Week 1 Module A: Instructions

Please view video 1 and review charts prior to starting this module.

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Week 1 Module A: Instructions

For each question, please choose one answer that best addresses the question and then hit “click here.”

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Week 1 Module A: Question 1

What is the ICD-9 diagnosis of Mrs. Rivera’s cognitive state?

A. Acute mental status change click here B. Subacute befuddlement click here C. Δ MS click here D. Delirium click here

Why should we care about delirium in the elderly?

Incidence Among Elderly Patients is HIGH

1/3 of patients presenting to ER 1/3 of inpatients aged 70+ on general med

units Occurs in 10-15% after elective noncardiac

surgery May exceed 50% after emergent hip

fracture repair

Delirium: Increased Mortality

Delirium is an independent predictor of higher mortality up to 1 year after occurrence:

Hazard ratio = 2-3 (people with delirium compared to people without it)– Even after adjustment for covariates such as age, illness severity,

comorbid conditions, dementia, use of sedatives or analgesic meds

– (McCusker J et al. Arch Intern Med. 2002; 162:457-463; Ely EW et al. JAMA. 2004; 291:1753-62)

Delirium: Increased Risk of…

Functional decline New nursing home placement Persistent cognitive decline:

– Only 18-22% of hospitalized elders had complete resolution of delirium 6-12 mo after discharge

– However: Many subjects in these studies had preexisting cognitive impairment

– (Levkoff SE et al. Arch Intern Med. 1992; 152:334-40; McCusker J et al. J Gen Intern Med. 2003; 18:696-704)

Week 1 Module A: Question 2

What features of Mrs. Rivera’s presentation are more consistent with delirium than with dementia?

A. Disorientation to place click here B. Acute change in mental status click here C. Inattention click here D. Lethargy click here

How to Distinguish Delirium from Dementia

Features seen in both:– Disorientation– Memory impairment– Paranoia– Hallucinations– Emotional lability– Sleep-wake cycle

reversal

Key features of delirium:– Acute onset– Impaired attention– Altered level of

consciousness

Assume it is Delirium until Proven Otherwise!!!

Delirium may be the only manifestation of life-threatening

illness in the elderly patient

There is a simple and quick way to diagnosis delirium…

CONFUSION ASSESSMENT METHOD

Inouye et al Ann of Intern Med 1990; 113: 941-948

(1) Acute change in mental status with a fluctuating course, with

(2) Inattention

AND

(3) Disorganized thinking

OR

(4) Altered level of consciousness

Inouye et al Ann Intern Med 1990; 113 (12): 941-948

Sensitivity: 94-100%, Specificity: 90-95%

Week 1 Module A: Question 3

Factors that may be contributing to Mrs. Rivera’s delirium include:

A. Underlying cognitive impairment click here

B. Over-the counter medications click here C. Pleuritic chest pain click here D. Hypoxia click here E. All of the above click here

A Model of Delirium

A multifactorial syndrome that arises from an interrelationship between:

Predisposing factors a patient’s underlying vulnerability

AND Precipitating factors noxious insults

Delirium arises when noxious insults act in combination with a patient’s predisposing factors.

Predisposing Factorsi.e. baseline underlying vulnerability

Baseline cognitive impairment– Dementia patients have a

2.5-fold increased risk of delirium

– 25-31% of delirious patients have underlying dementia

Medical comorbidities:– Any medical illness

Visual impairment Hearing impairment Functional

impairment Advanced age History of ETOH

abuse Male gender

“A Predictive Model for Delirium in Hospitalized Patients based on Admission

Characteristics”Inouye SK et al Ann Intern Med 1993; 119: 474-481

Two prospective cohort studies done in tandem

Age 70 and over Patients without delirium on admission Question: what characteristics were most

strongly associated with occurrence of delirium?

