delirium: part 1files.hgsitebuilder.com/hostgator257222/file/d26part1of2...(pogo, the portal for...
TRANSCRIPT
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Delirium: Part 1
Maria Orsini EdD, MSN, RN
Chief Nurse Performance Improvement and Research
Durham VA Health Care System
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OBJECTIVES
• Define Delirium
• Define Challenges with Delirium: Before and after COVID Era
• List Outcomes Associated with Delirium
• Use Validated Instrument to Measure Delirium
• Practice Using CHIMBOP Model
• Review Study on Restraints & Delirium
• List Differences between Delirium & Depression
• Review Studies on Medications & Consultation
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What is Delirium?
• Syndrome
• Sudden/Acute
• Confusion
• Unable to focus/Inattention
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What concerns do you have?Nursing Response…
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Challenges of Caring for Older Adults
Atypical Presentation of Illness
Reduced mobility Falling
Acute Confusion Fatigue
Anorexia Urinary Incontinence
Functional decline Lack of pain with a disease known to
Generalized weakness cause pain
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COVID ERA: Atypical Symptoms
• Decreased general well being
• Poor feeding
• No dyspnea
• No fever
• No cough
• (Kotfis, et al., 2020; O’Haulou & Inouye, 2020)
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Delirium in COVID ERA
Neurological Symptoms• Lack of smell and taste• Short and long-term memory loss• Short and long-term cognitive dysfunction• 8% headache• 1% central mediated nausea and vomiting• 45% neuro symptoms in severely ill patients• Look for early symptoms of delirium which may
indicate impending respiratory failure• (Kotfis, et al., 2020)
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2.5X (Han et al., 2009)
22-76% Delirium (McCusker, et al., 2002)
Mortality
55% COVID + Delirium 50 years or older (Garcez et al., 2020)
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NOT RECOGNIZED
delirium
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Lack of Recognition
• https://pogoe.org/content/9928
• https://pogoe.org/content/9929
(POGO, The Portal for Geriatrics Online Education)
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Mixed Delirium= Hyper + Hypo Deliriumhttps://pogoe.org/content/9930(POGO, The Portal for Geriatrics Online Education)
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Pain Recognition in Delirium
• https://pogoe.org/content/9926
(POGO, The Portal for Geriatrics Online Education)
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Diagnostic Accuracy of Confusion Assessment Method (Pamaiahgari, 2018)
Sensitivity (++)
CAM 82%
CAM-ICU 81%
Specificity (- -)
CAM 99%
CAM-ICU 98%
Delirium Superimposed on Dementia
CAM 77%
Delirium Superimposed on Dementia
CAM 96%-100%
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After learning how to use the Confusion Assessment Method (CAM), learners will demonstrate completing a CAM using an
scenario
Learning outcome #1
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How to Assess Inattention
Do not use orientation questions!
Ask one of these questions
• Tell me the dates of the month backwards, starting with December (six months)
• Spell the word “LUNCH” backwards
• Tell me the numbers from 10 to 1 backwards
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How to Assess Disorganized Thinking
• Clinical Symptoms: hallucinations, illusions, delusions• Answers from common sense Yes/No questions:
– Will a stone float on water?– Are there fish in the sea?– Does one pound weigh more than two pounds?– Can you use a hammer to pound a nail?
• In ICU CAM, for patients who cannot speak, patient must demonstrate understanding by:– Caregiver says: “Hold up this many fingers” (holding two)– Caregiver says: “Now do the same with the other hand” (Han et al., 2013)
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https://www.youtube.com/channel/UCCq13KNzxcopkOkGDsk4c8w?
view_as=subscriber
3 Hyper and 3 Hypo Delirium Interprofessional Videos
in Maria’s YouTube Chanel Developed using a Duke research grant
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Faculty Demonstrates completing bCAM
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Demonstration
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Learning Outcome #1
Learner will complete CAM after watching this video: Handoff
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PRACTICE
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Elements that can cause delirium. Delirium may be prevented or reversed with proper interventions.
