Graziano OnderDept. of Geriatrics, Neurosciences and OrthopedicsCatholic University of the Sacred Heart, Rome - Italy
LA GESTIONE DEL TRAUMA NELL’ANZIANOLe alterazioni cognitivo-comportamentali:
Il DELIRIUM
Introduzione: anziano con trauma/frattura
Fragile
Alta prevalenza di multimorbilità cronica
Polifarmacoterapia
Alto rischio di:
• Inappropriato uso di farmaci
• Eventi negativi
• Disidratazione
• Malnutrizione
Delirium: I numeri/background
In particolare:Il 25-65% dei pazienti con frattura di femore sviluppano delirium
• Soggetti ospedalizzati: dall’11% al 42%• Dopo chirurgia: fino al 60%• Peggiora la prognosi
• Aumenta la mortalità• Aumenta la durata della degenza• Aumenta la disabilità
Delirium: Le conseguenze
Witlox et al. JAMA 2010
Delirium: I costi
…delirium was associated with a mean incremental total length of hospital stay of 7.4 days (95% confidence interval [CI] = 3.7 to 11.2 days; p < 0.001), and a mean incremental episode-of-care cost (in 2012 Canadian dollars) of $8286 (95% CI = $3690 to $12,881; p < 0.001). The total incremental episode-of-care cost attributable to delirium over the study period was $961,131 in 2012 Canadian dollars.
Health Economic Implications of PerioperativeDelirium in Older Patients After Surgery for a Fragility Hip Fracture
Zywiel et al. J Bone Joint Surg Am 2015
Delirium: fattori di rischio
OBJECTIVES: To evaluate risk factors for postoperative delirium in a cohort of elderly hip-surgery patients and to validate a medical risk stratification model.
Kalisvaart et al. J Am Geriatr Soc 2006
Delirium: fattori di rischioRisk factors for postoperative delirium following hip fracture repair
• Cognitive impairment 3.21
• Advanced age 2.25
• Living in an institution 2.94
• Heart failure 2.46
• Total hip arthroplasty 2.21
• Multiple comorbidities 1.37
• Morphine usage 3.01
• Female gender 0.83
Odds Ratio
Yung Y et al. Aging Clin Exp Res 2016
Delirium e farmaci: Drug-GeriatricSyndrome interactions
NH (SHELTER) N=4023 Interacting drugs
Delirium (n=691)Falls (n=774)Incontinence (n=3098)Malnutrition (n=391)
65.7%79.1%72.2%66.8%
HC (IBenC) N=1778
Delirium (n=252)Falls (n=372)Incontinence (n=806)Malnutrition (n=161)
77.8%36.3%60.4%37.9%
Delirium: dolore e sintomi psichiatrici
0
10
20
30
40
50
Alterazione processi ideativi
Delirio Allucinazioni Qualsiasi sintomo
Non dolore Dolore
%
p<0.001 p=0.44 p<0.001p=0.006
Tosato et al. et al Pain 2012
Delirium
Delirium: dolore e sintomi psichiatrici
Husebo B et al BMJ 2011
Treatment of pain and behavioural symptoms in NH residents with dementia
Riconoscere precocemente il delirium
Early symptoms in the prodromal phase of delirium: a prospective cohort study in elderly patients undergoing hip surgery.
The Delirium Rating Scale-Revised (DRS-R-98) was used to measure early symptoms during the prodromal phase before the onset of delirium.RESULTS: The average DRS-R-98 total scores on day -4 to day -1 before delirium were 1.9 for the comparison group patients and 5.0, 4.3, 5.8, and 10.7 for patients with postoperative delirium. Multivariate analysis showed that the early symptoms memory impairments, incoherence, disorientation, and underlying somatic illness predict delirium.
De Jonghe et al. Am J Geriatr Psychiatry. 2007
Delirium: prevenzione
1. Evitare l’uso di farmaci a rischio2. Mantenere una buona idratazione3. Evitare l’ipossia4. Trattare prontamente patologie acute5. Stimolazione cognitiva/riorientamento (Really orientation)6. Correggere i deficit sensoriali7. Tenere l’ambiente ben illuminato e poco rumoroso8. Tenere sotto controllo il dolore9. Rassicurazione10. Facilitare la presenza dei familiari11. Ridurre al minimo mezzi di contenzione e utilizzo di presidi
invasivi (catetere vescicale, linee venose)12. Facilitare il ritmo sonno-veglia13. Favorire la mobilizzazione14. Prevenzione infezioni
Delirium: prevenzione
OBJECTIVES: To evaluate the effect of inpatient geriatric
consultation teams (IGCTs), which have been introduced to
improve the quality of care of older persons hospitalized on
nongeriatric wards, on delirium and overall cognitive
functioning in older adults with hip fracture.
