Duke GEC Lisa P. Gwyther, MSW, LCSW Duke Family Support Program Duke Center for Aging Delirium...

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Lisa P. Gwyther, MSW, LCSWDuke Family Support Program

Duke Center for AgingDelirium Teaching Rounds

Duke Geriatric Education CenterJanuary 11, 2013

Preventing Delirium in the Hospitalized Patient with Dementia

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Objectives• Describe the prevalence of delirium in persons with

dementia and its impact on the health of older patients

• Identify risk factors and key presenting features of delirium

• Describe Prevention and Management Strategies

• Identify resources for teams and families about delirium recognition and prevention

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Case• 92 year old AA female in own apt near son and

his ex-wife• 2009 GET Clinic dx of vascular dementia,

emotional lability, occasional delusions • May 2012: frequent tearful calls to son, fearful

of being alone & wandered away at night, delusions of being attacked, son had to stay at night - .25mg. risperidone

• Nov 2012 Family considering placement• Dec 2012 ED with complaints of abdominal pain,

nausea, vomiting, fever and not eating one week.

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Questions

• What are her risks for delirium?

• What can be done to reduce her risk of delirium/improve hospital care, given her dementia?

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Common Risk Factors for DeliriumPredisposing• 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.

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Hospital Course• Pelvic abscess drained well, but persistent difficulty

communicating symptoms and anxiety on day 4

• Helpful Strategies - CNA sitter experienced in dementia and familiar with hospital unit - Out of bed every day - Effective pain control - Help with bowels - Attention to eating and drinking - Lights on, reassurance - Reduced tethering constraints - Risperidone

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Hospital Course

• Day 5 developed C.dif colitis from antibiotics• Delirious, aggressive, increased disorientation• Delayed discharge to nursing home

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An email to Lisa Gwyther, Jan, 2013

My geriatric care management client is 94. He is an active community leader, teacher and pastor who lives independently and drove until a recent UTI caused extreme confusion. He left the hospital with a new diagnosis of FTD. The family wants to know: 1) how to tell him the diagnosis and prognosis and 2) now that the UTI has improved over six weeks, can he resume driving?

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What Dementia Families Tell Us• Her dementia progressed much faster after she was

hospitalized.• It seems like one hospitalization led to many more

and we never got the meds straight.• When I saw how he was in the hospital, I knew I

couldn’t take care of him at home any longer.• I thought it was just her dementia progressing, but

she was dehydrated and really sick.• The ED was like an exhausting time capsule – when

he finally got a room, we thought he was safe to sleep and we could finally get a break.

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What Dementia Families Tell Us• Shouldn’t they know the call light and the food

containers were totally beyond her? She fell trying to find some food and a bathroom.

• The hospital staff are clueless – it didn’t help for them to keep telling him where he was.

• Why do we have to pay a private aid, given all that hospital charges?

• They either asked him impossible questions he couldn’t hear anyway, or talked about him like he wasn’t even there.

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Risks for Patients with Dementia• Delayed presentation to ED and delayed detection

(Morandi,A et al, JAGS, 2012 review suggests limited evidence base for tools to detect delirium superimposed on dementia; and Thomas C et al, JAGS, 2012 found adding psychomotor change to the CAM algorithm improved specificity and diagnostic value against ICD-10 in hospitalized patients with dementia)

• If left alone, patients forget what they are waiting for and leave

• If left alone, patients are unreliable informants who may confabulate and sound reasonable to fill in holes in memory

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Risks for Patients with Dementia• Change is the enemy – any sudden change in routine

can lead to delirium in someone with Alzheimer’s.• Recent study estimate: 6% of deaths, 15% of

placements and 21% of cognitive decline in hospitalized patients with AD can be attributed to delirium. (Fong et al, Annals of Internal Medicine 2012)

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Risks for Patients with Dementia• Dementia is the leading risk factor for delirium and

two thirds of cases of delirium occur in patients with dementia (Inouye, 2006 NEJM)

