1. Week 1 Module A: Instructions  Please view video 1 and review charts prior to starting this module.  When you see this slide, put the mouse pointer over it and right click.  In the menu of options, click "full screen."  This opens the presentation. To advance the slides, either use the mouse or the arrow keys on the keyboard.

2. Week 1 Module A: Instructions  For each question, please choose one answer that best addresses the question and then hit “click here.”  For those slides where there are "click here" instructions, please do so or else you might skip over slides.

3. Week 1 Module A: Question 1  What is the ICD-9 diagnosis of Mrs. Rivera’s cognitive state?  A. Acute mental status change click hereclick here  B. Subacute befuddlement click hereclick here  C. Δ MS click hereclick here  D. Delirium click hereclick here

4. Why should we care about delirium in the elderly?

5. Incidence Among Elderly Patients is HIGH  1/3 of patients presenting to ER  1/3 of inpatients aged 70+ on general med units  Occurs in 10-15% after elective noncardiac surgery  May exceed 50% after emergent hip fracture repair

6. Delirium: Increased Mortality  Delirium is an independent predictor of higher mortality up to 1 year after occurrence:  Hazard ratio = 2-3 (people with delirium compared to people without it) – Even after adjustment for covariates such as age, illness severity, comorbid conditions, dementia, use of sedatives or analgesic meds – ( McCusker J et al. Arch Intern Med. 2002; 162:457-463; Ely EW et al. JAMA. 2004; 291:1753-62)

7. Delirium: Increased Risk of…  Functional decline  New nursing home placement  Persistent cognitive decline: – Only 18-22% of hospitalized elders had complete resolution of delirium 6-12 mo after discharge – However: Many subjects in these studies had preexisting cognitive impairment – (Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704)

8. Week 1 Module A: Question 2  What features of Mrs. Rivera’s presentation are more consistent with delirium than with dementia?  A. Disorientation to place click hereclick here  B. Acute change in mental status click hereclick here  C. Inattention click hereclick here  D. Lethargy click hereclick here

9. How to Distinguish Delirium from Dementia  Features seen in both: – Disorientation – Memory impairment – Paranoia – Hallucinations – Emotional lability – Sleep-wake cycle reversal  Key features of delirium: – Acute onset – Impaired attention – Altered level of consciousness

10. Assume it is Delirium until Proven Otherwise!!! Delirium may be the only manifestation of life-threatening illness in the elderly patient

11. There is a simple and quick way to diagnosis delirium…

12. CONFUSION ASSESSMENT METHOD Inouye et al Ann of Intern Med 1990; 113: 941-948  (1) Acute change in mental status with a fluctuating course, with  (2) Inattention AND  (3) Disorganized thinking OR  (4) Altered level of consciousness Inouye et al Ann Intern Med 1990; 113 (12): 941-948 Sensitivity: 94-100%, Specificity: 90-95%

13. Week 1 Module A: Question 3  Factors that may be contributing to Mrs. Rivera’s delirium include:  A. Underlying cognitive impairment click hereclick here  B. Over-the counter medications click hereclick here  C. Pleuritic chest pain click hereclick here  D. Hypoxia click hereclick here  E. All of the above click hereclick here

14. A Model of Delirium A multifactorial syndrome that arises from an interrelationship between:  Predisposing factors  a patient’s underlying vulnerability AND  Precipitating factors  noxious insults Delirium arises when noxious insults act in combination with a patient’s predisposing factors.

15. Predisposing Factors i.e. baseline underlying vulnerability  Baseline cognitive impairment – Dementia patients have a 2.5-fold increased risk of delirium – 25-31% of delirious patients have underlying dementia  Medical comorbidities: – Any medical illness  Visual impairment  Hearing impairment  Functional impairment  Advanced age  History of ETOH abuse  Male gender

16. “A Predictive Model for Delirium in Hospitalized Patients based on Admission Characteristics” Inouye SK et al Ann Intern Med 1993; 119: 474-481  Two prospective cohort studies done in tandem  Age 70 and over  Patients without delirium on admission  Question: what characteristics were most strongly associated with occurrence of delirium?

