Delirium: The Confusion Conundrum

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Delirium: The Confusion Conundrum

February 4, 2011Mitchell T. Heflin, MDBarbara Kamholz MDJuliessa Pavon, MD

Yvette West, RN

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Case PresentationMr. A

– 82 year old white male post-op day #18 from AAA repair

– Consult for agitation and altered mental statusHPI:

– Pulsatile mass found by PCP on routine exam– Confirmed as 8.2 cm infrarenal AAA on CT– Referred for elective surgical repair

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Case: History• Past Medical History:

– Hypertension– Hyperlipidemia– Smoked 1ppd until quit 1995– s/p finger amputation on left hand from work accident

• Home Medications:– Simvastatin 40 mg daily– Bisoprolol 5 mg bid– ASA 81 mg daily

• ROS: – Denied abd pain, back pain, chest pain, sob, claudication

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Case: History

• Family History:– Alzheimer’s disease in both parents

• Social History:– Lives at home alone, widower for 5 years– Independent in ADLs and IADLs– Physically active, playing golf daily– Son and daughter do not live locally

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Case: Hospital Course• Elective AAA repair on 12/15/10• Returned to OR on POD #0 for bleeding from

aneurysm• Following surgery:

– Mental status did not return to baseline despite weaning off sedation

– Failed trial of extubation due to AMS• POD #3: atrial fibrillation and tachycardia

– Amiodarone started• POD #7: Trach and PEG

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Case: Hospital Course

• POD #7-14: Restless and agitated – Pulling at trach and PEG– Attempts to treat with haldol, risperidone and ativan

• POD # 16: Adynamic ileus and aspiration– Vancomycin and ciprofloxacin

• POD # 18: Geriatrics consulted– Assist with management of agitation and altered mental

status

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Case: Medications• Aspirin• Amiodarone• Metoprolol• Vancomycin• Ciprofloxacin• Ativan 1 mg IV q6hrs• Risperidone 0.5 mg VT qhs• Haldol 0.5 – 1.5 mg IV PRN (5 mg in last 24 hrs)• Dilaudid 0.5 mg IV q6hrs PRN (0 mg in last 24 hrs)

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Case: ExamT 36.4 HR 100s BP 90s/60s Pulse ox 97% on 40 % FiO2Gen: Somnolent but easily arousable and anxious

Grimacing and tachypneic during examTrach in place on ventilation

CV: Tachycardic, irregular Pulm: Coarse breath soundsAbd: Mildly tender, + BS, healing midline wound and PEGExt: Restraints on hands, edema in LENeuro:

Opens eyes to loud voice and tracks but does not follow simple commands, moves all extremities, no Babinski or clonus

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Case: Diagnostic Testing

• Head CT: No focal lesions• CXR: Small bilateral effusions• KUB: Mildly distended loops of small bowel• WBC 12K, Hct 28%• Creatinine 1.0, Albumin 2.3, LFT’s and TSH normal• UA: 2+ blood, 1+ LE, 6 WBC, > 50 bacteria• EKG: Afib 100, no ischemia or conduction problems• Cardiac enzymes: normal

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Case: Daughter’s input

• Very physically and socially active• Had problems with forgetfulness, repeating and

perseverations in the prior year• Very hard of hearing and wears glasses for distance

vision• Drank at least two glasses of wine each night

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Delirium: Definitions

• Acute disorder of attention and global cognitive function

• DSM IV:– Acute and fluctuating– Change in consciousness and cognition– Evidence of causation

• Synonyms: organic brain syndrome, acute confusional state

• Not dementia

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So what’s the conundrum?

• Highly prevalent• Associated with much suffering and poor

outcomes• Complex and often multifactorial• Preventable but….

Better care requires a shift in paradigm

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Objectives• Describe the prevalence of delirium and its impact

on the health of older patients

• Identify pathophysiology, risk factors and key presenting features

• Describe strategies for prevention and management

• Find opportunities to improve current practice

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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.