• Delirium in hospitalized patients with dementia is associated with an 2.2-fold increase in the rate of cognitive decline over one year and 1.7 fold increased rate of cognitive deterioration maintained up to five years. (Weiner MF, Arch Neurol, 2012; Gross et al, Archives of Internal Medicine, 2012)

“Results challenge the notion that delirium is transient and reversible in Alzheimer’s, making an even stronger case for prevention”

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Risks of Delirium in Hospitalized Patients with Dementia

• Hospitalization alone results in poor outcomes for patients with Alzheimer’s, but hospitalization and delirium results in an even greater risk (Fong, 2012)

“We have to prevent hospitalizations and delirium in patients with Alzheimer’s disease and prepare families for the risks of complications” Apostolova, UCLA, June, 2012

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Home Alone: Family Caregivers Providing Complex Chronic Care 2012• 46% of 1677 family caregivers in a recent United

Hospital Fund survey say they have no choice but to perform a range of medical and nursing tasks, once only performed in hospitals or nursing homes, for family members with multiple chronic physical and cognitive conditions.

• Two-thirds had no home visit by a health care professional after hospital

• Unprepared, scared, stressed and depressed

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Prevention of Delirium in Hospitalized Patients with Dementia

• Constant presence of familiar transitional person• Reassuring communication: Identity props,

reminders, something to do, sensory aids• Eliminate wandering triggers – suitcase, coat, EXIT• Adjust noise, temperature, view, TV risks• Limit tethering, hide or use decoy• Label and unclutter hospital room• Increase mobility• Nutrition and hydration

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Talking with the Hospitalized Delirious Dementia Patient

• Limit background noise and stay visible• One step directions and two choice questions• I will help you – pause – proceed • Use gestures but don’t patronize• Don’t guess if you’re not sure – listen for key

ideas and assess non-verbal cues• Label and validate emotions, not facts• Assess and anticipate unmet needs

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Prevention: Talking to Families

• Teach family how to distinguish acute change vs. good days/bad days variability

• Re-establish preferred routines, soothers – favorite robe, pillow, newspaper, snack, iPad,

• Suggest they not ask pt. “who, what, where, when, why?” questions or extract promises.

• Help pt. start, sequence, organize tasks• Affirm disorientation if re-orient doesn’t work

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Prevention: Talking to Families

• Attention to pain and palliative care• Soothing props, cues, touch – Seskovitch, The

Anxiety Whisperer• Discuss risks/benefits/effectiveness/costs of

diagnostics and treatments• What scares you the most about taking him

home?• Hospitalization is a choice - next time

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Resources for Teams• Try this: Communication Difficulties: Assessment and

Interventions in Hospitalized Older Adults with Dementia (2013) 2pp. Consultgerirn.org/uploads/File/trythis/try_this_d7.pdf

• Try this: Assessing and Managing Delirium in Older Adults with Dementia (2013) 2pp. Consultgerirn.org/uploads/File/trythis/try_this_d8.pdf

• Try This: Working with Families of Hospitalized Older Adults with Dementia (2007) 2pp. Consultgerirn.org/uploads/File/trythis/try_this_d10.pdf

• Gitlin LN, Kales HC and Lyketsos, CG (2012) Nonpharmacologic Management of Behavioral Symptoms in Dementia. JAMA Care of the Aging Patient: From Evidence to Action.

• Flaherty JH & Milta MO, (2011) Matching the Environment to Patients with Delirium. JAGS

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Resources for Families• Hospitalization Happens (2009)

nia.nih.gov/sites/default/files/hospitalization_happens.pdf

• REASSURE for DELIRIUM (Poer, 2011)• Delirium: Unique to Older Adults (2012)

Healthinaging.org• Next Step in Care Family Caregiver Guide (2012):

Emergency Room (ER) Visits: A Family Caregiver’s Guide from the United Hospital Fund. nextstepincare.org

Duke GEC Lisa P. Gwyther, MSW, LCSW Duke Family Support Program Duke Center for Aging Delirium...

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