Delirium Teaching Rounds: Recognition For the students here, when you hear the word delirium, what comes to mind? September 2, 2011

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 Delirium most efficiently can be defined as ….. The Diagnostic and Statistical Manual of Mental Health Disorders (4) identifies four features: Like any common, non-specific condition, it goes by a variety of names: As important as understanding what it is, is understanding what it is not—dementia.

So what’s the conundrum? Highly prevalent Associated with much suffering and poor outcomes Complex and often multifactorial Preventable but…. Requires a shift in paradigm So, why the conundrum? Our biggest conundrum has been trying to put together a simple 1 hour session given the amount that’s written about this problem. Its highly prevalent and lethal—or at least associates with morbidity and mortality. Its almost never “clean” in that it is the result of multiple factors that you’ll hear about today—predisposing and precipitating. An important part of our message today is that it is indeed not inevitable—that is, it is preventable. However, the conundrum is that preventing it requires a shift in paradigm—both the way we think and practice here.

Objectives Describe the prevalence of delirium and its impact on the health of older patients Identify risk factors and key presenting features Find opportunities to improve communication about delirium Let me briefly outline the talk by way of objectives.

A BIG Problem Hospitalized patients over 65: ICU: 70-87% ER: 10-30% 10-40% Prevalence 25-60% Incidence ICU: 70-87% ER: 10-30% Post-operative: 15-53% Post-acute care: 60% End-of-life: 83% First, the obligatory numbers: Older adults in the hospital are almost as likely to have or develop delirium as not, and in certain settings, most folks will have it. ICU and surgical care seem to be particularly difficult settings. This will be no surprise once we take a look at the factors that bring it about. It also complicates care in LTC—either as a primary phenomenon or a residual complication of hospitalization. Additionally, there is a growing awareness of how delirium contributes to suffering at the end of life and, as a symptom, deserves attention and palliation. Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009.

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 Patients with delirium have higher rates of in-house complications and up to two-fold higher rates of death. The story doesn’t end there—if you’re lucky enough to survive to discharge, you have a 1 in 3 chance of still being delirious---it doesn’t just disappear. A recent sys review in JAMA by Witlox revealed some startling numbers…2 fold increase in death at just over a year; higher rates of dependence and institutionalization; newer evidence suggesting that delirium may result in some irreversible problems in that those patients are much more likely to go on to develop dementia in the next 4 years. It makes perfect sense, then that delirium would present significant expense to our health care system---accounting for an additional $2500 per hospitalization complicated by delirium and, if accounting for post acute care costs perhaps more than $100 billion a year in the US alone. 1-O’Keeffe 1997; 2-McCusker 2003; 3-Siddiqi 2006; 4-Witlox 2010

The experience… Difficult for everyone: 101 terminally ill cancer patients—54% recalled the experience Distress scale 1 (least severe)  4 (most severe) Patients 3.20 Family member 3.75 Nurses 3.10 So, numbers only tell half the story. Delirium is not some anesthetized experience---patients can be quite aware of it and quite anxious. Families, as well, find it quite distressing. Brietbart 2002.

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! Providers are pretty bad at recognizing what’s right under our noses. Various estimates place our incompetence at recognition at 33-95%. MD’s see about 20%, nurses about 40%. This starts in the ED and studies indicate that patients missed in the ED are either sent home or admitted without the diagnosis. Inouye 1998 ;Bair 1998.

Clinical Features of Delirium Acute or subacute onset Fluctuating intensity of symptoms Inattention – aka “human hard drive crash” Disorganized thinking Altered level of consciousness Hypoactive v. Hyperactive Sleep disturbance Emotional and behavioral problems Let’s spend some time talking, then, about what it looks like. In the definition slide, we acknowledged that its usually an acute or subacute change from baseline. That it changes constantly---sometimes in minutes or seconds. Another hallmark feature is inattentiveness—what Barb Kamholz has referred to as the human harddrive crash. There are a host of other characteristics, including

Clinical Features of Delirium Acute or subacute onset Fluctuating intensity of symptoms Inattention – aka “human hard drive crash” Disorganized thinking Altered level of consciousness Hypoactive v. Hyperactive Sleep disturbance Emotional and behavioral problems Let’s spend some time talking, then, about what it looks like. In the definition slide, we acknowledged that its usually an acute or subacute change from baseline. That it changes constantly---sometimes in minutes or seconds. Another hallmark feature is inattentiveness—what Barb Kamholz has referred to as the human harddrive crash. There are a host of other characteristics, including

In-attention Cognitive state DOES NOT meet environmental demands 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 The cardinal feature of delirium is inattention---its worth talking in a bit more detail about what it means and how to assess it. Most often these patients are unable to attend to task and cannot meet the demands of their environment. The result is an inability to… The clinical picture may be hypo or hyper attentive.

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 Key point: These folks are misdiagnosed and their delirium is missed. Farrell 1995

Mrs. Smith-1 Jot down observations about the patient in the case. In particular, think about how these signs might represent early signs of delirium.

Improving The Odds of Recognition Prediction by risk Predisposing and precipitating factors Team observations Nursing notes Clinical examination CAM MDAS The key to diagnosis is maintaining a high level of suspicion and communicating this effectively to other team members.

