complex cases across the continuum of care examples in acute care c.patterson september 20 th 2006...

COMPLEX CASES ACROSS THE CONTINUUM OF CARE

EXAMPLES IN ACUTE CAREC.Patterson

September 20th 2006(abbreviated version posted to rgpc.ca)

Objectives

• By the end of this presentation the participant will:

• Recognize specific complications of acute illness, and develop an approach to management

• Appreciate issues of the “difficult discharge” in today’s acute care setting

Background

• Most patients in acute care are elderly• Most now have multiple illnesses and co-

morbidities• Lengths of stay are constantly expected to

be shorter• Hospitals are funded according to factors

such as acuity, complications, length of stay (funding can be withheld for longer than expected stays)

Case 1

• 84 year old lady lives alone independently; some help for finances and driving from daughter

• Diagnosed with mild Alzheimer’s disease one year ago, commenced donepezil, with some improvement

• Treated for: osteopenia (Calcium and vitamin D): dementia (donepezil 10 mg): hypertension (hydrochlorthiazide 25mg): insomnia (lorazepam 1-2 mg at night)

Case 1

• Monday:

• Slipped and fell on sidewalk, injured right hip

• Taken by ambulance to emergency department

• X-rays confirmed intertrochanteric fracture

• Moved to ward after 12 hours

Case 1

• Tuesday:

• Surgery under spinal anaesthetic at 0900h went uneventfully

• On night of surgery she became confused, verbally abusive and aggressive

• Pulled out i.v, climbed out of bed, resistive to care

Case 1

• Wednesday:

• Drowsy, hallucinating when more alert

• Looses focus while speaking

• Picking at bedclothes

• Resists care at times, restraints applied

• Visiting family are alarmed…

Case 1

• What’s going on?

• What more information do we need to know?

• Will she recover?

DELIRIUM!

DELIRIUM

• 10-40% on admission to hospital

• 25-60% incidence during hospitalization

• Increased mortality

• Prolonged length of hospital stay

• Harbinger of future problems 20% annual incidence of dementia

Delirium: Confusion Assessment Measure (CAM)

(Inouye et al. Ann Intern Med 1990;113:941)

Acute onset, fluctuating course AND

Inattention PLUS

Disorganized thinking OR

Altered level of consciousness [Sensitivity and specificity over 90%]

Clinical data

Medications:

• meperidine (Demerol)

• dimenhydrinate (Gravol)

• acetominophen +codeine (Tylenol # 2)

• hydrochlorthiazide

• lorazepam (Ativan)

Clinical data

• Afebrile

• P=90/min; RR=20/min; BP110/80

• Inattentive, picking at bedclothes

• Lung bases-crackles

• Oxygen saturation 88% on room air

Clinical data

• Hb: 92 g/l

• WBC: 11.2 (9.1 granulocytes)

• Urea: 5.1mmol/L

• Creatinine: 82 umol/L

• Sodium (Na): 125 mmol/L

• Potassium (K): 3.5 mmol/L

• Urine: many WBC

Causes of delirium: a checklist

• D: drugs

• Meperidine: semisynthetic opiate with anticholineric properties. Metabolyte accumulates in renal impairment and elderly AVOID!

• Dimenhydrinate: antihistamine with anticholinergic properties

• Codeine: opiate • Lorazepam: benzodiazepine; problems with withdrawal

AND new use• Donepezil: sudden discontinuation may worsen dementia


• E: endocrine

• Na 125-mildly lowered may result from medications (hydrochlorthiazide, opiates) or surgery (SIADH)


• M: metabolic causes

• Hypoxemia-respirations increased, lung findings, oximetry reading

• Chest X-ray confirmed congestive heart failure


• D: drugs-starting or stopping

• E: endocrine causes


• E: epilepsy or siezures

• N: neoplasm or tumour

• T: trauma


• T: trauma

• Hip fracture, haemorrhage, surgery


• D: drugs-starting or stopping

• E: endocrine causes


• E: epilepsy or seizure disorder

• N: neoplasm or tumour

• T: trauma

• I: infection


• I: infection

• Evidence of urinary tract infection


• D: drugs-starting or stopping• E: endocrine causes• M: metabolic causes• E: epilepsy or siezures• N: neoplasm or tumour• T: trauma• I: infection• A: apoplexy or vascular event


• A: apoplexy or vascular event

• Reason for congestive heart failure was a myocardial infarction (heart attack) occurring during or immediately after surgery


• D: drugs-starting or stopping• E: endocrine causes• M: metabolic causes• E: epilepsy or siezures• N: neoplasm or tumour• T: trauma• I: infection• A: apoplexy or vascular event

A concept: “the bits”

Her delirium resulted from:

• A bit of hyponatremia

• A bit too much medication

• A bit of heart failure

• A bit of infection

i.e. delirium is often caused by multiple factors

Who is at increased risk for delirium?

