Post- Operative Delirium in the Elderly · Dementia (Mini-Cog Test) ... Delirium (1999) American...

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Post- Operative Deliriumin the Elderly

Thomas Robinson, MD

Surgery Grand RoundsMarch 10th, 2008

What is the most common post-operative complication in

elderly patients?

What is the most common post-operative complication in

elderly patients?

Marcantonio et al. JAMA (1994) 271:134.

DELIRIUM

Diagnostic Criteria for Delirium

1.Disturbance of Consciousness

2. Change in Cognition

3. Acute Onset

4. Coexisting Physiologic Disturbance

Diagnostic and Statistical Manual of MentalDisorders DSM IV - Fourth Edition (1994)

In 2004, what percent of all operations in the United States were performed

on patient older than 65 years?

In 2004, what percent of all operations in the United States were performed

on patient older than 65 years?

55% (Age > 65) 45% (Age < 65)

GRS: A Core Curriculum in Geriatric Medicine – 6th Ed. (2006)

U.S. Population Aged 65 and Over

1900 1930 1960 1980 2002 2030

Population(Millions)

Calendar Year

U.S. Population Aged 65 and Over

1900 1930 1960 1980 2002 2030

Population(Millions)

Percent Total

Population

Calendar Year

Post-Operative Delirium in the Elderly

Risk Factors

Natural History

Outcomes

Motor Subtypes

Risk Factors

Natural History

Outcomes

Motor Subtypes

Treatment

Organic Causes of Delirium

DELIRIUMS (mnemonic)

DEL I R I U MSS

rugs (anticholinergics, polypharmacy)motional (depression)ow PO2 states (MI, PE, anemia, CVA) nfection (sepsis)etention of urine or stoolctal states (seizure, post-ictal)nder-nutrition/under-hydration etabolic (electrolytes, glucose)ubdural (acute CNS processes) ensory (impaired vision & hearing)

Etiology of Post-Operative Delirium

• Consecutive patients older than 50 years being admitted post-operatively to the SICU.

• 88% (56/64) - No underlying cause identified.

• 12% (8/64) - Organic cause identified.

75% - Sepsis

12% - Stroke

12% - Alcohol Withdrawal

Age and Post-Operative Delirium

50 - 59 60 - 69 70 - 79 80 - 89

Age by Decade(years)

Incidence of Delirium

Pre-Operative Risk Factors

*p=.00918%82%History of Alcohol Abuse

*p<.0011.8±1.44.6±2.4Co-Morbidities (Charlson Index)

*p<.0014.6±0.72.8±1.6Dementia (Mini-Cog Test)

*p<.00199±391±11Functional Status(Barthel Index)

*p<.00144±438±7Hematocrit (%)

*p<.0013.9±0.43.3±0.8Albumin (g/dL)

*p<.00161±669±9Age (years)

Absent(n= 80)

Present(n=64)

DELIRIUM

Intra- and Post- Operative Risk Factors

*p=0.0011.3±2.13.1±3.3Blood Transfusion (units)

POST-OPERATIVE

*p<0.00127%88%Intra-Op Hypotension (SBP<90)p=.44282±105298±137OR time (minutes)p=.73655±1515752±1033Blood loss (ml)

INTRA-OPERATIVE

Absent(n= 80)

Present(n=64)

DELIRIUM

Strongest Risk Factors for the Development of Post-Operative Delirium

Pre-Existing Dementia

Functional Impairment

Older Age

More Co-Morbidities

Lower Albumin

Intra-Operative Hypotension

Frailty Predicts Delirium

Given a similar surgical stress, the core components of frailty are stronger predictors of developing post-operative delirium than the specific details of the operation.

Strongest Risk Factors for the Development of Post-Operative Delirium

Pre-Existing Dementia

Functional Impairment

Older Age

More Co-Morbidities

Lower Albumin

Intra-Operative Hypotension

“Threshold Theory” of Cognitive Decline

The hypothetical construct of reduced brain reserve capacity represented by changes in the brain’s actual neurons or the milieu of neurotransmitters which makes an individual more vulnerable to a cognitive clinical deficit such as delirium.

Satz P. Neuropsych (1993) 7:273.

Changing Cognitive Function in the Elderly

50 60 70 80 90 100

Age (Years)

Brain Reserve Capacity

Dementia

Threshold Theory of Cognitive Decline

50 60 70 80 90 100

Age (Years)

Dementia

Threshold Theory of Cognitive Decline

50 60 70 80 90 100

DementiaDelirium

Age (Years)

Risk Factors

Natural History

Outcomes

Motor Subtypes

Treatment

40%Hip Fracture3

44%DVAMC SICU6

59%DHMC Trauma ICU7

< 5%Cataract Surgery5

72%Medical ICU2

36%Vascular Operation4

15%Medial Ward1

Incidence of Delirium

1NEJM (1999) 340(9):669.2JAGS (2006) 54:479.3JAGS (2002) 50:850

4Gen Hosp Psych (2002) 24:28.5Int Psych (2002) 14:301.6DVAMC

44%Incidence

2.4±1.9Time to Onset (days)

