1. Delirium Literature Update 10/2011 N.J. O’Dorisio

2. Clinical case  Mrs. Johnson is 76 yo female with diabetes, heart failure and urosepsis.  Her exam reveals HR 96, BP 100/62, rr 20 and 94% on 2l nc  Labs-include wbc 14000, UA-+LE, + bacteria, +nitrites  You admit her to the step down unit

3. Clinical case  Hosp day # 2 your partner is called at 0100 to evaluate Mrs. Johnson  She is pulling at her IV, pulls off her telemetry leads and is talking about her deceased husband  You evaluate her that morning and she is oriented to name and answers questions  Is this Delirium?

4. What do you do?  A. Formal testing?  B. Psychiatry consult?  C. Family History/input?  D. “I know it when I see it”?

5. Review of Literature  Wong, C.L, Holroyd-Leduc, J. Does this Patient have Delirium. JAMA 2011; 304 (779-786)  O’Mahony, R, Murthy, L, et.al. Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of delirium. Annals of Internal Medicine 2011; 154 (746-752)  Witlox, J, Eurlings, L, et al. Delirium in Elderly Patients and the Risk of Postdischarge Martality, Institutionalization, and Dementia. JAMA 2010. 304; (443-451)  Wald, H, Galsheen, J, et al. Evaluation of a Hospitalist-Run Acute Care for the Elderly Service. Journal of Hospital Medicine 2011. 6; (313-321)

6. Is this Delirium  Wong, C.L, Holroyd-Leduc, J. Does this Patient have Delirium. JAMA 2011; 304 (779-786)  What is the appropriate test?

7. Background  Delirium is often mistaken for dementia, mental illness, withdrawl  There is no pathognemonic sign or lab to indicate the onset  Delirium adds to the M/M and cost of a Hospital stay

8. Clinical scenario  Diagnosed by sudden onset (v. dementia)  Careful observation  Inattention  Altered consciousness  Sleep disturbance

9. Who to test?  Age greater than 65  Oncology/Palliative care unit  ICU  Multiple co-morbidities  Surgical intervention

10. How to test?  Multiple different bedside tests  MMSE  Global Attentiveness Rating (GAR)  Memorial Delirium Assesment Scale (MDAS)  Clinical assesment of Confusion (CAC)  Delirium Observation Screening Scale (DOSS)  Based on DSM-IV criterion

11. Which is best?  CAM has been widely adopted translated in 10 languages requires training and 5 min  GAR Based on 2 min of conversation Based on analog scale

12. CAM

13. GAR

14. Clinical scenerio  Mrs. Johnson improves  She’s on cipro for sens E.coli  PT/OT are on board  No further Hospitlization needed  Is widowed, lives alone and dghtr lives “down the road”  What should we do and can we do?

15. Now what? How do you d/c?  A. D/C to home and ask her to call the PCP?  B. Social work consult for placement?  C. Arrange home health and nursing?  D. Schedule appt for PCP within 1 week?  E. Combination of discharge strategies?

16. What happens?  Witlox, J, Eurlings, L, et al. Delirium in Elderly Patients and the Risk of Postdischarge Martality, Institutionalization, and Dementia. JAMA 2010. 304; (443-451)  Assoc. with prolonged hosp. stay  Poor-outcomes  Increased cost  Mortality

17. Delirium sequelae  Pts. (esp. older) have high rates of post discharge complications  May lead to long term cognitive deficit  Higher rate of institutionalzation  Harbinger of dementia?

18. What to do?  O’Mahony, R, Murthy, L, et.al. Synopsis of the National Institute for Health and Clinical Excellence Guideline for Prevention of delirium. Annals of Internal Medicine 2011; 154 (746-752)  Get ‘em mobile (PT/OT)  Treat pain (trade off)  Reconcile meds  Max. nutrition

19. What to do?  Coordinated care team-min. hand offs  Screen at admission  Max. circadian rhythm/familiarity  Assure hydration  Fix hypoxia  Don’t forget infection!

20. Question # 1  What do you do?  A. Formal testing?  B. Psychiatry consult?  C. Family History/input?  D. “I know it when I see it”?

21. Question # 2  How do you discharge Mrs. Johnson?  A. D/C to home and ask her to call the PCP?  B. Social work consult for placement?  C. Arrange home health and nursing?  D. Schedule appt for PCP within 1 week?  E. Combination of discharge strategies?

22. Take home points  Delirium is a clinical diagnosis  Multifactorial-but predisposing factors  Has patient centered and health system costs  Is important to identify and treat  Don’t forget longitudinal care