Delirium in the hospitalized patient - Weebly

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Delirium in the hospitalized patient

Jennifer A. Tarin, M.D. Department of Hospital Medicine

Geriatric Health Safety Chair Colorado Permanente Medical Group

UCLA Reynolds Scholar

Delirium Preventing delirium or recognizing it early has the potential to dramatically improve safety, decrease morbidity and mortality for our patients, as well as reduce costs.

Learning Goals

S  Why should you care about Delirium

S  Recognizing Delirium

S  Four risk factors for Delirium

S  What physicians are thinking/doing…

S  The Delirium Order set/bundle changes

S  What can you do…

So why should you care if your patient has delirium?

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Prevalence of delirium is 14-24% at time of

admission.

Incidence in hospital (new cases) 6-56%

Inouye, SK NEJM 2006; 354: 1157-1165 Maldonado,

JR Crit Care Clin 2008; 24: 657-722

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Prevalence of delirium in the ICU is 70-87%.

Inouye, SK NEJM 2006; 354: 1157-1165

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Of the 13 million patients 65 and older hospitalized in 2002,

10% to 52% had delirium at some point during their

hospital stay.

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For 80% of patients some symptoms persist at > 6

months.

McCusker. J. J Gen Int Med. 2003; 18:696-704

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One year mortality is 35-40%

Inouye, SK NEJM 2006; 354: 1157-1165

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2 year survival may be as low as 33%

McCusker. J. J Gen Int Med. 2003; 18:696-704

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Adjusted average annual costs were 2.5 times higher

for patients w/ delirium.

Leslie DL, et al. Arch Intern Med 2008; 168:27-32

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Total annual costs attributed to delirium were $16,000-

$64,000 per patient.

Leslie DL, et al. Arch Intern Med 2008; 168:27-32

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We cannot diagnose delirium or manage and decrease its complications if we do not

look for it.

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Nurses play a crucial role in the recognition of

delirium.

Nurses’ Recognition of Delirium

S Study compared nurses’ recognition of delirium with trained interviewer ratings

S Nurses’ recognized delirium in only 31% of patients (or 40 of the 131 patients with delirium)

Inouye, SK, Arch Intern Med. 2001; 161: 2467-2473

Nurses’ Recognition of Delirium

S However the specificity of nurses’ rating delirium was high compared with the researchers (95.8%).

S This indicates the nurses did not over identify delirium.

Inouye, SK, Arch Intern Med. 2001; 161: 2467-2473

Nurses’ Recognition of Delirium

Nearly all disagreements in ratings were due to under-recognition by nurses.

Pts with 3 or 4 risk factors had a 20 fold risk for unrecognized delirium.

Risk factors: S  Age over 80 S  Hypoactive Delirium S  Vision impairment S  Dementia

Inouye, SK, Arch Intern Med. 2001; 161: 2467-2473

Nurses’ Recognition of Delirium

S Nurses’ are at the front line in the process of delirium recognition.

S Education and training are essential for detection of the key features of delirium by nursing staff.

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Who is at risk for developing delirium?

Patients’ at risk for developing delirium

S Age 65 or older

S Cognitive impairment (past or present) or dementia

S Current hip fracture

S Serious illness

(NICE clinical guideline 103, July 2010)

Risk factors

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Current screening outside of the ICU.

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The Intensive Care Delirium Screening

Checklist The ICDSC consists of 8 items based off the DSM-IV criteria

for diagnosing delirium.

8 items RN’s assess for

S Drowsiness or hypervigilance

S  Inattention

S Disorientation

S Hallucinations

S Agitation

S  Inappropriate speech

S Sleep/wake issues

S Symptom fluctuations

ICDSC

S The ICDSC has a 99% sensitivity and 84% specificity

S A score of ≥ 4 is suggestive of delirium and needs further physician assessment.

S Score will now show up on as a “vital sign” for providers.

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Diagnosis of Delirium What providers are doing/

thinkingJ

Confusion Assessment Method (CAM)

S Developed to provide a quick and accurate way for detecting delirium.

S For non-psychiatrist trained clinicians

S Translated into 12 languages and used in over 250 original publications to date

S 95% sensitivity and specificity Inouye, SK, et al Ann Int Med 1990; 113: 941-948

Wong, et al; JAMA 2010; 304: 779-789

CAM

1) Acute onset and fluctuating course

AND

2) Inattention

And either 3 or 4

3) Disorganized thinking

OR

4) Altered level of consciousness

Inouye, SK, et al Ann Int Med 1990; 113: 941-948

Mini-cog test

S  Orientation: person, place (city/state, hospital), time

S  Registration: name three objects, have them repeat until they know all three

S  Clock drawing

S  Recall: ask for all three words

S  Score: 1 pt for each correct word, 2 pts for correct clock

S  Score of 0-2 suggests cognitive dysfunction; score of 3-5 suggests no cognitive dysfunction