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Costs of Delirium• In-hospital complications1,3

– 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

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The experience…

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Grade for Recognition: D-

• 33-95% of in hospital cases are missed or misdiagnosed as depression, psychosis or dementia

• ER: 15-40% discharge rate of delirious patients

– 90% of delirium missed in ED is then also missed in hospital!

Inouye, J Ger Psy and Neurol., 11(3) 1998 ;Bair, Psy Clin N Amer 21(4)1998

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Clinical Features of Delirium

• Acute or subacute onset• Fluctuating intensity of symptoms

– ALL SYMPTOMS FLUCTUATE…not just level of consciousness

– Clinical presentation can vary within seconds to minutes

• Inattention – aka “human hard drive crash”

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In-attention• Cognitive state DOES NOT meet

environmental requirements• Result= global disconnect

– Inability to fix, focus, or sustain attention to most salient concern

• Hypoattentiveness or hyperattentiveness• Bedside tests

– Days of week backward– Immediate recall

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This Can Look Very Much Like…

….depression• 60% dysphoric• 52% thoughts of death or suicide• 68% feel “worthless” • Up to 42% of cases referred for psychiatry consult

services for depression are delirious

Farrell Arch Intern Med. 1995 155:22

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Improving The Odds of Recognition

• Clinical examination– CAM

• Team observations– Nursing notes

• Prediction by risk– Predisposing and precipitating factors

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Diagnosis: Confusion Assessment Method

• Geropsychiatry assessment gold standard• Recent systematic review2

– Sensitivity 86% (74-93)– Specificity 93% (87-96)– LR + 9.4 (5.8-16) – LR – 0.16 (0.09-0.29)

1 Inouye 1996; 2 Wong 2010.

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CAM

1. Acute onset and fluctuating course2. Inattention3. Disorganized thinking4. Altered level of consciousness

Or

Inouye 1994

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Nursing Input• Chart Screening Checklist• Nurses’ commonly charted behavioral signs

(Sensitivity= 93.33%, Specificity =90.82% vs CAM)• Pulling at tubes, verbal abuse, odd behavior,

“confusion”, etc• 97.3% of diagnoses of delirium can be made by

nurses’ notes alone using CSC• 42.1% of diagnoses made by physicians’ notes alone

using CSC

Kamholz, AAGP 1999

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Risk FactorsPredisposing factors: Adjusted RR

– Vision impairment 3.5– Severe illness (>APACHE 2) 3.5– Cognitive impairment (MMSE<24) 2.8– BUN/Cr >18 2.0

Precipitating factors: Adjusted RR– Physical restraints 4.4– Malnutrition (wt loss, alb) 4.0– >3 meds added 2.9– Bladder catheter 2.4– Any iatrogenic event 1.9

Inouye SK 1998

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Putting it all together...

0 RF 1-2 RF 3-4 RF

0 RF 0 0 0

1-2 RF 0 3.2 13.6

3-4 RF 1.4 4.9 26.3

Precipitating Factors

Pre

disp

osin

g F

acto

rs

Inouye SK 1998

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Oxidative StressModel: ARDS

• ANY source of ischemia– Low cardiac output– Impaired pulmonary function/oxygenation– Low Hgb/Hct

• Mechanisms: – Dysfunction of CAC – Rapid depletion of ATP– Depolarization of cell membrane– Ca++ influx, imbalance of neurotransmitters– Remodeling at all neuronal levels, including decreased

synaptic transmission, cell death

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Inflammatory ProcessModel: Sepsis

• Peripheral interleukins (IL6,TNF IL1B) induce symptoms of delirium– Direct neural pathways (primary autonomic afferents)– Transport across BBB– Circumventricular region/BBB non-continuous

• TNF can persist for months in CNS• Gradient from dementia to delirium of

TNF(amount, rate of cognitive decline)

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Neurotransmitter Dysfunction

• Dopamine– Hypoxiamitochondrial dysfunctioncellular

instabilityCa++influx:– Increases in production of DOPA due to upregulated

tyrosine hydroxylase– Decreased activity of COMT

• Acetylcholine– Synthesis very sensitive to hypoxia – Transmission is very sensitive to metabolic abnormalities,

especially of O2 and glucose– Suppresses immune dysregulation via vagal nerve pathway

