40
Delirium: Part 1 Maria Orsini EdD, MSN, RN Chief Nurse Performance Improvement and Research Durham VA Health Care System
Delirium: Part 1
Maria Orsini EdD, MSN, RN
Chief Nurse Performance Improvement and Research
Durham VA Health Care System
OBJECTIVES
• Define Delirium
• Define Challenges with Delirium: Before and after COVID Era
• List Outcomes Associated with Delirium
• Use Validated Instrument to Measure Delirium
• Practice Using CHIMBOP Model
• Review Study on Restraints & Delirium
• List Differences between Delirium & Depression
• Review Studies on Medications & Consultation
What is Delirium?
• Syndrome
• Sudden/Acute
• Confusion
• Unable to focus/Inattention
What concerns do you have?Nursing Response…
Challenges of Caring for Older Adults
Atypical Presentation of Illness
Reduced mobility Falling
Acute Confusion Fatigue
Anorexia Urinary Incontinence
Functional decline Lack of pain with a disease known to
Generalized weakness cause pain
COVID ERA: Atypical Symptoms
• Decreased general well being
• Poor feeding
• No dyspnea
• No fever
• No cough
• (Kotfis, et al., 2020; O’Haulou & Inouye, 2020)
Delirium in COVID ERA
Neurological Symptoms• Lack of smell and taste• Short and long-term memory loss• Short and long-term cognitive dysfunction• 8% headache• 1% central mediated nausea and vomiting• 45% neuro symptoms in severely ill patients• Look for early symptoms of delirium which may
indicate impending respiratory failure• (Kotfis, et al., 2020)
2.5X (Han et al., 2009)
22-76% Delirium (McCusker, et al., 2002)
Mortality
55% COVID + Delirium 50 years or older (Garcez et al., 2020)
NOT RECOGNIZED
delirium
Lack of Recognition
• https://pogoe.org/content/9928
• https://pogoe.org/content/9929
(POGO, The Portal for Geriatrics Online Education)
Mixed Delirium= Hyper + Hypo Deliriumhttps://pogoe.org/content/9930(POGO, The Portal for Geriatrics Online Education)
Pain Recognition in Delirium
• https://pogoe.org/content/9926
(POGO, The Portal for Geriatrics Online Education)
Diagnostic Accuracy of Confusion Assessment Method (Pamaiahgari, 2018)
Sensitivity (++)
CAM 82%
CAM-ICU 81%
Specificity (- -)
CAM 99%
CAM-ICU 98%
Delirium Superimposed on Dementia
CAM 77%
Delirium Superimposed on Dementia
CAM 96%-100%
After learning how to use the Confusion Assessment Method (CAM), learners will demonstrate completing a CAM using an
scenario
Learning outcome #1
How to Assess Inattention
Do not use orientation questions!
Ask one of these questions
• Tell me the dates of the month backwards, starting with December (six months)
• Spell the word “LUNCH” backwards
• Tell me the numbers from 10 to 1 backwards
How to Assess Disorganized Thinking
• Clinical Symptoms: hallucinations, illusions, delusions• Answers from common sense Yes/No questions:
– Will a stone float on water?– Are there fish in the sea?– Does one pound weigh more than two pounds?– Can you use a hammer to pound a nail?
• In ICU CAM, for patients who cannot speak, patient must demonstrate understanding by:– Caregiver says: “Hold up this many fingers” (holding two)– Caregiver says: “Now do the same with the other hand” (Han et al., 2013)
https://www.youtube.com/channel/UCCq13KNzxcopkOkGDsk4c8w?
view_as=subscriber
3 Hyper and 3 Hypo Delirium Interprofessional Videos
in Maria’s YouTube Chanel Developed using a Duke research grant
Faculty Demonstrates completing bCAM
Demonstration
Learning Outcome #1
Learner will complete CAM after watching this video: Handoff
PRACTICE
Elements that can cause delirium. Delirium may be prevented or reversed with proper interventions.
