1. Brain Failure: Prevention, Assessment, and Management of Delirium in Older Hospitalized Individuals Matthew J. Beelen, MD Geriatric Specialists Lancaster General Health June 18, 2013

2. Case  79 year old man, baseline mild cognitive impairment (MCI)  CABG in July 2012  Post-operative delirium  “mild bouts of confusion” post op  “confusion, delusions, and hallucinations”  “impulsive”  To rehab facility  Confusion gradually improved

3. Case, continued  Returned home – since then:  No longer able to manage finances  No longer able to manage medications  Confusing dates and appointments  Failed driving test (wife does not drive)  Unable to continue working part time  Depressed  Wife distressed about his decline, his repeating, his depression

4.  Almost 1/3 of hospitalized elderly will develop delirium

5. Learner Objectives  Articulate the significance of delirium  Recognize and identify delirium promptly as it occurs  Describe approaches to delirium prevention and incorporate these into  Compare approaches to delirium management and incorporate these into practice.

6. What is Delirium?  A disturbance in consciousness that:  Has acute onset (hours to days) and fluctuates over the course of the day  Involves reduced ability to focus, sustain, or shift attention  Involves a change in cognition (memory, orientation, language, etc) or perception (hallucinations)  Is associated with an underlying medical etiology APA; DSM-IV, 1994

7. Inflammatory Model of Delirium Marcantonio ER, JAMA. 2012;308:73-81.

8. Delirium Subtypes  Hyperactive  Agitation  Increased vigilance  Hallucinations  Hypoactive  Somnolent, lethargic, stupor, coma, decreased psychomotor activity  Often unrecognized 75% of cases in the elderly Associated with higher mortality

9. Delirium or Dementia?  Dementia and delirium often coexist  What is the patient’s baseline?

10. Identification: Confusion Assessment Method

11. Confusion Assessment Method (CAM)  86-94% sensitive, 89-93% specific  Validated in over 1000 patients  Used in over 250 original published studies  28 page training manual…  Improved accuracy with formal training  Improved accuracy when using a standard cognitive screen as part of the CAM (Modified Mini-Cog)  Takes about 5 minutes to perform http://hospitalelderlifeprogram.org

12. Modified Mini-Cog Assessment  Orientation  1. Time: Day, Year, day/night, last meal, how long in hospital.  2. Place: City/State, Hospital, Floor  Registration  3. Name 3 objects: (apple, watch, penny) Ask the patient all 3 after you have said them. Repeat until all 3 are learned  Clock-drawing  4. Draw a circle, draw numbers, and place hands at “ten past eleven”  Recall  5. Ask for 3 objects in question 3 http://hospitalelderlifeprogram.org

13. Identification in the ICU: CAM-ICU  Assesses same domains as CAM  Different questions/methods of assessment used  Ideal for non-verbal patients  Incorporates the Richmond Agitation and Sedation Scale (RASS)  To decide if patient can be assessed for delirium  To assess level of consciousness www.icudelirium.org; Ely EW et al, JAMA. 2001;286:2703-2710.

14. CAM-ICU: RASS www.icudelirium.org

15. Identification Using CAM-ICU  93-100% sensitive, 89-100% specific  Validated for ventilated and non-ventilated critically ill patients  28 page training manual…  Takes about 5 minutes to perform  Recommended to be done every shift  Evidence of benefit? www.icudelirium.org; Ely EW et al, JAMA. 2001;286:2703-2710.

16. The Role of CAM and CAM-ICU  Evidence of benefit of screening is lacking  “We cannot manage delirium or decrease its complications unless we recognize it”  Useful as a means to monitor for delirium as part of QI process

17. Delirium is Common Prevalence of Delirium at Various Points of Hospitalization

18. Delirium Has Significant Impacts  For patients while in the hospital  For patients after they leave the hospital  For society  Population management

19. Impact in the Hospital   physical function   nutrition   post-op complications (2-5x risk)   self-extubation or removal of lines   death: 22-76% mortality rate (10-fold risk)   pneumonia   falls   pressure ulcers   exposure to physical and chemical restraints   family distress   burden on nurses and patient care staff Inouye SK. N Engl J Med 2006;354:1157-65 Marcantonio ER. JAMA 2012;308:73-81

