Delirium Teaching Rounds: My place…. Or Yours Delirium Teaching Rounds: My place…. Or Yours? Eleanor McConnell, PhD, RN, GCNS-BC & Mitchell Heflin, MD December 9, 2011

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

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 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

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.

Framework for Risk Baseline Vulnerability Precipitating Stimulus High Low High Mild/None Noxious Delirium! Delirium! EM Drawn from Brenda Puns’ slides

Objectives Discuss challenges in evaluation and management after the recognition of delirium, including: Challenges in communication among providers, caregivers & patients Challenges in communication across sites of care Opportunities for improvement in communication across settings and key actors JM Let me briefly outline the talk by way of objectives.

Meet Mr. Crevasse 82 year old retired, divorced veteran from Garner, NC brought to the VA Emergency Department by his daughters for evaluation of aggression. 4 days ago he was discharged from a community hospital for similar behavioral problems. Discharge diagnoses: Urinary retention with acute renal failure, indwelling catheter placement Cerbrovascular disease: Head CT-MRI consistent with prior infarct Disposition: Home with family & hospice support – indwelling catheter remains Placed on Depakote & Zyprexa for behavior EM Ask students to describe what they see Ask students to “name” what they see Ask students to guess how often this occurs Ask students to describe their role as nurses in preventing or caring for patients like this.

Past Medical History Problem List Medications Transient Ischemic Attack Pravastatin 20 mg. @ HS Diabetes Mellitus Lisinopril 5 mg. daily Hypertension Amlodipine 5 mg. daily Mild Cognitive Impairment Vit D & Calcium h/o of Traumatic Brain Injury (Remote) Zyprexa h/o Head and Neck Cancer Depakote Recently relocated to NC d/t family concerns about managing at home alone

You are the emergency room staff assigned to his care…. Consider the following questions: Could this patient have delirium? What predisposing/precipitating factors are important to consider in this case? What is the role of standardized cognitive assessment in helping to clarify the diagnosis or treatment approach? What additional assessment would you recommend? Where is that assessment best conducted?

Assessment: Part 1 1 Triage RN 1300 hrs Time/ Event Key Information 1 Triage RN 1300 hrs VS: BP 169/68, p = 65/reg, T = 97.5, SpO2 = 99%, Pain = 0 NAD, calm, cooperative initially but became increasingly aggressive verbally, insisting upon going home, threatening physical violence. Oriented to name only 2 ED Care RN Rec’d rpt from triage RN, accompanied by family, trying to get out of room Restless, follows commands when instructed to sit down, keeps refusing blood work. Notes episode of pt. locking self in BR while with social worker 3 1430 hrs MOD Imp: Dementia, urine retention s/p Foley placement, Ongoing combative behavior that cannot be managed by family. Plan: 1. CBC/Chem 7; no other localizing s/s to pursue 2. Request assistance of Psychiatric Emergency Team for management, possible admission for placement

Assessment Part 2 4 PEC SW Assess. Time/ Event Key Information 4 PEC SW Assess. CC: “I have no communicable diseases – why won’t they let me go?” PPH: No h/o inpatient or outpatient treatment MSE: Clean, appropriately dressed; Speech: volume low, mumbles; Mood: Anxious, paranoid, laughs inappropriately, AH/VH: Denies, but warned SW to be careful as we crossed bridge to golf course Imp: Axis I: Delirium & cognitive problems – further psychiatric screen 5 POD Assess. MMSE: 21/30, Further MSE & behavioral description Assessment: AMS -- recent hosp. & rpt. of elev. WBC suggest medical illness as etiology. Presentation c/w delirium in addition to underlying dementia. Significantly impaired cognition & capacity – specifically to refuse blood work or evaluation for medical illnesses Recs: 1) Ongoing medical evaluation for AMS 2) Admit to either medicine or psychiatry (if medically cleared). 6 RN transfer Ward noted & Receiving RN report given & references triage note Templated info: IVs, MRSA swab & Pt. education High risk/Falls status communicated to receiving RN

Use to include in text case material Time/ Event Key Information 7 Admitting MD 5AM the next day Unable to obtain history, family gone, copied from ED note PE – unremarkable except for disorientation, Labs: WBC = 12.6; Glu = 160, BUN = 10, Cr = 1.1; Urine: + leukocyte esterase, - nitrite, 1+ bacteria Imp: Behavioral changes more c/w dementia. Pt. refused admission to psychiatry with concerns this is delirium with underlying medical cause. However, patient does not appear to have waxing/waning mental status with marked inattention which would be expected in delirium.

Summary Delirium recognition can be challenging in ED because of limited time with patient Even when delirium recognized – challenges can emerge with respect to decision-making about follow-up evaluation and management Multiple team members should be involved to optimize management of precipitating factors and patient safety