Duke GEC Delirium Basics Jason Moss, PharmD, & Eleanor McConnell, PhD, RN, GCNS-BC October 24,...

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Delirium BasicsJason Moss, PharmD, &

Eleanor McConnell, PhD, RN, GCNS-BC

October 24, 2011

Duke GEC


Objectives

• Describe the prevalence of delirium and its impact on the health of older patients

• Discuss pathophysiology, risk factors and key presenting features

• Distinguish presenting features of delirium, dementia and depression

• Use nursing process to organize thinking about key nursing activities in preventing and managing delirium

• Find opportunities to improve current practice

Duke GEC


Item #1 from 3-D quiz

Question: A chronic, progressive loss of brain cells resulting in decline of day-to-day cognition and functioning. A.DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC



Question: At least 6weeks, but can last several months to years, especially if not treated. A.DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC



Question: Performance on mental status exam may vary from poor to good depending of time of day and fluctuation in cognition.A. DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC



Question: Often of a frightening or paranoid nature. A.DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC



Question: Treatable and reversible especially if caught early. A.DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC


Meet Mrs. Florence

• 78 year old resident of Durham admitted to the hospital after a fall in her home…..

• https://phw-lmsc.duhs.duke.edu/production/DUHS_Common/delirium/videos/hyper_clip1_101711/hyper_clip1_101711.html• https://phw-lmsc.duhs.duke.edu/production/DUHS_Common/delirium/videos/hyper_clip2_101711/hyper_clip2_101711.html

• Have you ever seen anyone like this?• How would you describe her behavior?• What do you think is wrong?

Duke GEC


What is Delirium?1. Acute onset of mental status

changes

or a fluctuating course

and

2. Inattention

and or

3. Disorganized Thinking

4. Altered level of consciousness

= Delirium

CAM, CAM-ICUCAM, CAM-ICU

Duke GEC


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.

Duke GEC


Rudolph J et al, 2011

Duke GEC


Costs of Delirium• In-hospital complications1,3

– 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

Duke GEC


So…If delirium such a big problem, why don’t we hear more about it?

https://phw-lmsc.duhs.duke.edu/production/DUHS_Common/delirium/videos/hypo_clip1_101811/hypo_clip1_101811.html

https://phw-lmsc.duhs.duke.edu/production/DUHS_Common/delirium/videos/hypo_clip2_101811/hypo_clip2_101811.html

1. Acute or subacute onset

2. Fluctuating intensity of symptoms

3. Inattention 4. Disorganized thinking5. Altered level of

consciousness• Hypoactive v.• Hyperactive

6. Sleep disturbance7. Emotional and

behavioral problems

Duke GEC


Delirium Pathophysiology

Flacker, et al. Gerontol. Bio Scie 1999; 54A: B239-B246

Duke GEC


Let’s go back to our case!

Duke GEC


Mrs. Florence: Background

• 78 year old female who fell climbing into attic• PMH significant for Knee Osteoarthritis

Hypertension, Restless legs, Stroke• Married, lives with husband of 52 years• 4 beers a dayOn admission to the hospital:• BAL=80• Na=128• Pain score 9/10

Duke GEC


Medications

Outpatient– clonazepam– ropinirole– lisinopril

– aspirin– furosemide– amlodipine– oxycodone– oxybutynin– OTC benadryl as needed

for allergies

Inpatient– ropinirole– lisinopril

– aspirin– furosemide– amlodipine– oxycodone prn– oxybutynin– sliding scale insulin– ranitidine

Duke GEC


Risk Factors

• Baseline Vulnerability (Predisposing)-Risk factors r/t person’s baseline - Often we cannot modify these

• Precipitating– These are things that happen to the

patient– Insults– Often Iatrogenic

• Baseline + Precipitating = Delirium

Duke GEC


Risk Factors- General• Baseline Vulnerability

– Underlying Brain Disease (Dementia, Stroke, Parkinson’s Disease)

– Increased Age– Institutionalization– Chronic disease

(HIV, ETOH dependency, diabetes, etc)

– Visual/Hearing deficits

• Precipitating– Medications– Infection– Dehydration– Immobility/restraints– Malnutrition– Tubes/catheters– Medications– Electrolyte imbalance– Sleep Deprivation

Duke GEC


Framework for Risk

Baseline Vulnerability

Low

High

Mild/None

Noxious

Precipitating Stimulus

Duke GEC


Medication Side Effects

• Anticholinergic

• CNS sedation

• Constipation

• Abrupt withdrawal of chronic psychotropic medications

Duke GEC


Concerning MedicationsAnticholinergic

OxybutyninAmitriptyline

(**furosemide, ranitidine)

Antihistamines Diphenhydramine (Benadryl)Chlorpheniramine

Anticonvulsants PrimidonePhenobarbital

Antiparkinsonian Levodopa-carbidopaDopamine agonists

Antipsychotics Clozapine and other atypicals

Benzodiazepines Diazepam, clonazepam

Hypnotics Zolpidem (Ambien)

Opioid analgesics Meperidine, morphine, oxycodone

Duke GEC


Medications

Outpatient– clonazepam– ropinirole– lisinopril

– aspirin– furosemide– amlodipine– oxycodone– oxybutynin– OTC benadryl as needed

for allergies

Inpatient– ropinirole– lisinopril

– aspirin– furosemide– amlodipine– oxycodone prn– oxybutynin– sliding scale insulin– ranitidine

Duke GEC


What Predisposing Factors Did She Have?