20. Impact Post-Hospitalization  3-fold increased risk of institutional placement at discharge  2-fold  risk of 30-day readmission from ECF  Death  3 fold risk of death at 6 months  Every day an ICU patient spends in delirium increases risk of death at 6 months by 10%  1 year mortality rate is 35-40%  Risk of higher mortality persists for up to 2 years Ely EW et al. JAMA 2004;291:1753-1762 Marcantonio ER et al. J Am Geriatri Soc 2005;53:963-969 Inouye SK. N Engl J Med 2006;354:1157-65 Marcantonio ER. JAMA 2012;308:73-81

21. Impact Post-Hospitalization  Worsening cognition in those with pre-existing cognitive impairment  Patients with Alzheimer’s who develop delirium:  Rate of cognitive decline is doubled in the year after delirium compared to those without delirium More rapid rate of decline persists for 5 years Gross AL et al. Arch Int Med 2012;172:1324-1331 Fong TG et al. Ann Int Med 2012;156:848-856 Fong TG et al. Neurology 2009;72:1570-1575

22. Delirium and Cognitive Decline Saczynski JS et al. N Engl J Med 2012;367:30-39

23. Impact Post-hospitalization  New cognitive impairment:  Greater then 10-fold increase risk in new development of dementia over the next 4 years  Cognitive reserve theory Witlox J et al. JAMA 2010;304:443-451.

24. Cognitive Reserve and Delirium delirium

25. Impact on Society  Increased length of stay  2-5 days longer than those without delirium  Increased ICU and ventilator days  Increased costs of care  $60,000 incremental costs over the following year  $6.9 billion annual cost to Medicare to treat delirium  Impact on caregiver burden  Assistance with activities of daily living  Emotional impact Marcantonio ER. JAMA 2012;308:73-81. O’Mahony R et al. Ann Intern Med 2011;154:746-751.

26. Delirium - Cost to Society Monthly Health Care Costs After Discharge from Hospital Leslie DL. Arch Int Med 2008;168:27-32

27. Approach to Delirium Prevention Recognize Risk Reduce Risk

28. Prevention of Delirium  “At least 30-40% of cases may be preventable. Prevention is the most effective strategy for reducing delirium frequency and complications.” (Inouye, 2006)  “We should not wait for delirium to happen but must work to implement proven interventions that prevent delirium” (Ely, 2012)  “Effective strategies that prevent delirium should be a high priority for health care systems.” (O’Mahony, 2011)

29. Risk Factors for Delirium Inouye SK. J Geriatr Psychiatry Neurol 1998;11:118-125.

30. Predisposing Factors  Baseline cognitive impairment***  Vision Impairment  Hearing Impairment  Older age  Low educational level  ADL impairment  From ECF  Depression  Alcohol abuse  Multiple significant chronic conditions  High numbers of home medications  Use of opioids or benzodiazepines prior to admission

31. Predisposing Factors  Dehydration  Bun/Cr > 18  Severe Illness on Admission  Sepsis/SIRS/infection  Acute organ failure  Electrolyte/metabolic  Acute cardiac event  Stroke/seizures  Malnutrition  Surgical patient  Hip fracture  Fracture/trauma  Prior stroke  Parkinson’s  Prior delirium*

32. Predictive Value of Risk Factors  4 predisposing risk factors (low vision, cognitive impairment, dehydration, severe illness) “Primary prevention of delirium should address important delirium risk factors and target patients at intermediate to high risk for delirium at admission.” Inouye SK. J Geriatr Psychiatry Neurol 1998;11:118-125

33. Precipitating Factors Derangements in Normal Functions:  Fluid intake  Bladder emptying  Nutrition intake  Bowel movements  Oxygen intake  CO2 release  Sleep/wake cycle  Mobility New Acute Conditions:  Metabolic  Acid/base  Electrolyte  Glucose  Anemia  Infection/fever  CNS event/condition  Cardiac event/condition  Hypotension/shock