• C = Constipation
• H = Hypovolemia or hypoglycemia
• I = Infection
• M = Medications
• B = Bladder catheter and bladder outlet obstruction
• O = Oxygen deficiency & Others (ie. Hearing aids, glasses, lighting, environment, theaters)
• P = Pain
Learning Outcome #2
CHIMBOP Practice
• Individually
• Use all the resources provided to identify factors in the CHIMBOP Model that could be affecting the patient in the following case study
Learning Outcome #2 Resources
Next: American Geriatric Society 2019 BEERS Criteria: Inappropriate medications for elderly: http://files.hgsitebuilder.com/hostgator257222/file/ags_2019_beers_pocket_printable_rh.pdf
American Geriatric Society 2019 BEERS Criteria: Inappropriate medications for elderly
Black Box Warning
Learning Outcome #2 Resources:Quicksofa.org: suspicion of infection & 2 elements in
the scale
Glasgow Scale <=13 points >= 22 rpm Systolic BP<=100
References for Delirium and COVID-19
• Garcez, et al. (2020). Delirium and adverse outcomes in hospitalized patients with COVID-19, Journal of American Geriatrics Society,00(00), 1-7. DOI: 10.1111/jgs.16803
• Kotfis, K., Roberson, S. W., Wilson, J. E., Dabrowski, W., Pun, B. T., and Wesley Ely, E. (2020). COVID-19: ICU delirium management during SARS-COV-2 pandemic. Critical Care, 24(176). DOI: https://doi.org/101186/s13054-020-02882-x
•
• LaHue, S. C., James, T. C., Newman, J. C., Esmali, A. M., Ormseth, C. H., Wesley, Ely, E. (2020). Collaborative delirium prevention in the age of COVID-19. Journal of American Geriatric Society, 68(5), 947-949. DOI: 10.1111.jgs.16480
•
• Newman, J. C., Ormseth, C. H., and Wesley Ely, E. (2020). Collaborative delirium prevention in the age of COVID-19. Journal of American Geriatric Society, 68(5), 947-949. DOI: 10.1111/jgs.16480. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262233/
•
•
• O’Hanlou, S. and Inouye, S. K. (2020). Delirium, a missing piece in the COVID-19 pandemic puzzle. Age Ageing. DOI: 10.1093/ageing/afaa094. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239228/
•
• American Geriatrics Society. (2020). Delirium Resources. https://www.hospitalelderlifeprogram.org/for-clinicians/covid19-resources•
• American Geriatrics Society. (2020). COVID-19 Help Toolkit.• https://www.hospitalelderlifeprogram.org/uploads/delirum/FINAL_COVID19_HELP_Resources.pdf•
• World Health Organization. (2020). COVID-19 Dashboard. Retrieved from https://covid19.who.int/•
• World Health Organization. (2020). Timeline: Who’s COVID-19 Response. Retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline#!•
• Zambrelli, E. Canevini, M., Gambini, O., and D’Agostino, A. (2020), Delirium and sleep disturbances in COVID-19: a possible role for melotonin. Sleep Science, 70, 111. Retrieved from https://www.sciencedirect.com/science/article/pii/S1389945720301672?via=ihub
•
• Zhang, R., Wang, X., Ni, L., Di, X., Ma, B., Niu, S, Liu, C, and Reiter, R. J. (2020). COVID-19: Melatonin as a potential adjuvant treatment. Life Science, 1, 250. DOI: 10.1016/j.lfs.2020.117583. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102583/
•
• Liu, K., Chen, Y., Lin, R, and Han, K. (2020). Clinical features of COVID-19 in elderly patients: a comparison with young and middle-aged patients. Journal of Infection, 80(60). Retrieved from https://www.sciencedirect.com/science/article/pii/S016344532030116X
•
• Nikolich-Zugich, J, Knox, K. S., Rios, C. T., Natt, B., Bhattacharya, D., and Fain, M. J. (2020).SARS-CoV-2 and COVID-19 in older adults: what we may expect regarding pathogenesis, immune responses, and outcomes. Gero Science, 42, 505-514. Retrieved from https://doi.org/10.1007/s11357-020-00186-0
•
• National Center for Immunization and Respiratory Diseases. (2020, February). Coronavirus Types: https://www.cdc.gov/coronavirus/types.html•
•
References• Barron, E. A. & Holmes, J. (2013). Delirium within the emergency care setting,
occurrences, and detection. Emergency Medical Journal, 30(4) 263-268.• Craig, J. V. & Smyth, R. L. (2007). The evidence-based practice manual for
nurses. Philadelphia, PA: Churchill Livingstone Elsevier.• Department of Veterans Affairs (2011). VHA national patient safety
improvement handbook. Retrieved from http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2389
• Durham VA Medical Center. (2014). Durham VA medical center 2014 strategic plan. Retrieved from http://www.durham.va.gov/about/leadership.asp
• Fong, T. G., Tulebaev, S. R., Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention, and treatment. Nature Review Neurology, 5(4), 210-220. doi: 10.1038/nrneurol.2009.04
• Francis, J. & Young, G. B. (2014). Patient information: Delirium (beyond the basics). Wolters Kluwer Health. Retrieved from http://www.uptodate.com/contents/delirium
• Grossman, F. F., Hasemann, W., Graber, A., Bingisser, R., Kressig, R. W., & Nickel, C. H. (2014). Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 22(19). doi: 10.1186/1757-7241-2219.