Borson et al Geriatric Psychiatry 2000; 15: 1021-1027

Etiologies for delirium:

S  infection (PNA, UTI, CNS),

S  metabolic (electrolytes, AKI, dehydration)

S  neurological (stroke, subdural)

S  cardiac (MI, HF)

S  pulmonary (PE, hypoxia)

S  adequate pain control

S  Medication side effect (antihistamines, TCA’s, benzos, opiates),

S  bowel or bladder dysfunction (constipation, retention),

S  drug withdrawal (alcohol, benzos, opiates)

S  sensory deficit (glasses, hearing aids)

(Royal College of Physicians National Guidelines on Delirium 2006; 1-17)

(NICE clinical guideline 103, July 2010)

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Our updated delirium bundle

Delirium Team

S  Our team is very diverse and consists of physicians from various Exempla hospitals, psychiatry, behavioral health, nurses’, residents, clinical pharmacists, physical therapy and IT support.

AIM statement

S  Through the implementation of a comprehensive delirium bundle we hope to decrease the incidence of delirium throughout our hospitals.

S  Secondarily we hope to decrease the average length of stay for our geriatric patients, the incidence of falls and the need for institutional care post discharge.

Delirium Prevention

S All patients at risk for delirium should receive a multi-component intervention to reduce the likelihood of developing delirium.

S This is aided by the use of the delirium order set.

(NICE clinical guideline 103, July 2010; NEJM 1999; 340(9): 669-676)

Yale Delirium Prevention Study

Modifiable Risk factor Intervention

Cognitive Impairment Reality Orientation

Sleep Deprivation Sleep enhancement protocol*

Immobilization Early mobilization, physical therapy

Vision Impairment Vision aids, adaptive equipment

Hearing Impairment Amplifying devices

Dehydration Early recognition, volume repletion

Inouye, SK NEJM 1999; 340: 669-679; Viden MT, JAGS 2009; 57: 2029-2036

The multi-component intervention should address:

S  cognitive impairment and/or disorientation

S  dehydration and/or constipation

S  hypoxia and optimize oxygen saturation if necessary

S  infectious issues

S  immobility and utilize physical therapy as indicated

S  sensory impairment

S  poor nutrition

S  promote good sleep patterns and sleep hygiene.

S  review medications that could elicit or exacerbate delirium

NICE clinical guideline 103, July 2010; NEJM 1999; 340(9): 669-676

Current Delirium Order set

Delirium Order set

Delirium order set changes

S  All patients at risk for delirium outside of the ICU should be screened by the nurses for delirium in the hospital on admission and at 12-hour intervals using the ICDSC

S  The ICDSC screening should occur toward the end of the nursing shift (~6PM and 6AM).

S  This will allow the nurses the majority of their shift to evaluate the patient.

Intensive Care Med 2001; 859-864; NICE clinical guideline 103, July 2010)

Delirium order set changes

S  The ICDSC scores will populate the clinical summary and be available to clinicians as another vital sign in the accordion section of eSummit.

S  An ICDSC score of 1-3 will prompt the “At risk for delirium” plan for the nursing plan of care.

S  An ICDSC score of ≥ 4 will prompt “delirium” to be incorporated as a problem in the nursing plan of care.

Delirium order set changes

S  If a patient has a ICDSC score of ≥ 4, the provider should be notified.

S  Patients with suspected delirium should have the dx confirmed by a physician using the Confusion Assessment Method (CAM).

S  When available and ordered by the provider, Clinical Pharmacy will perform a one-time screen of medications within 24 hours. This review will be an option providers can choose on the delirium order set.

JAMA 2010; 304 (7): 779-786; NICE clinical guideline 103, July 2010; Annal Intern Med 1990; 113: 941-948)

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So what can you do?

Call us to discuss

S  Think about Delirium

S  Try warm milk before po Rx sleep aids.

S  Feel free to call us to discuss if concerned about delirium.

“Restraint rounds”

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Quick review

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Who is at risk for developing delirium?

Patients at risk for developing delirium

S Age 65 or older

S Cognitive impairment (past or present) or dementia

S Current hip fracture

S Serious illness

(NICE clinical guideline 103, July 2010)

Summary

S  Think about delirium.

S  Remember those risk factors.

S  Use the screening tool.

S  Remember you are a very important member of the team. If concerned please discuss with the provider.

This man is 100 years old. On October 19th, 2011 Fauja Singh, became the world’s oldest person to complete a marathon, when he crossed the finish line at 8 hours and 25 minutes.

Delirium Preventing delirium or recognizing it early has the potential to reduce costs, dramatically improve safety as well as decrease morbidity and mortality for our patients.

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Thank you for your attention!

Questions/comments? Feel free to contact me!

Jennifer.A.Tarin@kp.org