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Summary: Feet of Sand

• Delirium in frail patients often associated with disturbances of most basic substrates and cellular functions:– Impaired oxygenation (blood loss, pulmonary disease)– Metabolic disturbances, commonly Na, Calcium– Infection/inflammation (UTI, Pneumonia)– Medications, especially those that affect vital, basic

pathways• Helps with prediction• Primary CNS causes are in the distinct minority

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Multicomponent Intervention to Prevent Delirium

• 852 patients over 70 on Gen Med– IM risk (1-2 RF’s) or High risk (3-4 RF’s)

• Randomized by units with prospective matching• Standardized protocols for 6 risk factors• ID Team: Nurse specialist, PT, RT, MD and volunteers• Outcomes assessed daily by CAM

Inouye 1999.

Elder Life ProgramRisk factor Protocol Outcome

Cognitive impairment

Orientation and therapeutic activities Orientation score

Sleep deprivation

Non-Rx sleep protocolQuiet nights

Use of sleep meds

Immobility Early mobilizationRemoval of tethers

ADL score

Vision problems

Visual aids and adaptive equipment Early vision correction

Hearing loss Wax disimpaction, amplifying devices, other comm. techniques

Whisper test

Dehydration Early recognition and volume repletion BUN/Cr < 18

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Results of Multicomponent Intervention Trial *

Control Intervention

Delirium incidence

15.0% 9.9%

Days of delirium 161 105

Inouye 1999.

* p< 0.02 for both outcomes

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Results• Most effective for IM risk group• No change in severity of delirium• Cost

– $327/pt– $6341/case prevented

• No lasting beneficial effect on functional status or resource utilization

• Benefit replicated

Inouye 1999; Rizzo 2001; Bogardus 2003

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Reducing Delirium After Hip FractureGeriatrics Consultation

• CNS oxygen delivery• Fluid and electrolytes• Treatment of pain• Unnecessary

medications• Bowel/bladder • Early mobilization

• Prevention, early detection and treatment of complications

• Nutrition• Environmental stimuli• Agitated delirium

Marcantonio 2001.

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Results

• No change in length of stay• Most effective in patients without

– Pre-existing dementia– ADL impairment

Control (n=64)

Intervention (n=62)

RR

Any delirium

50% 32% 0.64 (0.37-0.98)

Severe delirium

29% 12% 0.40 (0.18-0.89)

Marcantonio 2001.

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Pharmacotherapy

• Dopamine blockade1

– Haldol (1.5 mg daily) prophylaxis in high risk hip fracture patients

– No change in incidence– Decrease in severity and duration

• Acetylcholinesterase inhibitor2

– Donepezil did not decrease incidence or severity of delirium

1 Kalisvaart 2005, 2 Liptzin 2005.

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Treating pain

• Prospective cohort study >500 hip fracture patients with and without delirium

• Patients receiving <10 mg IV Morphine/day were 5x more likely to become delirious

• Patients reporting severe pain 10x more likely to develop delirium

Morrison 2003.

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Delirium Management: Key Points

• Early recognition of high risk patients and situations is key to effective management

• Prevention is more effective than treatment• Address:

– Physiologic– Environmental– Pharmacologic– Psychosocial

• Enlist a team

Sendelbach and Guthrie, 2009.

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PsychosocialAssess substance useAddress stress and distressEducate patient and familyAssess decision makingConsider function and safety

PharmaceuticalReduce/avoid certain meds- Benadryl, Benzo’sMonitor for S.E.’s of pain medsLow dose neuroleptic Benzo’s for withdrawal

PhysiologicO2 and BPFood and fluidsSleep/wake cycleActivity and mobilityBowel and bladderPainInfections

EnvironmentalReorientationContinuity in careFamily or sittersHearing aids, glassesQUIET at nightNo restraintsAMBULATE!