34. Precipitating Factors Extrinsic Factors  Procedures / Surgery  Ventilators / ICU  Tubes, lines, catheters, restraints, devices  Environment change Other Symptoms  Pain  Emotional Distress Medications  >3 added the previous day  “polypharmacy”  Benzodiazepines  Anticholinergics  ETOH or drug withdrawal  Opioids (+/-)

35. Prevention Strategies  Prevention should focus on those at intermediate to high risk  Effective prevention must address the complex array of precipitating risk factors  Limited evidence of benefit for isolated interventions  Prevention requires cooperative interdisciplinary effort

36. Multi-Component Interventions  Methods and specific interventions vary widely Reston JT and Schoelles KM. Ann Intern Med. 2013;158:375-380.

37. Hospital Elder Life Program (HELP)  Age ≥ 70 on a general medicine unit, ≥1 risk factor (impaired cognition, elevated BUN/Cr ratio, vision impairment, severe illness) = medium to high risk  Additional risks assessed in the first 48 hours:  Sleep deprivation: interview and nurse input  Immobility: ADL assessment scale  Hearing impairment: Whisper test  Initial and daily assessment for delirium: CAM Inouye SK et al. N Engl J Med 1999;340:669-676

38. The HELP Team  Elder Life Nurse Specialist – Masters level with geriatric training and experience  Elder Life Specialist/Volunteer Coordinator  Performs screening, develops care plans, oversees and coordinates volunteers, training, data collection  Masters level with experience with human services or healthcare, geriatrics, supervisory experience  Geriatrician  Program Director (may be one of the above)  Volunteers (3-4 hours, 1-2 times per week) Inouye SK et al. N Engl J Med 1999;340:669-676

39. HELP - Intervention  What did the HELP Team do?  Performed initial and ongoing assessments  Administered a set of care protocols for at-risk patients Targeted 6 risk factors for delirium  Provided ongoing staff education  Led interdisciplinary meetings and rounds  Led ongoing CQI process

40. HELP Interventions for 6 Risk Factors Targeted Risk FactorStandardized Intervention Cognitive impairment Orientation & therapeutic activity protocol (discuss current events, word games, reorient, etc) Sleep deprivation Sleep enhancement & nonpharm sleep protocol (noise reduction, back massages, schedule adjustment) Immobility Early mobilization protocol (active ROM, reduce restraint use, ambulation, remove catheters) Visual impairment* Vision protocol (glasses, adaptive equipment, reinforce use) Hearing impairment* Hearing protocol (amplification devices, hearing aids, earwax disimpaction) Dehydration* Dehydration protocol (early recognition of dehydration & volume repletion)

41. HELP Outcomes – Original Study  852 patients  Delirium incidence  9.9% intervention  15% controls  Decrease in total number of days of delirium Inouye SK et al. N Engl J Med 1999;340:669-676

42. Subsequent HELP Outcomes  Disseminated to sites worldwide  Less functional and cognitive decline, falls, and pressure ulcers during hospitalization  Little impact on delirium severity once it occurred*  Cost effectiveness has been demonstrated  Cost savings to hospitals has been demonstrated  Improves geriatric education within the hospital  Volunteer use benefits the community  Implementation support is available Inouye SK et al. J Am Geriatr Soc 2000;48 Rubin FH et al. J Am Geriatr Soc 2011;59:359-365.

43. General Prevention Recommendations  Early risk assessment and develop plan to address risk factors  Plan carried out by competent inter- disciplinary team  Minimize staff and location changes  Orienting interventions  Familiar visitors  Treat pain  Minimize infection risk  Optimize:  hydration and nutrition  bowel/bladder function  oxygenation  activity and mobility  medications  sensory input  sleep O’Mahony R et al. Ann Intern Med 2011;154:746-751.