• Older people

• Preexisting cognitive changes (especially dementia)

• Poor functional status

• Electrolyte imbalance (Na, K, Glu)

• Poor vision, hearing

• Alcohol abuse

Precipitants of delirium

• 3 or more additional medications• Physical restraint• Bladder catheters• Malnutrition• Any iatrogenic event• Certain surgery (AAA, hip repair…)

Inouye & Charpentier JAMA 1996;275:852, Marcantonio et al JAMA 1994;271:134

Management of delirium

• TREAT UNDERLYING CAUSES!• Protect patient and carers• Familiar surroundings especially familiar

people• Cautious sedation • Many authorities prefer haloperidol

(Haldol) in small regular doses• Benzodiazepines (BZP) for alcohol and

BZP withdrawal

Outcome of delirium

• About 50% recover

• About 25% persist for prolonged periods or permanently

• About 25% decease in hospital (22-76%)

• One year mortality 35-45%

Prevention of delirium (by 40%)

The HELP program

• Early mobilization

• Adequate hydration and nutrition

• Vision aids

• Hearing

• Orientation

• Non pharmacological sleep measures S Inouye et al NEngJMed 1999;340:669

Case 2

• 87 year old man, collapsed in grocery store• Brought to hospital by ambulance• Febrile, unkempt, dirty• Confused, cooperative• Dehydrated, consolidation in lung• Chest X-ray showed right lower lobe pneumonia• Blood glucose 18.0 mmol/L = diabetes mellitus

Case 2

• Treated with i.v. fluids, oxygen, antibiotics, insulin then oral hypoglycemics

• Confusion improved, regained mobility

• Day 3, keen to go home; attending MD planned discharge on day 4.

• Nursing staff expressed concern about his safety at home

• Patient insisted that he would be fine

Case 2: day 4, morning

• Ward staff received call from son in USA concerned about his imminent discharge

Staff called:

• His family physician- who had not seen him for 2 years; non adherent with prescriptions..

• His pharmacy- periodic prescriptions from drop-in clinic for NSAIDS

Case 2: day 4, midday

• He insists on going home

• Permission obtained to call neighbour-reported squalid conditions at home

• OT asked to see re safety at home

• SW referral requested

Case 2: day 4, midday

• He insists on going home

• Permission obtained to call neighbour-reported squalid conditions at home

• OT asked to see re safety at home

• SW referral requested

• Angry doctor/manager/surgeon/discharge planner calls “We need that bed! He must go to LTC if he cannot go home!”

Case 2: day 4 pm

• Agreed to stay one more day

• Re examined; clinically improved; no major neurological findings

• Lab tests (calcium, TSH, B12,)-normal

• Brainscan

Case 2: OT assessment

• BADLs OK• Concern re safe meal preparation,

medications (antibiotics, hypoglycemics0• MMSE 27 (stm, temp orientation)• MOCA 20 (exec, fluency, abstraction)• Poor insight, poor judgement, • Impaired verbal reasoning/problem solving• Recommends home visit

Case 2

• What to do now?

• Safe to go home?

How much risk?(After Patterson & Rosenthal Lancet 1997; 350: 1164)

Risk tolerance

Severity of risk

Degree of insight

Summary

Risk

Careless High Poor Very high

Moderate Moderate Moderate Moderate-high

Cautious Low Full Low

Capable of deciding?

Does he have the ability to:Understand his problemsUnderstand proposed treatmentsUnderstand alternativesUnderstand option of refusing proposed treatmentsAppreciate consequences of accepting or refusing

proposed treatmentsMake decision not based on delusion or

depression After: Etchells et al CMAJ 1996;155:657

Case 2: follow up

• 2 months after discharge

• Living at home

• Neighbours continue to be supportive

• MOW cancelled, resumed his own shopping (neighbours take him)

• Minimal requirement for medications

• Son has withdrawn from scene

Conclusions

• Importance of complete, relevant data collection

• Be not content with one explanation (e.g. “the bits” and delirium)

• Bring in the troops to help assess risk (OT, SW, pharmacist…)

• Mobilize community resources (e.g. family, neighbours, parishioners + CCAC) to manage risk

Conflicts of interest

• Research funds from Pfizer

• Research funds from Janssen-Ortho

• Speakers fees from Pfizer, Janssen-Ortho,

• Consultation fees from Pfizer

complex cases across the continuum of care examples in acute care c.patterson september 20 th 2006...

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