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PsychosocialWatch for w/d symptoms off AtivanEducate patient and familyProvide reassurance and means

of communication

PharmaceuticalTaper AtivanMonitor for S.E.’s of OxycodoneRisperidone 0.5 mg bid

PhysiologicControl HR, BP improvedIncrease trach sizeTreat UTI and aspirationBowel regimenSchedule oxycodone and acetaminophenAdvance tube feeds

EnvironmentalLight, activity, orientation during dayQUIET at night—avoid VS, meds, etc.Remove restraintsGlasses on, loud voice and lip reading

What about Mr. A?

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Geriatrics

• Inpatient consult service• Assistance with older adults with:

– Delirium and other cognitive disorders– Multiple, complex medical problems– Medications, medications, medications– Goals of care

• Pager 970-0370

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Old way….

D = DehydrationE = Electrolytes (including glucose, Ca)L= Low oxygenI = InfectionR = Retention of urine/stoolI = In painU = Under-diagnosed withdrawalM = Medications

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A better way….

PsychosocialPsychosocial

PharmacologicPharmacologic

PhysiologicPhysiologic

EnvironmentalEnvironmental

Medicine

Nursing

PT/OT

Pharmacy

Social work

Nutrition

PA’s

Patients and

Caregivers

Administrators

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• 5 year, $1.2 million project funded by HRSA• Goal: Create Geriatrics Education Hub

- Staffed by interprofessional faculty- Focused on improving the care of older adults with

or at risk for delirium- Learning resources, clinical experiences and

practice improvement projects- Part of six school consortium addressing this issue

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Delirium: Nursing Strategies

Duke NICHEGeriatric Resource Nurse Initiative

Kristin Nomides RNKristin Nomides RN

Grace Kwon RNGrace Kwon RN

Samantha Badgley RN Samantha Badgley RN

Duke Hospital 2100Duke Hospital 2100

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Supporting Literature: Nursing InterventionsYale Delirium Prevention Program : multi-component interventionsYale Delirium Prevention Program : multi-component interventions

Cognitive impairment with Reality OrientationCognitive impairment with Reality Orientation Sleep enhancement protocolSleep enhancement protocol Sensory impairment with therapeutic activities protocol Sensory impairment with therapeutic activities protocol Sensory deprivation Sensory deprivation DehydrationDehydration

Reduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodesReduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodesInouye, s. 2004Inouye, s. 2004

Delirium education for team (MD and RN)Delirium education for team (MD and RN) Provided post program support and learning reinforcement Provided post program support and learning reinforcement 250 acute admit patients > 70 recruited on 2 units250 acute admit patients > 70 recruited on 2 units

Delirium 12/122 intervention unit vs. 25/128 control unitDelirium 12/122 intervention unit vs. 25/128 control unitTabet N,, et al, 2005Tabet N,, et al, 2005

Post op multi-factorial intervention educational programPost op multi-factorial intervention educational program Teamwork and care planning on prevention and treatment of deliriumTeamwork and care planning on prevention and treatment of delirium Targeted delirium risk factorsTargeted delirium risk factors

Post op delirium compared to controls (56/102 and 73/97) Post op delirium compared to controls (56/102 and 73/97) Lundrtrom, et al. 2007Lundrtrom, et al. 2007

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Nursing Interventions:• Delirium & Risk Factors Staff EducationDelirium & Risk Factors Staff Education• Activity Cart / Busy ApronActivity Cart / Busy Apron

– Stimulate cognitive and motor skillsStimulate cognitive and motor skills• All About Me All About Me PosterPoster

– Orientation InformationOrientation Information• MeMe File File

– Orientation information provided by patient / Orientation information provided by patient / family for high risk patientsfamily for high risk patients

• Question MarkQuestion Mark– Identification of patients with AMSIdentification of patients with AMS ??

AlteredMental Status

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Summary

• Delirium is common and caustic for older adults

• It can be diagnosed using validated tools (e.g. CAM)

• Predisposing and precipitating factors are well established

• Prevention is more effective than treatment• Management requires a team approach

Delirium: The Confusion Conundrum

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