44. Prevention - Interdisciplinary Team Balas MC et al. Crit Care Nurse 2012;32:35-47 Patient NursesPhysicians Respiratory Therapist Physical Therapist Pharmacist The Health System

45. Barriers to Optimal Prevention  Culture change is needed – proactive vs. reactive  System change is required  To ensure interdisciplinary team coordination  QI processes related to key components of prevention Initial assessment Development of management plan Completion of individual components of plan Monitoring for delirium for early detection and for monitoring effectiveness of program  Institutional support (“buy-in” and resources)

46. Treatment of Delirium

47. Management of Delirium  There is little rigorous evidence of benefit  Non-pharmacologic measures show a trend toward:  Shorter duration of delirium  Decreased severity  Shortened hospital LOS  Medications: as of 2011 there was only one randomized placebo-controlled trial – it showed no difference in outcomes  So what can we do? Flaherty JH. Med Clin N Am 2011;95:555-577.

48. Management – Team Approach  Communicate the diagnosis  To team members  To family  In the medical record: “encephalopathy” - $$ irony  Multi-factorial assessment of precipitating factors  Management plan to address these factors  Sound familiar?  Brain Failure: serious problem, possible emergency  Immediate attention is crucial

49. Review Precipitating Factors Derangements in Normal Functions:  Fluid intake  Bladder emptying  Nutrition intake  Bowel movements  Oxygen intake  CO2 release  Sleep/wake cycle  Mobility Acute Illnesses:  Metabolic  Acid/base  Electrolyte  Glucose  Anemia  Infection/fever  CNS event/condition  Cardiac event/condition  Hypotension/shock

50. Review Precipitating Factors Extrinsic Factors  Procedures / Surgery  Ventilators  Tubes, lines, catheters, restraints, devices  Environment change Other Symptoms  Pain  Emotional Distress Medications  >3 added the previous day  “polypharmacy”  Benzodiazepines  Anticholinergics  ETOH or drug withdrawal  Opioids (+/-)

51. Management – Focus on Safety  Environment  Optimize orientation, comfort, sleep/wake cycle  1:1 supervision or “sitter”  Family or friend presence  Is a room or unit change indicated?  “Don’t neglect the hypoactive”  For severe distress or risk of harm to self or others  Consider medication  Consider restraints – the least necessary

52. Treatment With Medications  Limited, small studies  Only 1 with a blinded placebo comparison group  Underlying dementia either not mentioned or was used as exclusion criteria in most studies  Delirium subtypes were not accounted for  No clear evidence that medications decrease severity or shorten duration  No clear evidence that newer antipsychotics are more favorable than haloperidol  People with delirium get better without medications… Seitz DP et al. J Clin Psychiatry 2007;68:11-21. Campbell N et al. J Gen Intern Med 2009;24:848-853. Flaherty JH et al. J Am Geriatr Soc 2011;59:S269-S276.

53. Treatment with Medications  No FDA approved medications for delirium  Haloperidol  0.25-0.5mg PO Q4 hours PRN  0.5-1.0mg IM q30-60min  IV doses have much shorter duration of action: q60min  Atypical antipsychotics – oral  Risperidone 0.25mg-0.5mg Q12-24 hours  Olanzapine 2.5-5.0mg Q12-24 hours  Quetiapine 12.5-25mg Q12-24 hours

54. Treatment With Medications  Antipsychotics  Can prolong the QT interval (get baseline EKG)  Can cause parkinson-like symptoms at high doses  Can cause worsening or irreversible decline in Parkinson’s or Lewy Body dementia Quetiapine is thought to be best choice for these conditions  If used – start with low end of dose range  Benzodiazapines  2 nd line or last resort (unless alcohol withdrawal)  Can induce, worsen, or prolong delirium

55. Final Case  Nov. 2012: 87-year-old woman admitted to hospital from nursing home with mental status change, tachycardia, tachypnea, fever. Baseline MCI.  3 day hospital stay  E coli UTI  New onset Atrial fibrillation, fluid overload / CHF  NSTEMI  Confused, lethargic, “encephalopathy”  Discharged to nursing home “comfort care, hospice consult, NPO”  Now – back to baseline!

56. Summary  Delirium has significant impacts, especially after discharge  Watch for the hypoactive subtype  We may be able to prevent 1/3 of cases  Prevention is the best treatment  Effective prevention and treatment requires a careful assessment for risk factors and a plan to minimize them – culture and system change  Medications: limited role

57. Questions?