Duke GEC DELIRIUM What’s in a name? Duke Geriatric Education Center

Duke GEC Objectives Compare diagnostic terminology in a case Deliberate the clinical importance of the choice of a term Review core concepts of delirium

Duke GEC Group exercise

Duke GEC Diagnosis Cheung, Intensive Care Med, 2008.

Duke GEC Cheung, Intensive Care Med, 2008.

Duke GEC Cheung, Intensive Care Med, 2008.

Duke GEC What makes a diagnosis a diagnosis? Identifiable and distinct clinical features Defined risk factors Discernible causes Underlying pathophysiology ? Distinct/unique management strategy

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

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 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

Duke GEC Psychosocial Assess substance use Address stress and distress Educate patient and family Assess decision making Consider function and safety Pharmaceutical Reduce/avoid certain meds - Benadryl, Benzo’s Monitor for S.E.’s of pain meds Low dose neuroleptic Benzo’s for withdrawal Physiologic O2 and BP Food and fluids Sleep/wake cycle Activity and mobility Bowel and bladder Pain Infections Environmental Reorientation Continuity in care Family or sitters Hearing aids, glasses QUIET at night No restraints

Duke GEC Advantages to calling it “delirium”? Improve awareness and recognition Improve communication – Team – Family – Patient Standardize treatment protocols

Duke GEC Mnemonic challenge Create a mnemonic for risk factors and/or management using D-E-L-I-R-I-U-M Judging criteria: – Creativity – Memorizability – Represents perspective of different professions