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

Marcantonio, 2011.


Low

High

Mild/None

Noxious

Precipitating Stimulus

Duke GEC


Common Risk Factors for DeliriumPredisposing• 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.

Duke GEC


What Predisposing Factors Did She Have?

Marcantonio, 2011.


Low

High

Mild/None

Noxious

Precipitating StimulusPrecipitating

• 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

Delirium!

Duke GEC


What is Delirium?1. Acute onset of mental status

changes

or a fluctuating course

and

2. Inattention

and or

3. Disorganized Thinking

4. Altered level of consciousness

= Delirium

CAM, CAM-ICUCAM, CAM-ICU

Duke GEC


Improving The Odds of Recognition

Prediction by risk– Predisposing and precipitating factors

Team observations– Nursing notes

Clinical examination– CAM

Duke GEC


Team Input

• Nursing recognition of high risk medications for delirium– Ask– Observe– Be suspicious– Communicate

Kamholz, AAGP 1999

Duke GEC


1 month before adm PCP Note Episode of confusion following her knee surgery. She does not feel confused presently.

Presents to ED 20:20 ED Verbally converses and oriented 5

Day Admitted 01:25 Adm Data She can’t tell me how many stairs she fell down. She is a little disoriented…reports ~2 beers per day which puts her at risk for withdrawal...monitor closely for signs/symptoms of withdrawal.

Day Admitted 03:05 PRM 10:40 AM BSN Findings: Independent prior to admission: Newly dependent

Hospital Day 1 03:10 Nursing Patient is very drowsy.

Hospital Day 1 10:14 OT Cognition: Alert, changed to lethargic once medication had taken affect.

Hospital Day 1 11:40 PT Cognition: Impaired…Oriented to self, place, time, situation, with significant prompting.

Hospital Day 1 17:25 Post Anesthesia Reports mild post-operative confusion, but per husband significantly better anesthesia recovery than the previous surgery 1 year prior.

Hospital Day 1 18:55 Nursing Pt a/o x 3, unaware of correct date/time…pulling at soft cast on left hand but reorients well.

Hospital Day 1 22:22 Nursing Pt is alert and orientedx4, with mild anxiety present…pulling wrap to arm…told numerous times to leave it alone…order for a hand mitt restraint…is aware if tugging again will be restrained.

Hospital Day 2 03:03 Nursing alert and orientedx2-3, with mild anxiety and occasional hallucinations… pulled out foley catheter...pulled at cast… Bilat hand mitts and wrist restraints were applied.

Hospital Day 2 14:04 Nursing Pt. AOx1-2, very agitated and restless at times... Pt. resting quietly at this time. Family at bedside.

Hospital Day 4 15:00 PT The patient reports "Take this off of me (referring to restraints and mits) so I can run an errand."

Hospital Day 4 18:52 Nursing Pt s/p right radial fracture, right hip fracture, now with delirium r/t possible alcohol w/d.

Hospital Day 5 05:08 Nursing Has been agitated…Sitter at bedside. Restraints. Pt not agitated at the time the BP taken.

Hospital Day 5 18:32 Nursing A&ox4 today with some stm deficits noted.

Hospital Day 5 15:01 Nursing PATIENT CAN BE IMPULSIVE AT TIMES…EMOTINOAL SUPPORT GIVEN

Duke GEC


Assessment: Standardized Tool

• Confusion Assessment Method (CAM-ICU)Puts definition into action!

1.Change in cognitive status in past 24 hours?2.Inattention?3.Altered Consciousness?4.Content of consciousness http://www.mc.vanderbilt.edu/icudelirium/

Duke GEC


• http://www.mc.vanderbilt.edu/icudelirium/

Duke GEC


Richmond Agitation-Sedation Score (RAAS)

Duke GEC


Intervention

• Prevention 1st!

• Management 2nd

Duke GEC


Nursing Interventions & EvaluationYale Delirium Yale Delirium PreventionPrevention Program : Program : multi-component multi-component

interventionsinterventions Cognitive impairment with Reality OrientationCognitive impairment with Reality Orientation Sleep enhancement protocolSleep enhancement protocol Sensory impairment with therapeutic activities protocol Sensory impairment with therapeutic activities protocol Sensory deprivation Sensory deprivation DehydrationDehydration

Reduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodesReduction in delirium 9.95% (c) vs. 15% (i); LOS & # episodesInouye 2004Inouye 2004

Post op multi-factorial Post op multi-factorial intervention intervention educational programeducational program Teamwork and care planning on prevention and treatment of deliriumTeamwork and care planning on prevention and treatment of delirium Targeted delirium risk factorsTargeted delirium risk factors

Post op delirium compared to controls (56/102 and 73/97) Post op delirium compared to controls (56/102 and 73/97) Lundrtrom, et al. 2007Lundrtrom, et al. 2007