17. Independent Predisposing Risk Factors Inouye et al Ann Intern Med 1993;119:474-481

18. “A Predictive Model for Delirium in Hospitalized Patients based on Admission Characteristics”: Performance of the Predictive Model Inouye et al Ann Intern Med 1993;119:474-481 Risk group# of Risk Factors (see preceding slide for factors) Development Cohort % delirium Validation Cohort % delirium Low09%3% Intermediate 1-223%16% High3-483%32% P<0.0001P<0.002

19. The more predisposing risk factors present…  The more likely delirium becomes.  Perhaps you can target elderly patients at the start of their hospitalization for interventions that would decrease their risk of developing delirium…  More to follow later

20. Precipitating Factors i.e. noxious insults  Medications  Bedrest  Indwelling bladder catheters  Physical restraints  Iatrogenic events  Uncontrolled pain  Fluid/electrolyte abnormalities  Infections  Medical illnesses  Urinary retention and fecal impaction  ETOH/drug withdrawal  Environmental influences

21. Some drug classes that are associated with delirium  Medications with psychoactive effects: – 3.9-fold increased risk of delirium – 2 or more meds: 4.5-fold  Sedative-hypnotics: 3.0 to 11.7-fold  Narcotics: 2.5 to 2.7-fold  Anticholinergic meds: 4.5 to 11.7-fold  Risk of delirium increases as number of meds prescribed increases

22. Always ask about over-the- counter medications  Remember: many OTC sinus and cold preparations contain antihistamines with anticholinergic activity.

23. References and Resources  Inouye SK. Delirium in hospitalized older patients. Clinics in Geriatric Medicine 14(4):745-64, 1998.  Ely EW. et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 291(14): 1753-62, 2004.  Levkoff SE et al. Delirium: The Occurrence and Persistence of Symptoms among Elderly Hospitalized Patients. Arch Intern Med. 152:334-340, 1992.  Inouye SK et al. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Based on Admission Characteristics. Ann Intern Med. 119:474-481, 1993.  Inouye SK et al. Clarifying Confusion: The Confusion Assessment Method: A New Method for Detection of Delirium. Ann Intern Med. 113: 941-948, 1990.  Inouye SK et al. Delirium in Older Persons. NEJM. 354:1157-1165, 2006.  McCusker J. Cole M. Abrahamowicz M. et al. Delirium predicts 12-month mortality. Arch Intern Med. 162(4): 457-63, 2002 Feb 25.  McCusker J. Cole M. Dendukuri N. et al. The course of delirium in older medical inpatients: a prospective study. J Gen Intern Med. 18: 696-704, 2003.  Delirium. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Teaching Slides. Volume 1, Fifth Edition. Blackwell Publishing, copyright American Geriatrics Society, 2003  Click here to end Click here to end

24. This is Delirium  While the terms acute mental status change, subacute befuddlement and Δ MS have all been used in the medical literature to describe this condition, you cannot bill for these entities.  Delirium has a few ICD-9 codes.  ICD-9 code for delirium= 780.09  ICD-9 code for acute delirium= 293.0  Click here for next slide Click here for next slide

25. Correct: This is Delirium  Mrs. Rivera has delirium. This is a billable diagnosis, whereas the other choices do not have actual ICD-9 codes.  ICD-9 code for delirium= 780.09  ICD-9 code for acute delirium= 293.0  Click here for the next slide Click here for the next slide

26. Delirium and dementia share common features  It is very difficult to distinguish delirium from dementia in patients that you are evaluating for the first time.  There are symptoms that are common to both conditions.  For example, disorientation to place can occur in both dementia and delirium.  click here for the correct answer click here for the correct answer

27. Correct answer. Delirium differs from dementia in the following key ways:  Time course: whereas dementia usually progresses over time, delirium occurs acutely  Inattention: demented patients have intact attention span  Altered level of consciousness: demented patients are generally alert  click here for the next slide click here for the next slide

28. Correct answer.  There are likely many factors contributing to Mrs. Rivera’s delirium. Her acute illness, with its concomitant fever, hypoxia, tachycardia, pleuritic chest pain, is likely playing a large role.  She may have taken over-the-counter cold preparations that contain antihistamines with anticholinergic side effects.  She also has a few predisposing factors for developing delirium: cognitive impairment (MMSE 22/30), visual impairment (cataracts).  click here for the next slide click here for the next slide

29. Usually, there is more than one factor contributing to delirium  In elderly patients, look for more than one etiology of delirium.  While Mrs. Rivera’s cognitive impairment, pleuritic chest pain, OTC medication use, and hypoxia are all possible etiologies, it is unlikely that just one of these factors is the sole source of her delirium.  click here for the correct answer click here for the correct answer

30. End of Week 1 Module A