• C = Constipation
• H = Hypovolemia or hypoglycemia
• I = Infection
• M = Medications
• B = Bladder catheter and bladder outlet obstruction
• O = Oxygen deficiency & Others (ie. Hearing aids, glasses, lighting, environment, theaters)
• P = Pain
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Learning Outcome #2
CHIMBOP Practice
• Individually
• Use all the resources provided to identify factors in the CHIMBOP Model that could be affecting the patient in the following case study
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Learning Outcome #2 Resources
Next: American Geriatric Society 2019 BEERS Criteria: Inappropriate medications for elderly: http://files.hgsitebuilder.com/hostgator257222/file/ags_2019_beers_pocket_printable_rh.pdf
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American Geriatric Society 2019 BEERS Criteria: Inappropriate medications for elderly
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Black Box Warning
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Learning Outcome #2 Resources:Quicksofa.org: suspicion of infection & 2 elements in
the scale
Glasgow Scale <=13 points >= 22 rpm Systolic BP<=100
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References for Delirium and COVID-19
• Garcez, et al. (2020). Delirium and adverse outcomes in hospitalized patients with COVID-19, Journal of American Geriatrics Society,00(00), 1-7. DOI: 10.1111/jgs.16803
• Kotfis, K., Roberson, S. W., Wilson, J. E., Dabrowski, W., Pun, B. T., and Wesley Ely, E. (2020). COVID-19: ICU delirium management during SARS-COV-2 pandemic. Critical Care, 24(176). DOI: https://doi.org/101186/s13054-020-02882-x
•
• LaHue, S. C., James, T. C., Newman, J. C., Esmali, A. M., Ormseth, C. H., Wesley, Ely, E. (2020). Collaborative delirium prevention in the age of COVID-19. Journal of American Geriatric Society, 68(5), 947-949. DOI: 10.1111.jgs.16480
•
• Newman, J. C., Ormseth, C. H., and Wesley Ely, E. (2020). Collaborative delirium prevention in the age of COVID-19. Journal of American Geriatric Society, 68(5), 947-949. DOI: 10.1111/jgs.16480. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7262233/
•
•
• O’Hanlou, S. and Inouye, S. K. (2020). Delirium, a missing piece in the COVID-19 pandemic puzzle. Age Ageing. DOI: 10.1093/ageing/afaa094. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239228/
•
• American Geriatrics Society. (2020). Delirium Resources. https://www.hospitalelderlifeprogram.org/for-clinicians/covid19-resources•
• American Geriatrics Society. (2020). COVID-19 Help Toolkit.• https://www.hospitalelderlifeprogram.org/uploads/delirum/FINAL_COVID19_HELP_Resources.pdf•
• World Health Organization. (2020). COVID-19 Dashboard. Retrieved from https://covid19.who.int/•
• World Health Organization. (2020). Timeline: Who’s COVID-19 Response. Retrieved from https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline#!•
• Zambrelli, E. Canevini, M., Gambini, O., and D’Agostino, A. (2020), Delirium and sleep disturbances in COVID-19: a possible role for melotonin. Sleep Science, 70, 111. Retrieved from https://www.sciencedirect.com/science/article/pii/S1389945720301672?via=ihub
•
• Zhang, R., Wang, X., Ni, L., Di, X., Ma, B., Niu, S, Liu, C, and Reiter, R. J. (2020). COVID-19: Melatonin as a potential adjuvant treatment. Life Science, 1, 250. DOI: 10.1016/j.lfs.2020.117583. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7102583/
•
• Liu, K., Chen, Y., Lin, R, and Han, K. (2020). Clinical features of COVID-19 in elderly patients: a comparison with young and middle-aged patients. Journal of Infection, 80(60). Retrieved from https://www.sciencedirect.com/science/article/pii/S016344532030116X
•