4.0±5.1Duration (days)

Natural History of Delirium

Cumulative Incidence of Post-Operative Delirium

CumulativeIncidence

1 2 3 4 5 6 7

Post-Operative Day

The Biphasic Distribution of Post-Operative Delirium

*p=0.021.9±0.95.6±3.5Initial Presentation of Delirium (Post-Operative Days)

No Identifiable

Organic Identifiable

DELIRIUM

The Biphasic Distribution of Post-Operative Delirium

1 3 5 7 9 112 4 6 8 10 12

Post-Operative Day

No identifiable cause of delirium

Delirium due to an organic cause

Number of Subjects

Risk Factors

Natural History

Outcomes

Motor Subtypes

Treatment

Outcomes and Delirium

*p<0.0011%33%Post-Discharge Institutionalization

*p<0.00131.6±14.150.1±33.6Cost of Hospitalization ($ in 1,000s)

*p<0.0017.9±3.916.3±10.9Length of Hospital Stay (days)

*p<0.0014.6±2.19.7±8.0Length of ICU Stay (days)

Absent(n= 80)

Present(n=64)

DELIRIUM

Mortality and Delirium

*p=0.0013%a20%Six Month Mortality

*p=0.0451%9%30 Day Mortality

p=0.0860%5%Hospital Mortality

Absent(n= 80)

Present(n=64)

DELIRIUM

a n=78 – two patients lost to 6 month follow up

Risk Factors

Natural History

Outcomes

Motor Subtypes

Treatment

Motor Subtypes of Delirium

• A spectrum of psychomotor behavior is found in delirium.

• Delirium Motor Subtypes Hypoactive HyperactiveMixed Type

Meagher et al. J of Neuropsych and Clin Neurosc (2000) 12(1):51.

Motor Subtypes of Delirium

Hypoactive Pure lethargy, somnolence

Hyperactive Pure agitation

Mixed Type Fluctuation between lethargy and agitation

Meagher et al. J of Neuropsych and Clin Neurosc (2000) 12(1):51.

Incidence - Motor Subtypes of Delirium

Trauma ICU

Post-Op SICU

Mixed Type

Hyperactive

Hypoactive

Medical ICU

Trauma ICU

Post-Op SICU

Mixed Type

Hyperactive

Hypoactive

Medical ICU

Trauma ICU

Post-Op SICU

55%Mixed Type

2%Hyperactive

44%Hypoactive

Medical ICU

Peterson et al. JAGS (2006) 54:479.

Adverse Events - Motor Subtypes of Delirium

• 23% (17/74) incidence of adverse events

• 21 events occurred in 17 subjects

• Adverse Events 52% (11/21) Pulled tube/line 29% (6/21) Sacral decubitus ulcer 20% (2/21) Falls 5% (1/21) Extubation

Adverse Events - Motor Subtypes of Delirium

*p=0.001075%Sacral Decubitus Ulcer

p=0.02482%25%Pulled line/tube

Mixed(n=11)

Hypoactive(n=8)

MOTOR SUBTYPE

Outcomes - Motor Subtypes of Delirium

MOTOR SUBTYPE

71±9*

Hypoactiven=50

65±9*

Mixedn=23

No Deliriumn=98

*p=0.0416 Month Mortality

*p=0.001Age (years)

Risk Factors

Natural History

Outcomes

Motor Subtypes

Treatment

Haldoperidol 2 mg q20 min(while agitation persists)

4-8mgSevere

2-4mgModerate

0.25-2mgMild

Initial Dose HaldoperidolPO, IM or IV

Degree of Agitation

Pharmacologic Treatment - ICU

Jacobi et al. Crit Care Med (2002) 30(1):119.

Maintenance Dose: 50% of total loading dose is the

maintenance dose divided every 6-8 hours daily

Continue maintenance dose for 24-48 hours before tapering

Taper: Taper maintenance dose by 20-

30% daily until off.

0.5mg PO BID for 24 hrs. then DCTaper

Order 1mg TID IV or PO x 24 hrs.Keep daily dose for 24 – 48 hrs.

Maintain

Moderate Agitation2:00AM – 2mg IV2:30AM – 2mg IV3:00AM – 2mg IV3:30AM – Agitation controlled

Control

Haldoperidol Administration

General Recommendation:Haldoperidol 1-2 mg q2-4 hrs PRNMay be administered PO/IM/IV

For Elderly Patients:Haldoperidol 0.25-0.5mg q4hrs PRN

Pharmacologic Treatment - Ward

Practice Guideline for Treatment of Patients with Delirium (1999) American Psychiatric Association

Dementia is the strongest risk factor for delirium.

Delirium resulting from an organic cause occurs later in the post-op course compared to “geriatric” delirium.

Outcomes are worse in subjects who develop delirium.

Delirium presents in three distinct motor subtypes.

Hypoactive delirium has the worst prognosis.

Post- Operative Delirium in the Elderly · Dementia (Mini-Cog Test) ... Delirium (1999) American...

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