Risk Factors Predisposing 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 Prospective cohort study and validation cohort of older inpatients on Gen Med used to created a predictive model. 1-2 characterized as moderate, 3-4 as high risk. We can acknowledge that some of these factors may have been the result of looking at a very specific population and validating it in a similar cohort, however it gives us a solid foundation on which to build. Specifically, if you walk by the door and see someone in restraints and they aren’t diagnosed with delirium, then you better darn well look harder. Inouye 1996

Putting it all together... Precipitating Factors Predisposing Factors So, this table shows us how these predisposing and precipitating levels of risk predict the onset of delirium during hospitalization. Specifically, we see a real, but moderate increase in risk in those with 1-2 risk factors---3-5 fold increase. This is the group in which we have the best chance of preventing delirium. Once we move on to the high risk group with 3-4 risk factors, we find an overwhelming increase in risk. This is the group we can be almost assured will develop problems and you will see we have a harder time preventing or treating delirium. Inouye 1996

Common Risk Factors for Delirium 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 Predisposing • Advanced age • Preexisting dementia • History of stroke • Parkinson disease • Multiple comorbid conditions • Impaired vision • Impaired hearing • Functional impairment • Male sex • History of alcohol abuse Marcantonio, 2011.

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 The key point is we are making the observations and describing the behaviors, but not making the diagnosis. Its kind of like noting cough, fever and infiltrate—but not recognizing pneumonia. Kamholz, AAGP 1999

Confusion Assessment Method (CAM) Acute onset and fluctuating course Inattention Disorganized thinking Altered level of consciousness Or Inouye 1994

CAM Recent systematic review2 Other tools: Sensitivity 86% (74-93) Specificity 93% (87-96) LR + 9.4 (5.8-16) LR – 0.16 (0.09-0.29) Other tools: CAM-ICU Delirium Rating Scale (DRS) 1 Inouye 1996; 2 Wong 2010.

Memorial Delirium Assessment Scale (MDAS) Rates severity of delirium Validated in palliative care 10 item, 4 point clinician-rated scale (0-30) Awareness, orientation, memory, digit span, attention, organization, perception, delusions, psychomotor activity, sleep-wake cycle Cut-off of 13 for diagnosis of delirium Sensitivity 71%, Specificity 94% Is a widely used and validated screening tool developed by W. Breitbart for delirium in cancer patients to measure the severity of delirium, and it reflects all the main diagnostic criteria for delirium according to the DSM IV of the American Psychiatric Association as well as the symptoms of delirium. The MDAS is structured as a ten-item, four-point clinician-rated scale (possible range 0–30) designed to quantify the severity of delirium in medically ill patients. This instrument measures relative impairment in domains itemized as follows: 1, awareness; 2, orientation; 3, short-term memory; 4, digit span; 5, attention capacity; 6, organizational thinking; 7, perceptual disturbance; 8, delusions; 9, psychomotor activity; and 10, sleep–wake cycle. Items are rated on a four-point scale from 0 (none) to 3 (severe) depending on the level of impairment, rendering a maximum possible score of 30. A score of 13 has been recommended as a cut-off for establishing the diagnosis of delirium with a sensitivity of 70.59 % and a specificity of 93.75 %. Reference: Fadul N, Kaur G, Zhang T, Palmer L, Bruera E. Evaluation of the memorial delirium assessment scale (MDAS) for the screening of delirium by means of simulated cases by palliative care health professionals Support Care Cancer 2007;15:1271–1276. Breitbart W, Rosenfeld B, Roth A, Smith MJ, Cohen K, Passik S. The memorial delirium assessment scale. J Pain Symptom Manage 2007;13:128–137. Brietbart 2007.

Mrs. Smith- 2 List the predisposing and precipitating factors that you recognize here. How might you communicate your concern about risk to other team members? Who would need to know and why?

Summary Maintain a high level of suspicious Screen for delirium using a validated tool Document findings in the chart Discuss with other members of the team Inform/educate patients and families

Address stress and distress Educate patient and family Psychosocial Assess substance use Address stress and distress Educate patient and family Assess decision making Consider function and safety Physiologic O2 and BP Food and fluids Sleep/wake cycle Activity and mobility Bowel and bladder Pain Infections Pharmaceutical Reduce/avoid certain meds - Benadryl, Benzo’s Monitor for S.E.’s of pain meds Low dose neuroleptic Benzo’s for withdrawal Environmental Reorientation Continuity in care Family or sitters Hearing aids, glasses QUIET at night No restraints This schematic presents four different domains and the specific issues---of course, geriatricians also love venn diagrams, because most issues cross over to other domains. These are the issues addressed in the Inouye and Marcantonio studies… remind yourselves of these when encountering older adults in the hospital or any setting for that matter—perhaps when seeing someone in clinic who is having surgery! Relist as predisposing and precipitating factors.

Patients and Caregivers A better way…. NP’s Physiologic PA’s Psychosocial Medicine Nursing Environmental Social work Pharmacologic Patients and Caregivers Pharmacy Nutrition I want you to think about how to engage other team members in the recognition and management of delirium across all domains. Nurses will see what’s going on, nutrition will help feed them, PT will get them out of bed and may benefit from someone letting them know that the patient is delirious, pharmacy can review the list and make recommendations, social work can help with instructions and transitions and PA’s, NP’s and MD’s can help with management. Admin--- if we work on facilitating cross talk and practice improvement---order sets, signs, education—then we’ve gotten started. It starts with acknowledging that this is a team effort. Administrators PT/OT

Delirium Teaching Rounds: Insult to Injury Define delirium… October 7, 2011