References
• Han, J. H., Zimmerman, E. E., Cutler, N., Schnelle, J., Morandi, A., Dittus, R. S.,… Ely, E. W. (2009). Delirium in older emergency department patients: Recognition, risk factors, and psychomotor subtypes. Academic Emergency Medicine, 16(3), 193-200.
• Institute of Medicine. (2001). Crossing the quality chasm. Retrieved form www.nap.edu/html/quality_chasm/reportbrief.pdf
• Institute of Medicine. (2011). The future of nursing. Retrieved from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change
• Larrabee, J. H. (2009). Nurse to nurse: Evidence-based practice. New York, New York: McGraw Hill.
• Leslie, D. L., Marcantonio. E. R., Zhang, Y., Leo-Summer, L., & Inouye, S.K. (2008). One-year healthcare costs associated with delirium in the elderly population. Journal of American Association Internal Medicine, 168(1), 27-32.
• Mergenhagen, K. A. & Arif, S. A. (2008). Delirium in the elderly: Medications, causes, and treatments. U.S. Pharmacist. Retrieved from http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/105762/
• National Healthcare Quality Report, National Healthcare Disparities. (2012). National older adult quality measures compared to achievable benchmarks. Rockville, MD: Agency for Healthcare Research and Quality.
• Pamaiahgari, P. (2018). Evidence Summary. Delirium in Critical Care Settings: Screening and Assessment. The Joanna Briggs Institute EBP Database, JBI@Ovid. JBI5419.
References
• Mazur, K, Willckinsi, K, & Szewieckek, J. (2016). Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors. Clinical Interventions in Aging, 2016, (11). DOI https://doi.org/10.2147/CIA.S115755
• O’Sullivan, R., Inouye, S. K., & Meagher D. (2014). Delirium and depression: Inter-relationship an overlap in elderly people. Lancet Psychiatry, 1(14), 303-311. DOI:10.1016/S2215-0366(14)70281-0
• Casarett D. J. & Inouye, S. K. (2001). Diagnosis and management of delirium near the end of life. Annals of Internal Medicine, 135(32), 40.
• National Library of Medicine (NLM). (2020). Melatonin. Access via: https://pubchem.ncbi.nlm.nih.gov/compound/Melatonin
• Zhou, Y, et al., (2020, November 6). A network medicine approach to investigation and population-based validation of disease manifestations and drug repurposing for COVID-19. PLOS Biology. DOI: 10.1371/journal.pbio.3000970. Retrieved from https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.3000970
References for Delirium & Dementia
• Tahir, T. A., Eeles, E., Karapareddy, V., c, Muthuvelu, P., Chapple, S., Phillips, B. , Adyemo, T., & Farewell, D., Bisson, J. I. (2010). A randomized controlled trial of quetiapine versus placebo in the treatment of delirium. Journal of Psychosomatic Research, 69(5), 485-490. http://dx.doi.org/10.1016/j.jpsychores.2010.05.006
• Marcantonio, E. R., Jonathan M. Flacker, J. M., R. John Wright, R. J., & Neil M. Resnick, N. M. (2003). Reducing Delirium After Hip Fracture: A Randomized Trial. Journal of the American Geriatrics Society, https://doi.org/10.1046/j.1532-5415.2001.49108.x
• Girard, T. D. (2010). Feasibility, Efficacy, and Safety of Antipsychotics for ICU Delirium: the MIND Randomized, Placebo-Controlled Trial. Critical Care Medicine. 2010 Feb; 38(2): 428–437.
• Tareef Al‐Aama, T., Brymer, C., Gutmanis , I.,Woolmore‐Goodwin, S. M., Jacquelin Esbaugh, J., & Dasgupta, M.(2010). Melatonin decreases delirium in elderly patients: A randomized, placebo‐controlled trial. Geriatric Psychiatry, https://doi.org/10.1002/gps.2582
• Hatta, K., Kishi, Y. Ken Wada, K., Takeuchi, T., Odawara, T., Usui, C., & Nakamura, H.(2014). Preventive Effects of Ramelteon on Delirium: A Randomized Placebo-Controlled Trial. JAMA Psychiatry, 71(4), 397-403. doi:10.1001/jamapsychiatry.2013.3320. https://jamanetwork.com/journals/jamapsychiatry/article-abstract/1831407
• Mitsuaki, N. (2018). Effect of adminitration of Ramelteon, a Melatonin receptor agonist, on the duration of stay in the ICU: a singled-center randomized placebo-controlled trial. Critical care Medicine, 46(7), 1099-1105. DOI: 10.1097/CCM.0000000000003132
