Subsyndromal Delirium and Pain Following Joint

Replacement Surgery

_____________________________________

Dawn L. Denny, PhD, RN, ONCGlenda Lindseth, PhD, RN, FADA, FAAN (Advisor)

College of Nursing and Professional DisciplinesUniversity of North Dakota (Getty Images, 2013; Used with permission)

Conflict of Interest Slide

I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.

A Dissertation Research Study:

“Subsyndromal Delirium And Pain In Older Adults Following Major Orthopedic Surgery”(Denny, 2014)

Source: [Creative Commons license] Beautiful trouble. Retrieved from http://beautifultrouble.org/case/

Objectives• Define subsyndromal delirium• Describe the identification of delirium

symptoms in older adults• Discuss the role of pain management in

prevention of delirium symptoms in older adults following joint replacement surgery

Define Subsyndromal

Delirium

Delirium

• Global brain dysfunction(Inouye, 2006; Fong, Tulebaev & Inouye, 2009)

• Presence of 3 or 4 core symptoms on Confusion Assessment Method (CAM)

(Inouye et al., 1990)

Subsyndromal Delirium (SSD)• Subclinical delirium symptoms that do not precede or

follow delirium

• Presence of 1 or 2 core symptoms according to the CAM delirium diagnostic detection tool, without meeting full criteria for a diagnosis of delirium

• Develops quickly over a few hours or days(Blazer & Van Nieuwenhuizen, 2012)

(Cole, McCusker, Dendukuri, & Hans, 2003)

Delirium Continuum

DeliriumSubsyndromal Delirium

1 2 3 4

Number of Delirium Symptoms

0

Why Should Nurses be Concerned about SSD?Delirium Symptoms are under-recognized (Ryan et al., 2013)

Delirium Symptoms are verycommon• Up to 68 percent of older adults

develop SSD following major orthopaedic surgery(Liptzin, Laki, Garb, Fingeroth, & Krushell, 2005)

Source: [Public Domain], via Creative Commons Images. Retrieved March 28, 2016 from https://kathmanduk2.wordpress.com

Why Should Nurses be Concerned about SSD? (Cont.)High risk for adverse outcomes (Vaurio, Sands, Wang, Mullen, & Leung, 2006)

• Increased falls• Long-term care admits• Increased length of stay

Costly• Distressing (Bélanger & Ducharme, 2011; Partridge, Martin, Harari, & Dhesi, 2012)

• $152 Billion annually (Leslie, Marcantonio, Zhang, Leo-Summers, & Inouye, 2008)

(Cole et al., 2003):

Describe the identification of delirium symptoms in older

adults

1. Acute Onset Or Fluctuating Course2. Inattention3. Disorganized Thinking4. Altered LOC

Source: Pixabay. (2016). [Public Domain]. Retrieved March 29, 2016 from https://pixabay.com/en/stickman-thinking-worry-confused-310590/

(Inouye et al., 1990)

Core Symptom of Delirium #1 (CAM)

Acute onset or fluctuating course• “Is there any evidence of an acute change in

mental status?”

• “Does the abnormal behavior fluctuate during the day?

(Inouye, 2003).

Core Symptom of Delirium #2 (CAM) Inattention• “Did the patient have difficulty focusing attention

(easily distracted, trouble tracking what is said in a conversation)?”

(Inouye, 2003)

Core Symptom of Delirium #3 (CAM)Disorganized thinking• “Was the patient’s

thinking disorganized or incoherent?

(Inouye, 2003)Source: [Public Domain, labeled for reuse] Deviant art. Retrieved October 7, 2016 from http://laura-c-f.deviantart.com/art/Confused-Dog-286725830

Core Symptom of Delirium #4 (CAM)Altered level of consciousness

• Alert = Normal• Lethargic = Drowsy, easily

aroused• Hyperalert = Vigilant• Difficult to arouse = Stupor• Unable to arouse = Coma

(Inouye, 2003)

Source: [Public Domain]. Wikimedia Commons. Retrieved October 7, 2016 from https://commons.wikimedia.org/wiki/File:Taro_shiba,_the_sleepy_snaggletooth.jpg

Pain and SubsyndromalDelirium

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Pain and Subsyndromal Delirium• Postoperative pain is an independent risk

factor for delirium (Morrison et al., 2003)

• Inconsistent results about risk factors for subsyndromal delirium from research studies with long-term care residents (Cole et al., 2003; Cole et al., 2011; Cole et al., 2012)

• The relationship between pain and subsyndromal delirium had not been examined

Opioid Intake and Delirium

• Delirious patients receive up to 34 percent of opioid analgesics following hip fracture than those without delirium (Adunsky, Levy, Mzrahi, & Arad, 2002)

Used with permission from Dreamstime.com – Retrieved October 7, 2016 from https://www.dreamstime.com/stock-photo-despair-son-assisting-dying-father-photo-ill-home-image63455029#res13695496. Used with permission.

