 65 years old admitted to Family Medicine Unit
in an acute care facility between November 1, 2008 and February 28, 2009
• Retrospective chart review and data extraction
Methodology Data Extraction
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
Results
Age/Gender of Sample Population
n = 250
AgeMean (yrs) 83.04SD 7.83Range (yrs) 65-103
Research Question #1
What is the prevalence of delirium in patients 65 years of age or older, admitted to a Family Medicine unit at a community based Acute
Care Hospital?
Prevalence of Delirium/Acute Confusion/Agitation
n = 250
Prevalence of Delirium/Acute Confusion/Agitation
n = 78
Research Question #2
What are the most common risk factors and precipitants in older hospitalized patients with
delirium?
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
RF/Precipitants for Delirium in Sample Population
n = 250
RF/Precipitants in Delirium versus Non-Delirium Group
*
**
**
*
*
*
Age Difference Between Delirium and Non-Delirium Group
n Mean Age (yrs)
SD p-value
Delirium 78 84.6 7.54 0.03No Delirium 172 82.3 7.89
Gender Difference Between Delirium and Non-Delirium Group
Male Femalen % n %
Delirium 28 35.9 50 64.1No Delirium 62 36.0 110 64.0
Differences Not Statistically Significant
Breakdown of Sample Population by Number of RF
for Delirium
Breakdown of Delirium and Non-Delirium Group by Number of RF
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
Breakdown of Sample Population into Low Risk or
High Risk Groupsn = 250
Prevalence of Delirium in the Low and High Risk Groups
p < 0.001
Age Difference Between High and Low Risk Groups
n Mean Age (yrs)
SD p-value
Low (≤ 3 RF) 92 81.7 7.49 0.04High (≥ 4 RF) 158 83.8 7.96
Gender Difference High and Low Risk Groups
Male Femalen % n %
Low (≤ 3 RF) 31 33.7 61 66.3High (≥ 4 RF) 59 37.3 99 62.7
Differences Not Statistically Significant
Difference in # Medications Between Low and High Risk
Groups
n Mean (# meds)
SD p-value
Low (≤ 3 RF) 92 5.03 2.81 <0.001High (≥ 4 RF) 158 6.41 2.97
Examining the Most Predictive Risk Factors for Delirium
• Logistic regression used to determine the most predictive risk factors for delirium
• First step was to look at correlations between risk factors ( n = 15) and delirium
• Those risk factors found to be positively correlated with delirium were selected for use in the regression equation (10 of the 15 were significant)
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
Most predictive Risk Factors for Delirium
Risk Factors p-valueHx Dementia 0.001Immobility 0.003Dehydration 0.02Physical Restraints 0.001# Medications <0.001
Bladder Catheter 0.06
Research Question #3
Is the Seniors’ Delirium Protocol being utilized in patients with a change in behaviour or
cognition?
- Delirium- Acute confusion- Agitation (new onset)
Seniors’ Delirium Protocol Use Conclusions
• Delirium is very common in our sample population (31%)
• Acute Confusion is documented more often in the chart than the diagnosis of delirium
• Significant predictors of delirium are a history of dementia, immobility, dehydration, use of physical restraints, and # of medications
• Seniors’ Delirium Protocol is underused
Conclusions
• Patients with ≥ 4 RF/Precipitants develop delirium 3 times more often then patients with ≤ 3 RF/Precipitants
Limitations
• Not all RF/Precipitants for delirium were included in data extraction
• Some RF/Precipitants were difficult to assess with retrospective chart review and might have been missed
• Unsure if all delirium diagnosis were correct since CAM score not mentioned in chart
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009
Recommendations
• Since delirium is common and affects patient outcome we should anticipate it in certain patients (hx of dementia/stroke, older age)
• If there is change in behaviour/cognition use Seniors’ Delirium Protocol which addresses most RF and precipitants
Recommendations
• At least address the most predictive RF/Precipitants:
– Hx of dementia– Immobility– Dehydration– Use of physical restraints– Medications that can cause delirium
Recommendations
• If delirium is confirmed use this as diagnosis (instead of Acute Confusion)
• Document delirium in discharge summary
Future Directions
• Staff surveys to find out why Seniors’ Delirium Protocol is not being used
• Regular inservices regarding Seniors’ Delirium Protocol with follow up in 1 year (focus on physicians, residents, students)
• Possibly develop an intervention protocol based on the most predictive RF/Precipitants
Thank You!
• Dr. Bonnie Dobbs and Rhianne McKay• Dr. Jennifer Stickney-Lee and Dr. Namita Rao• Medical Records Staff• Bonnie Launhardt
References1. American Psychiatric Association, Diagnostic and Statistical Manual, 4th ed, Text Revision,
APA Press, 20002. Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med 1998; 14(4):7456-643. Siddiqi N et al. Occurence and outcome of delirium in medical in-patients; a systematic
literature review. Age Ageing 2006;35:350-644. Inouye SK. Delirium in older persons. N Engl J Med 2006. 354.1157-11655. Pisani MA et al. Cognitive impairment in the intensive care unit. Clin Chest Med 2003;24:727-
376. Casarett D et al. Diagnosis and management of delirium near the end of life. Ann Intern Med
2001;135:32-407. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis
and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97 (3):278-88
8. Inouye SK, Charpentier PA. Precipitating risk factors for delirium in hospitalized elderly persons: predictive model and inter-relationship with baseline vulnerability. JAMA 1996; 275:852-7
9. Young J, Inouye SK. Delirium in older people. BMJ 2007;334;842-84610. Inouye SK et al. Clarifying confusion: The Confusion Assessment Method, a new method for
detection of delirium. Ann Intern Med 1990; 113:94111. McCusker J, Cole M et al. Delirium predicts 12- month Mortality. Arch Intern Med
2002;162:457-463
Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP
Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009