Independent Predisposing Risk Factors Inouye et al Ann Intern Med 1993;119:474-481

Risk Factor Adjusted RR 95% CI

Vision impairment

3.51 1.15 to 10.71

Severe illness 3.49 1.48 to 8.23

Cognitive impairment

2.82 1.19 to 6.65

High BUN/Cr ratio

2.02 0.89 to 4.60

“A Predictive Model for Delirium in Hospitalized Patients

based on Admission Characteristics”: Performance of the Predictive Model Inouye et al Ann Intern Med 1993;119:474-481

Risk group # of Risk Factors (see

preceding slide for factors)

Development

Cohort

% delirium

ValidationCohort

% delirium

Low 0 9% 3%

Intermediate 1-2 23% 16%

High 3-4 83% 32%

P<0.0001 P<0.002

The more predisposing risk factors present…

The more likely delirium becomes. Perhaps you can target elderly patients at

the start of their hospitalization for interventions that would decrease their risk of developing delirium…

More to follow later

Precipitating Factorsi.e. noxious insults

Medications Bedrest Indwelling bladder

catheters Physical restraints Iatrogenic events Uncontrolled pain Fluid/electrolyte

abnormalities

Infections Medical illnesses Urinary retention

and fecal impaction ETOH/drug

withdrawal Environmental

influences

Some drug classes that are associated with delirium

Medications with psychoactive effects: – 3.9-fold increased risk of delirium– 2 or more meds: 4.5-fold

Sedative-hypnotics: 3.0 to 11.7-fold Narcotics: 2.5 to 2.7-fold Anticholinergic meds: 4.5 to 11.7-fold Risk of delirium increases as number of

meds prescribed increases

Always ask about over-the-counter medications

Remember: many OTC sinus and cold preparations contain antihistamines with anticholinergic activity.

References and Resources

Inouye SK. Delirium in hospitalized older patients. Clinics in Geriatric Medicine 14(4):745-64, 1998.

Ely EW. et al. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 291(14): 1753-62, 2004.

Levkoff SE et al. Delirium: The Occurrence and Persistence of Symptoms among Elderly Hospitalized Patients. Arch Intern Med. 152:334-340, 1992.

Inouye SK et al. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Based on Admission Characteristics. Ann Intern Med. 119:474-481, 1993.

Inouye SK et al. Clarifying Confusion: The Confusion Assessment Method: A New Method for Detection of Delirium. Ann Intern Med. 113: 941-948, 1990.

Inouye SK et al. Delirium in Older Persons. NEJM. 354:1157-1165, 2006. McCusker J. Cole M. Abrahamowicz M. et al. Delirium predicts 12-month mortality. Arch Intern

Med. 162(4): 457-63, 2002 Feb 25. McCusker J. Cole M. Dendukuri N. et al. The course of delirium in older medical inpatients: a

prospective study. J Gen Intern Med. 18: 696-704, 2003. Delirium. Geriatrics Review Syllabus: A Core Curriculum in Geriatric Medicine, Teaching Slides.

Volume 1, Fifth Edition. Blackwell Publishing, copyright American Geriatrics Society, 2003

Click here to end

This is Delirium

While the terms acute mental status change, subacute befuddlement and Δ MS have all been used in the medical literature to describe this condition, you cannot bill for these entities.

Delirium has a few ICD-9 codes. ICD-9 code for delirium= 780.09 ICD-9 code for acute delirium= 293.0 Click here for next slide

Correct: This is Delirium

Mrs. Rivera has delirium. This is a billable diagnosis, whereas the other choices do not have actual ICD-9 codes.

ICD-9 code for delirium= 780.09 ICD-9 code for acute delirium= 293.0 Click here for the next slide

Delirium and dementia share common features

It is very difficult to distinguish delirium from dementia in patients that you are evaluating for the first time.

There are symptoms that are common to both conditions.

For example, disorientation to place can occur in both dementia and delirium.

click here for the correct answer

Correct answer.

Delirium differs from dementia in the following key ways:

Time course: whereas dementia usually progresses over time, delirium occurs acutely

Inattention: demented patients have intact attention span

Altered level of consciousness: demented patients are generally alert

click here for the next slide

Correct answer.

There are likely many factors contributing to Mrs. Rivera’s delirium. Her acute illness, with its concomitant fever, hypoxia, tachycardia, pleuritic chest pain, is likely playing a large role.

She may have taken over-the-counter cold preparations that contain antihistamines with anticholinergic side effects.

She also has a few predisposing factors for developing delirium: cognitive impairment (MMSE 22/30), visual impairment (cataracts).

click here for the next slide

Usually, there is more than one factor contributing to delirium

In elderly patients, look for more than one etiology of delirium.

While Mrs. Rivera’s cognitive impairment, pleuritic chest pain, OTC medication use, and hypoxia are all possible etiologies, it is unlikely that just one of these factors is the sole source of her delirium.

click here for the correct answer

End of Week 1 Module A