1. Duke GEC www.interprofessionalgeriatrics.duke.edu DELIRIUM What’s in a name? Duke Geriatric Education Center 5-16-12

2. Duke GEC www.interprofessionalgeriatrics.duke.edu Objectives Compare diagnostic terminology in a case Deliberate the clinical importance of the choice of a term Review core concepts of delirium

3. Duke GEC www.interprofessionalgeriatrics.duke.edu Group exercise

4. Duke GEC www.interprofessionalgeriatrics.duke.edu Diagnosis Cheung, Intensive Care Med, 2008.

5. Duke GEC www.interprofessionalgeriatrics.duke.edu Cheung, Intensive Care Med, 2008.

6. Duke GEC www.interprofessionalgeriatrics.duke.edu Cheung, Intensive Care Med, 2008.

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

8. Duke GEC www.interprofessionalgeriatrics.duke.edu 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

9. Duke GEC www.interprofessionalgeriatrics.duke.edu

10. Duke GEC www.interprofessionalgeriatrics.duke.edu 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.

11. Duke GEC www.interprofessionalgeriatrics.duke.edu 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

12. Duke GEC www.interprofessionalgeriatrics.duke.edu 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.

13. Duke GEC www.interprofessionalgeriatrics.duke.edu

14. Duke GEC www.interprofessionalgeriatrics.duke.edu 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

15. Duke GEC www.interprofessionalgeriatrics.duke.edu Advantages to calling it “delirium”? Improve awareness and recognition Improve communication – Team – Family – Patient Standardize treatment protocols

16. Duke GEC www.interprofessionalgeriatrics.duke.edu 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