Methodology Used To Examine Subsyndromal Delirium And

Postoperative Pain

Purpose and Study DesignPurpose To determine the relationship between the

delirium symptoms and pain in older adults following elective orthopedic surgery.

Predictive Correlational Design

Specific Aims1. Determine the frequency of delirium symptoms

and the frequency distributions of preoperative risk factors, pain and 24 hour opioid intake of patients age 65 years and older following major elective orthopedic surgery.

2. To determine the relationship between delirium symptoms and the preoperative risk factors in older adults undergoing elective orthopedic surgery

Specific Aims (Cont.)

3. To determine the relationship between delirium symptoms and pain intensity ratings in older adults following major elective orthopedic surgery .

4. To determine the relationship between delirium symptoms and 24 hour opioid intakes, in older adults following major elective orthopedic surgery.

Study Variables1. Pain intensity (Morrison et al., 2003; DeCrane, Stark, Johnston, Lim, Hicks, & Ding, 2014)

2. Opioid intake (DeCrane et al., 2011)

Preoperative Variables• Advanced

age/Comorbidity (Cole, Ciampi, Belzile, & Dubuc-Sarrasin, 2012)

• Cognitive impairment (Bjoro, 2008)

• Recent fall history (Fong et al., 2009;)

• Prolonged preoperative fasting time (Levkoff et al., 1996; Radtke et al., 2010)

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Sample Characteristics• 62 older adults were

invited to participate, 53 consented

• Average age was 73 years (M = 73.7, SD 6.2)

• Setting: Critical Access Hospital (25 beds) in Northwest United States

57%43%

Gender of Participants

FemaleMale

32%

30%

21%

11%4% 2%

Age Breakdown of Sample

65-69 yrs70-74 yrs75-79 yrs80-84 yrs85-89 yrs

(%, N = 53)

(%, N = 53)

62 Older Adults ≥ 65 years: Scheduled for Joint

Replacement Surgery During Study Period

Participants Enrolled in Study (n = 53)

Refused to participate (n = 9)Surgery Cancelled (n = 2)

Withdrew from Study (n = 2)

Completed Study (n = 51)

Inclusion/Exclusion Enrollment of 53 participantsTwo participants withdrew after POD 1Refusal rate = 14.5%

Predisposing Factors Precipitating Factors

Adapted from ”Precipitating factors for delirium in hospitalized elderly persons: A predictive model and interrelationship with baseline vulnerability,” by S. K. Inouye and P. A. Charpentier, 1996, Journal of the American Medical Association, 275, p. 853. Copyright 1996 by the American Medical Association.

Multifactorial Model for Delirium

Patient 1Pain Controlled

Patient 2UncontrolledPain

Data Collection: Pain IntensityPain Intensity Ratings• Iowa Pain Thermometer (Herr, Spratt, Garand, &

Li, 2007)

• Preferred by older adults (Li, Herr, & Chen, 2007)

• Concurrent validity with NRS and VDS (.78 - .86) (Taylor, Harris, Epps & Herr, 2005)

24 Hour Opioid Intake (in morphine sulfate-equivalent doses (IV), in mg)

Used with permission, Keela Herr, PhD, RN, AGSF, FAAN, College of Nursing, The University of Iowa, Iowa City, IA, USA

Study VariablesVariables Methods Time of Data CollectionDelirium Assessment Confusion Assessment Method Preoperatively and once on

postoperative 1, 2, and 3.Pain Intensity Rating Complete pain assessments

utilizing the Iowa Pain Thermometer

Preoperatively and every 4 hours postoperatively x 3 days.

24 Hour Opioid Intake

Calculated for each 24 hour period for 3 following surgery in MS equivalent doses (in mg)

Medication administration recordsfor postoperative period for 3 days extracted following study participation.

Comorbidity Score Age-Adjusted Charleston Comorbidity Index score

Demographic form supplemented by information from the medical record following completion of the study.

Cognitive Status Mini-Cog score (0-3) Preoperatively at the time of enrollment

Fall History Number of fall in 6 months prior to surgery

Demographic form supplemented by information from the medical record following completion of the t d

Data Collection

DAY 1• Pain assessments q4h• Delirium assessments daily (CAM)

DAY 2• Pain assessment q4h• Delirium assessments daily (CAM)

DAY 3• Pain assessments q4h• Delirium assessments daily (CAM)

Data were analyzed using descriptive statistics, correlational analyses, and hierarchical (linear) multiple regressions.

