DELIRIUM AS A PROGNOSTIC INDICATOR TERESA CARO CLINICAL PROBLEM SOLVING I

DELIRIUM Symptoms By Mayo Clinic Staff  “Delirium is a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking. The onset of delirium is usually sudden, often within hours or a few days.  Delirium can often be traced to one or more contributing factors, such as a severe or chronic medical illness, medication, infection, surgery, or drug or alcohol abuse.

DEMOGRAPHICS OF PATIENT X 51 yo Caucasian male obese Speaks English No occupation No hx tobacco or alcohol abuse reported Lived with girlfriend in an apartment on first story with no stairs Pt used a walker or a cane due to partial blindness (from DM retinopathy) before admission No assistance available upon discharge, gf no longer able to care for patient x

PATIENT HISTORY Comorbidities DM with retinopathy HLDHTNPVDGERDDepression

DIAGNOSIS March 3/29: Pt admitted to Hospital with PNA April 4/6: Pt developed UTI & AMS May 5/1: PT evaluation June ?

EXAMINATION ExamInitial Findings MobilityPt rolled L & R with Max A PROMPt was WFL Static SittingPt sitting with Max A

EVALUATION CognitionPt had cognitive deficits, & showed no evidence of learning after initial evaluation, followed 40% of 1-step commands, constant verbal cueing for safety Functional LimitationsLack of independent mobility, lack of ambulation, lack of independent ADL performance Participation RestrictionsPt unable to return home to PLOF Predicted Discharge Skilled Nursing Facility

PROGNOSIS Postive Prognostic FactorsNegative Prognostic Factors Pt demonstrated progress and motivation throughout therapy session Pt AMS Major deconditioning Several co-morbidities Original prognosis: Expected pt to make progress with acute PT, but limited due to AMS

TREATMENT GOALS 1. Pt supine to sit with moderate assist 2. Pt sit to stand with max assist 3. Pt bed to chair with max assist 4. Pt sit unsupported, static with moderate assist for 5 minutes

PLAN OF CARE  Mobility training  Gait training  Balance activities  Endurance activities

OUTCOMES  Pt progressed from dependent mobility to mobility with CGA or minA  Pt progressed from no ambulation to ambulating 52ft, RW, minA and 1 seated rest break  Pt goals were achieved and surpassed before pt was transferred to inpatient rehab

IS DELIRIUM PREDICTIVE OF A PATIENT’S ABILITY TO RETURN TO PRIOR LEVEL OF FUNCTION?

OBJECTIVE  To compare the 6 and 12 month outcomes of patients who recovered from delirium by 8 weeks with those who did not have an index episode. The outcomes measured were:  Cognition  Basic & instrumental ADLs  Institutionalization  Mortality

METHODS - CHOOSING SUBJECTS - Pts aged 65 yo and older from the ED St. Mary’s Hospital in Montreal Inclusion & Exclusion Study Nurse (SN) screened all pts with Short Portable Mental Status Questionnaire ( SPMSQ ) and examined nursing notes SN administered Confusion Assessment Method ( CAM ) [Sen: 89%, Spec: 100%] to pts who scored 3 or higher on SPMSQ or pts whose nursing notes indicated delirium

METHODS - PROCEDURE -  Pts assessed at enrollment, 2, 6 and 12 months by research assistant (RA)  RA completed the following  Clinical Severity of Illness measure  Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)  Charlson Co-morbidity Index  Delirium Index (DI)  based on DSM-III-R  Mini-Mental State Examination (MMSE)  Barthel Index (BI)  Pre-morbid OARS Instrumental Activities of Daily Living

RESULTS

DISCUSSION No significant differences between no delirium and delirium- recovered groups after adjustments (for age, sex, clinical severity of illness, Charlson score and dementia status) No significant difference between groups institutionalization at 6 mo No significant difference between groups in MMSE, BI and IADL scores at 6 and 12 mo (after adjusted for Charlson, IQCODE, illness severity) No significant difference between groups death rates at 6 and 12 mo, however could be clinically significant However, there were trends for worse outcomes in delirium-recovered group

STRENGTHS & WEAKNESSES Strengths:  large sample size  Pts assessed several points in time  Interrater reliability  Multivariate analysis adjusted for potential confounders Weaknesses:  92 pts lost to death or withdrawal  Used DI to determine recovery (maybe pt misclassified as recovered, due to fluctuating nature of delirium  2 groups different from each other demographically  Delirium-recovered group had only mild/moderate delirium  Diagnoses of delirium is subjective

OBJECTIVE To compare morbidity and mortality between patients who experienced transient-delirium, prolonged- delirium and patients who did not experience delirium after hip surgery

METHODS Pts aged 65 yo and older who underwent hip fracture surgery from at tertiary referral center Inclusion & exclusion All pts underwent a global clinical and geriatric evaluation Used Confusion Assessment Method (CAM) to evaluate the duration of delirium Used Mini-Mental State Examination (MMSE) and the CAM diagnostic algorithm to determine preoperative dementia (in first 24 hours of admission) Pts categorized into 3 groups: no delirium, transient delirium or prolonged delirium

METHODS Pt followed up with at 1, 3, 6 and 12 months (& every 6 months thereafter) At F/U: MMSE CAM Pts interviewed using a questionnaire that addressed activity level I: normal II: essentially independent outdoors but requiring help with some activities III: independent indoors but always requiring help outdoors IV: not independent indoors but able to transfer and walk independently V: confined to bed or chair and not ambulatory

RESULTS

DISCUSSION No significant differences between no-delirium and transient-delirium groups Prolonged-delirium related to poor functional outcome and increased mortality

STRENGTHS & WEAKNESSES Strengths: Used psychiatric experts to interpret interviews & exams Able to test baseline function in pts pre-hip surgery Weaknesses Used a questionnaire as an outcome measure Wide range of time between F/Us Some pts followed until death Hip surgery strongly correlated to poorer outcomes Phone interviews could have led to misinterpretation In comparison to Patient X: older population, delirium of surgical origin

CONCLUSIONS- IS DELIRIUM A GOOD PROGNOSTIC INDICATOR? Maybe not? Based off 1 st study, if delirium is recovered in < 8 weeks, no significant difference in outcomes Based off 2 nd study, if delirium is recovered in < 4 weeks, no significant difference in outcomes

RELATING BACK TO PATIENT X Maybe delirium should not have been as heavily-weighted in d/c decisions Despite co-morbidities, deconditioning and AMS, Patient X demonstrated much progress toward returning to PLOF

REFERENCES  conditions/delirium/basics/symptoms/CON conditions/delirium/basics/symptoms/CON   20Index%20July%2027_% pdf 20Index%20July%2027_% pdf  df df   Cole MG, You Y, McCusker J, Ciampi A, Belzile E. The 6 and 12 month Outcomes of Older Medical Inpatients. Int J Geriatr Psychiatry. 2008; 23:  Lee K, Ha Y, Lee Y, Kang H, Koo K. Frequency, Risk Factors, and Prognosis of Prolonged Delirium in Elderly Patients. Clinical Orthopaedics and Related Research. 2011; 469: