Duke GEC Delirium Teaching Rounds: Insult to Injury October 7, 2011

Duke GEC Objectives Identify risk factors and key presenting features of delirium Appreciate the role of different professions in recognition and management Find opportunities to improve communication about delirium

Duke GEC 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.

Duke GEC Costs of Delirium In-hospital complications 1,3 – 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

Duke GEC Clinical Features of Delirium Acute or subacute onset Fluctuating intensity of symptoms Inattention Disorganized thinking Altered level of consciousness – Hypoactive v. Hyperactive Sleep disturbance Emotional and behavioral problems

Duke GEC Insult to Injury Mrs. F is a 78 year old resident of Durham admitted after a fall in her home….. Gather with others in your profession Read the case and discuss the questions Designate a spokesperson Have fun!

Duke GEC Improving The Odds of Recognition Prediction by risk – Predisposing and precipitating factors Team observations – Nursing notes Clinical examination – CAM

Duke GEC Common Risk Factors for Delirium 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 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.

Duke GEC Rudolph J et al, 2011

Duke GEC Rudolph J et al, 2011

Duke GEC Team 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

Duke GEC 1 month before admPCP NoteEpisode of confusion following her knee surgery. She does not feel confused presently. Presents to ED20:20EDVerbally converses and oriented 5 Day Admitted01:25Adm Data She can’t tell me how many stairs she fell down. She is a little disoriented…reports ~2 beers per day which puts her at risk for withdrawal...monitor closely for signs/symptoms of withdrawal. Day Admitted03:05PRM10:40 AM BSN Findings: Independent prior to admission: Newly dependent Hospital Day 103:10NursingPatient is very drowsy. Hospital Day 110:14OTCognition: Alert, changed to lethargic once medication had taken affect. Hospital Day 111:40PTCognition: Impaired…Oriented to self, place, time, situation, with significant prompting. Hospital Day 117:25Post Anesthesia Reports mild post-operative confusion, but per husband significantly better anesthesia recovery than the previous surgery 1 year prior. Hospital Day 118:55NursingPt a/o x 3, unaware of correct date/time…pulling at soft cast on left hand but reorients well. Hospital Day 122:22Nursing Pt is alert and orientedx4, with mild anxiety present…pulling wrap to arm…told numerous times to leave it alone…order for a hand mitt restraint…is aware if tugging again will be restrained. Hospital Day 203:03Nursing alert and orientedx2-3, with mild anxiety and occasional hallucinations… pulled out foley catheter...pulled at cast… Bilat hand mitts and wrist restraints were applied. Hospital Day 214:04NursingPt. AOx1-2, very agitated and restless at times... Pt. resting quietly at this time. Family at bedside. Hospital Day 415:00PTThe patient reports "Take this off of me (referring to restraints and mits) so I can run an errand." Hospital Day 418:52NursingPt s/p right radial fracture, right hip fracture, now with delirium r/t possible alcohol w/d. Hospital Day 505:08NursingHas been agitated…Sitter at bedside. Restraints. Pt not agitated at the time the BP taken. Hospital Day 518:32NursingA&ox4 today with some stm deficits noted. Hospital Day 515:01NursingPATIENT CAN BE IMPULSIVE AT TIMES…EMOTINOAL SUPPORT GIVEN

Duke GEC Substance Abuse and Older Adults Alcohol can trigger/exacerbate serious problems including: High blood pressure, arrhythmias and heart attacks Stroke Impaired immunity Cirrhosis / liver diseases Osteoporosis GI bleeding Depression, anxiety, and other mental health problems Malnutrition Sleep disturbances Alcohol is the major substance abuse/misuse problem among older adults. Approx. 2.5 million older adults in the US have alcohol related problems. Physiological changes affecting alcohol metabolism with aging: – Decrease in body water – Increased sensitivity/ decreased tolerance – Decrease in the metabolism in GI tract

Duke GEC Substance Abuse and Older Adults Early Onset – “hardy survivor” Majority are early onset drinkers – Drink for the same reasons younger people do - to cope with psychosocial or medical problems Comorbidities include depression, bipolar disease, and thought disorders More health problems Continue established drinking patterns as age Late Onset 1/3 of older adults with drinking problems Psychologically and physically healthier – too “normal," to raise suspicions More likely to have increased drinking due to recent losses: death of a spouse divorce, change in health status, life changes Milder and more amenable to treatment than early onset drinking problems sometimes resolves spontaneously. Both appear to use alcohol almost daily; in social settings and at home alone. Both more likely to use alcohol as palliative/self-medicating measure in response to hurts, losses, and affective changes.

Duke GEC

Duke GEC Management Benzodiazepines – Diazepam or lorazepam – Older adults may require lower doses Symptom triggered therapy – Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-A) Supportive therapy – Comorbidities – Hydration and nutrition Team care

Duke GEC Mrs. F History: Delirium with knee replacement in beers a day and 2mg Clonazepam twice daily On presentation: BAL=80 Na=128

Duke GEC Mrs. F Hospital Course and beyond: Pain management Sitters and family Activity Clonazepam Geriatrics consultation

Duke GEC Summary Maintain a high level of suspicion – Screen for alcohol use Document findings in the chart Discuss with other members of the team Inform/educate patients and families

Duke GEC A better way…. Medicine Nursing PT/OT Pharmacy Social work Nutrition PA’s Patients and Caregivers Administrators NP’s

Duke GEC Delirium Teaching Rounds “Itching for a Fight!” November 4, 2011