Duke GEC


Delirium: Nursing Strategies

Duke NICHEGeriatric Resource Nurse Initiative

Kristin Nomides RNKristin Nomides RN

Grace Kwon RNGrace Kwon RN

Samantha Badgley RN Samantha Badgley RN

Duke Hospital 2100Duke Hospital 2100

Duke GEC


Duke NICHE: Nursing Interventions:• Delirium & Risk Factors Staff EducationDelirium & Risk Factors Staff Education• Activity Cart / Busy ApronActivity Cart / Busy Apron

– Stimulate cognitive and motor skillsStimulate cognitive and motor skills• All About Me All About Me PosterPoster

– Orientation InformationOrientation Information• MeMe File File

– Orientation information provided by patient / Orientation information provided by patient / family for high risk patientsfamily for high risk patients

• Question MarkQuestion Mark– Identification of patients with AMSIdentification of patients with AMS ??

AlteredMental Status

Duke GEC


Other Management• Medications

– Low doses of certain antipsychotics– Short-acting benzodiazepines– Older adults may require lower doses

• Symptom triggered therapy– Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-A)

• Supportive therapy– Comorbidities– Hydration and nutrition

• Team care

Duke GEC


Back to Mrs. Florence

Hospital Course and beyond:•Pain management•Sitters and family•Activity•Clonazepam•Geriatrics consultation

Duke GEC


Summary• RESPECT delirium. Its common and caustic.• PREDICT delirium. Assess for common

predisposing and precipitating factors.• RECOGNIZE delirium. It can be diagnosed with

simple tools (e.g. CAM).• PREVENT delirium. It can be averted with

multicomponent strategies.• RECRUIT team members to improve care.

Duke GEC


Summary

• Maintain a high level of suspicion• Document findings in the chart• Discuss with other members of the team• Inform/educate patients and families

Duke GEC


A better way….

PsychosocialPsychosocial

PharmacologicPharmacologic

PhysiologicPhysiologic

EnvironmentalEnvironmental

Medicine

Nursing

PT/OT

Pharmacy

Social work

Nutrition

PA’s

Patients and

Caregivers

Administrators

NP’s

Duke GEC


Supplemental Resources

• GRECC 5-D Card• Delirium brochure for direct caregivers• – Vanderbilt University www.icudelirium.org

– RASS pocket cards– Videos for CAM administration (2 minutes!)

• Vancouver Health Authority– http://www.viha.ca/mhas/resources/delirium/

tools.htm

Duke GEC


Delirium Teaching Rounds “Itching for a Fight!”

November 4, 2011

Duke GEC


GEC crew• Eleanor McConnell, RN, MSN,

PhD• Anthony Galanos, MD• Jason Moss, PharmD• Julie Pruitt, RD• Cornelia Poer, MSW• Gwendolen Buhr, MD• Mamata Yanamadala, MD• S. Nicole Hastings, MD• Jennie De Gagné, PhD, MSN, MS,

RN-BC , CNE• Katja Elbert-Avila, MD• Mitch Heflin, MD

• Sandro Pinheiro, PhD• Robert Konrad, PhD• Emily Egerton, PhD• Heidi White, MD• Kathy Shipp, PT, PhD• Deirdre Thornlow, RN, PhD• Lisa Shock, MHS, PA-C• Michelle Mitchell, LMBT• Michele Burgess, MCRP• Joan Pelletier, MPH• Sujaya Devarayasamudram, RN,

MSN• Loretta Matters, RN, MSN

Duke GEC


Acknowledgements

• Mitchell Heflin, MD & Cornelia Poer, MSWDuke University Geriatrics Division for case material & slides adapted from Medicine Grand Rounds February, 2011

• Brenda Pun, RN, MSN, ACNP – slides adapted from Delirium II Module prepared for Duke University School of Nursing Geriatric Innovations in Nursing Education (GNIE) Project

• Duke-NICHE Geriatric Resource Nurses:Duke-NICHE Geriatric Resource Nurses:– Kristin Nomides, RNKristin Nomides, RN– Grace Kwon RNGrace Kwon RN– Samantha Badgley, RN Samantha Badgley, RN – Yvette West, RN, C MSN, Director, Duke-NICHE Yvette West, RN, C MSN, Director, Duke-NICHE

Duke GEC



Question: A chronic, progressive loss of brain cells resulting in decline of day-to-day cognition and functioning. A.DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC



Question: At least 6weeks, but can last several months to years, especially if not treated. A.DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC



Question: Performance on mental status exam may vary from poor to good depending of time of day and fluctuation in cognition.A. DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC



Question: Often of a frightening or paranoid nature. A.DepressionB. DeliriumC. DementiaD. I don’t know.

Duke GEC



Question: Treatable and reversible especially if caught early. A.DepressionB. DeliriumC. DementiaD. I don’t know.

Date post:	28-Dec-2015
Category:	Documents
Upload:	jocelin-boyd
View:	216 times
Download:	2 times

Duke GEC Delirium Basics Jason Moss, PharmD, & Eleanor McConnell, PhD, RN, GCNS-BC October 24,...

Documents