POSTOPERATIVE DELIRIUM Geriatrics for Surgeons Teaching Conference

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

Slide 6

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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0

20

40

60

80

100

50 60 70 80 90 100

Age, years


Dementia

Slide 8


0

20

40

60

80

100

50 60 70 80 90 100

Dementia

Delirium

Age, years


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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 15

Risk factors:Age >65DementiaFunctional impairmentComorbiditiesLow albumin

Slide 16


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

Risk Factors:Age >65DementiaFunctional ImpairmentCo-MorbiditiesLow Albumin

Operation

Assess sedationCAM-ICU evaluationMotor Subtypes:- Hypoactive- Hyperactive- Mixed

Slide 21



POST-OPDELIRIUM

Operation

Slide 22

Evaluation for an organic cause:



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 25

Evaluation for an organic cause: Electrolyte imbalanceHypoglycemiaHypoxemiaSepsisSubstance withdrawalReview medications



POST-OPDELIRIUM

Operation

Slide 26

Organic cause:Treat appropriately




POST-OPDELIRIUM

Operation

Slide 27

Multi-component treatment plan





POST-OPDELIRIUM

Operation

Pharmacologic treatment:

Slide 28

Supportive measures:

Slide 28






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


Slide 32

Supportive measures:ReorientationSleep enhancementVision/hearing protocolRemove Foley Medication choices

Slide 32






POST-OPDELIRIUM

Operation


Screen high-risk patients in preoperative clinic

Slide 33


Slide 33






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


• 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


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

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POST-OPDELIRIUM

Operation

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POSTOPERATIVE DELIRIUM Geriatrics for Surgeons Teaching Conference

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