Deschodt et al. JAGS 2012
Results
• More controls (53.2%; n = 41) than intervention group participants (37.2%; n = 35; p=.04; OR=1.92, 95% CI 1.04–3.54) were delirious at any point after surgery.
• Cognitive decline at discharge was higher in controls than in those assigned to geriatric intervention (38.7% vs 22.6%; P = .02; OR = 2.16, 95% CI = 1.10–4.24).
Deschodt et al. JAGS 2012
OBJECTIVES: To compare the feasibility (adherence) andeffectiveness (prevalence of delirium, length of stay, mortality, discharge site) of delirium-friendly preprinted post-operative orders (PPOs) for individuals with hip fracture, administered by regular orthopedic nurses, with routine postoperative orders.
Freter S et al. JAGS 2016
Delirium: “intervention”
• Acetaminophen administration scheduled and doses and frequency of as-needed opioid analgesics are lower.
• The option for nighttime sedation is trazodone.
• Benzodiazepines are not initiated or abruptly withdrawn.
• For nausea, domperidone was available.
• Urinary catheters were removed on postoperative Day 2.
• Laxatives are scheduled.
• Postoperative blood work is expanded to help the treating team identify dehydration.
• In case of severe agitation, low doses of haloperidol are used.
Freter S et al. JAGS 2016
Delirium: results
Freter S et al. JAGS 2016
Delirium: terapia
Farmacologica
IL TRATTAMENTO SI BASA SULL’IDENTIFICAZIONE E TRATTAMENTO DELLA CAUSA SCATENANTE
Non farmacologica
Gli obiettivi sono principalmente tre: 1) trattare la causa2) fornire terapia di supporto3) prevenire gli infortuni del paziente stesso e di chi gli sta vicino
Delirium: terapia non farmacologica
• Interventi ambientali (riduzione degli stimoli sonori e luminosieccessivi, ri-orientamento temporale, oggetti personali), presenzadei familiari, assistenza infermieristica
• Correzione delle cause metaboliche, trattamento delle patologiesottostanti, revisione della terapia farmacologica:
eziologia multifattoriale -> trattamento multifattoriale
• Normalizzazione del ritmo sonno-veglia
Delirium: terapia farmacologica
• Three studies were found that satisfied selection criteria.
• Low dose haloperidol may be effective in decreasing the degree and duration of delirium in post-operative patients.
• Haloperidol in low dosage has similar efficacy in comparison with the atypical antipsychotics.
• High dose haloperidol was associated with a greater incidence of side effects than the atypical antipsychotics.
Antipsychotics for delirium
Lonergan et al. Cochrane Database Syst Rev. 2007
Delirium: terapia farmacologica
• Only one trial satisfying the selection criteria could be identified. • No adequately controlled trials could be found to support the use of benzodiazepines • Benzodiazepines cannot be recommended for the control of this condition.
Benzodiazepines for delirium
Lonergan et al. Cochrane Database Syst Rev. 2009
Delirium e farmaci: Antipsychotic druginteractions
Potential Adverse Effects caused
from interactions with antipsychotics
n (%)
• Decreased blood pressure and falls 210 (34.8%)
• QT prolongation 44 (7.3%)
• Sedation 43 (7.1%)
• Interactions with inhibitors of cytochrome p450
9 (1.5%)
• Anticholinergic effects 2 (0.3%)
All 278 (46.0%)
Liperoti et al. J Clin Psychiatry in press
SHELTER study (n=604)
Incident rate
per person-year
RR
(95% CI)
No interactions
Interactions
0.17
0.26
1
1.68 (1.13-2.49)
No interactions
Interactions
Log-Rank= 0.02
Liperoti et al. J Clin Psychiatry in press
Delirium e farmaci: Antipsychotic druginteractionsSHELTER study (n=604)
Delirium: conclusioni
Il delirium è comune nei pazienti con frattura
E’ importante:
- CONOSCERE e RICONOSCERE questa condizione
- Ricercare le possibili CAUSE e rimuoverle/trattarle
- Rivalutare sempre la TERAPIA FARMACOLOGICA
Delirium da farmaci
•Antipsicotici triciclici (fenotiazine)•Antidepressivi triciclici (Nortriptilina)•Barbiturici•Benzodiazepine•Antistaminici•Antiparkinsoniani•Antidiarroici (difenossilato)•Miorilassanti, spasmolitici•Prodotti da banco per il trattamento sintomatico della tosse (Codeina)•Digitale•Narcotici (Meperidina, Morfina)•Prednisolone•Antibiotici (Cefalosporine)•Oppiodi
