duke gec delirium what’s in a name? duke geriatric education center 5-16-12

Duke GEC

www.interprofessionalgeriatrics.duke.edu

DELIRIUMWhat’s in a name?

Duke Geriatric Education Center5-16-12

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Objectives

• Compare diagnostic terminology in a case• Deliberate the clinical importance of the

choice of a term• Review core concepts of delirium

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Group exercise

Duke GEC

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Diagnosis

Cheung, Intensive Care Med, 2008.

Duke GEC

www.interprofessionalgeriatrics.duke.eduCheung, Intensive Care Med, 2008.

Duke GEC

www.interprofessionalgeriatrics.duke.eduCheung, Intensive Care Med, 2008.

Duke GEC

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What makes a diagnosis a diagnosis?

• Identifiable and distinct clinical features• Defined risk factors• Discernible causes• Underlying pathophysiology• ? Distinct/unique management strategy

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Clinical Features of Delirium

• Acute or subacute onset• Fluctuating intensity of symptoms • Inattention • Disorganized thinking• Altered level of consciousness

– Hypoactive v. Hyperactive• Sleep disturbance• Emotional and behavioral problems

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Duke GEC

www.interprofessionalgeriatrics.duke.edu

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

www.interprofessionalgeriatrics.duke.edu

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

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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

www.interprofessionalgeriatrics.duke.edu

Duke GEC

www.interprofessionalgeriatrics.duke.edu

PsychosocialAssess substance useAddress stress and distressEducate patient and familyAssess decision makingConsider function and safety

PharmaceuticalReduce/avoid certain meds- Benadryl, Benzo’sMonitor for S.E.’s of pain medsLow dose neuroleptic Benzo’s for withdrawal

PhysiologicO2 and BPFood and fluidsSleep/wake cycleActivity and mobilityBowel and bladderPainInfections

EnvironmentalReorientationContinuity in careFamily or sittersHearing aids, glassesQUIET at nightNo restraints

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Advantages to calling it “delirium”?

• Improve awareness and recognition• Improve communication

– Team– Family– Patient

• Standardize treatment protocols

Duke GEC

www.interprofessionalgeriatrics.duke.edu

Mnemonic challenge

• Create a mnemonic for risk factors and/or management using D-E-L-I-R-I-U-M

• Judging criteria:– Creativity– Memorizability– Represents perspective of different professions