Findings

Frequency of Delirium Symptoms

[CATEGORY NAME]32.%

[CATEGORY NAME]

68%

Overall Incidence of Delirium Symptoms

(%, N = 53)

28.3

[VALUE]

[VALUE]

[VALUE]

Delirium SymptomsPostop Day 3

No DeliriumSSD1SSD2Delirium

(%, N = 53)

75.5

[VALUE]

Delirium Symptoms Postop Day 1No DeliriumSSD1SSD2Delirium (%, N = 53)

[VALUE]

[VALUE]

[VALUE]

[VALUE]Delirium Symptoms

Postop Day 2

No DeliriumSSD1SSD2Delirium (%, N = 53)

Frequency of Delirium Symptoms (cont.)

3.23.43.63.8

44.24.4

0 - 24 hrs 24 - 48 hrs 48 - 72 hrs

3.83.6

4.3

Pain Intensity RatingsM

ean

Pain

Inte

nsity

Rat

ings

2021222324252627

0 - 24 hours 24- 48 hours 48 - 72 hours

25.9 26.1

22.3

24 Hour Opioid Intake (in mg)M

ean

24-H

r Opi

oid

Inta

ke (i

n m

g)

Correlation of Preoperative Risk Factorsand Delirium Symptoms: Postoperative Day 2

Variable Pearson’s r N pComorbidity burden

.12 53 .20

Cognitive status-.13 53 .14

Recent fall history.37** 53 .007

Preoperative fastingtime .24 53 .09

*p ≤ .05 level, **p ≤ .01 level

Preoperative Risk Factorsand Delirium Symptoms: Postoperative Day 3

Variable Pearson’s r N pComorbidity burden .01 53 .43

Cognitive status-.06 53 .33

Recent fall history .33** 53 .01

Preoperative fasting time

.31* 53 .03

Pain and Delirium Symptoms

Time of Delirium Assessment Pain

Pearson’sr N p

Postoperative Day 1 0 – 24 hr -.26 53 .06

Postoperative Day 2 24 – 48 hr .22 53 .10

Postoperative Day 3 48 – 72 hr .05 53 .73

*p ≤ .05 level, **p ≤ .01 level

Pain and Opioid Intake

Time of Delirium Assessment

Opioid Intake

Pearson’sr N p

CAM score POD-1 0 - 24 hr -.17 53 .20

CAM score POD-2 24 – 48 hr .24 53 .08

CAM score POD-3 48 - 72 hr .12 53 .39

*p ≤ .05 level, **p ≤ .01 level

When Preoperative Risk Factors were Accounted for in Multiple Regression Analysis Pain from 24 to 48 hours

after surgery was related to a significant (p≤.05) increase in delirium symptoms on POD 2

Pain from 0 to 24 hours was related to a significant (p≤.05) increase in SSD on POD 2

Pain

Age-Adjusted

Comorbidity

Cognitive Status

Recent Fall History

Preoperative Fasting Time

DeliriumSymptoms

Delirium Symptoms and Opioid Intake

24-hour Opioid Intake was not

significantly (p > .05) related to

delirium symptoms or SSD after

accounting for preoperative

risk factors and pain.Pain

Age-Adjusted

Comorbidity

Cognitive Status

Recent Fall History

Preoperative Fasting Time

Opioid Intake

DeliriumSymptoms

Conclusions

• Older adults with higher levels of pain during the first 24 hours after surgery were more likely to have subsyndromal delirium on the second day after surgery

• Older adults with higher levels of pain from 24 to 48 hours after surgery were more likely to have delirium symptoms on the second day after surgery

• Opioid medications intake after surgery in older adults did not significantly contribute to delirium symptoms

• Analgesic trials should be considered

Pain management and the prevention of delirium symptoms in older adults following

joint replacement surgery

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Subsyndromal Delirium Prevention and DetectionRole of Pain Management:√ Medicate older adults per physician orders√ Attempt self-report

Avoid suggestive questionsNot, “Is your pain okay?” Instead: “How would you rate your pain when you try to move your

(affected extremity)?”Do not rely on nonpharmacological interventions alone in the

immediate postoperative period.

√ Follow up any reports of unusual behavior with a delirium assessment

√ Aggressively manage pain in older adults following joint replacement surgery, through the 2nd postoperative day

Future Research• Tools to assist with early identification of

subsyndromal delirium• Patient and family experiences of

subsyndromal delirium

Acknowledgments

• Dr. Glenda Lindseth• Primary Mentor and Adviser• Professor at the College of Nursing at the University of North Dakota

• Research Site Nurses: Dee, Kathy, and Sue (Nurse Champions)

• Volunteers who participated in this study

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