• Nikolich-Zugich, J, Knox, K. S., Rios, C. T., Natt, B., Bhattacharya, D., and Fain, M. J. (2020).SARS-CoV-2 and COVID-19 in older adults: what we may expect regarding pathogenesis, immune responses, and outcomes. Gero Science, 42, 505-514. Retrieved from https://doi.org/10.1007/s11357-020-00186-0
•
• National Center for Immunization and Respiratory Diseases. (2020, February). Coronavirus Types: https://www.cdc.gov/coronavirus/types.html•
•
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References• Barron, E. A. & Holmes, J. (2013). Delirium within the emergency care setting,
occurrences, and detection. Emergency Medical Journal, 30(4) 263-268.• Craig, J. V. & Smyth, R. L. (2007). The evidence-based practice manual for
nurses. Philadelphia, PA: Churchill Livingstone Elsevier.• Department of Veterans Affairs (2011). VHA national patient safety
improvement handbook. Retrieved from http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2389
• Durham VA Medical Center. (2014). Durham VA medical center 2014 strategic plan. Retrieved from http://www.durham.va.gov/about/leadership.asp
• Fong, T. G., Tulebaev, S. R., Inouye, S. K. (2009). Delirium in elderly adults: diagnosis, prevention, and treatment. Nature Review Neurology, 5(4), 210-220. doi: 10.1038/nrneurol.2009.04
• Francis, J. & Young, G. B. (2014). Patient information: Delirium (beyond the basics). Wolters Kluwer Health. Retrieved from http://www.uptodate.com/contents/delirium
• Grossman, F. F., Hasemann, W., Graber, A., Bingisser, R., Kressig, R. W., & Nickel, C. H. (2014). Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 22(19). doi: 10.1186/1757-7241-2219.
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References
• Han, J. H., Zimmerman, E. E., Cutler, N., Schnelle, J., Morandi, A., Dittus, R. S.,… Ely, E. W. (2009). Delirium in older emergency department patients: Recognition, risk factors, and psychomotor subtypes. Academic Emergency Medicine, 16(3), 193-200.
• Institute of Medicine. (2001). Crossing the quality chasm. Retrieved form www.nap.edu/html/quality_chasm/reportbrief.pdf
• Institute of Medicine. (2011). The future of nursing. Retrieved from http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change
• Larrabee, J. H. (2009). Nurse to nurse: Evidence-based practice. New York, New York: McGraw Hill.
• Leslie, D. L., Marcantonio. E. R., Zhang, Y., Leo-Summer, L., & Inouye, S.K. (2008). One-year healthcare costs associated with delirium in the elderly population. Journal of American Association Internal Medicine, 168(1), 27-32.
• Mergenhagen, K. A. & Arif, S. A. (2008). Delirium in the elderly: Medications, causes, and treatments. U.S. Pharmacist. Retrieved from http://www.uspharmacist.com/continuing_education/ceviewtest/lessonid/105762/
• National Healthcare Quality Report, National Healthcare Disparities. (2012). National older adult quality measures compared to achievable benchmarks. Rockville, MD: Agency for Healthcare Research and Quality.
• Pamaiahgari, P. (2018). Evidence Summary. Delirium in Critical Care Settings: Screening and Assessment. The Joanna Briggs Institute EBP Database, JBI@Ovid. JBI5419.
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References
• Mazur, K, Willckinsi, K, & Szewieckek, J. (2016). Geriatric falls in the context of a hospital fall prevention program: delirium, low body mass index, and other risk factors. Clinical Interventions in Aging, 2016, (11). DOI https://doi.org/10.2147/CIA.S115755
• O’Sullivan, R., Inouye, S. K., & Meagher D. (2014). Delirium and depression: Inter-relationship an overlap in elderly people. Lancet Psychiatry, 1(14), 303-311. DOI:10.1016/S2215-0366(14)70281-0
• Casarett D. J. & Inouye, S. K. (2001). Diagnosis and management of delirium near the end of life. Annals of Internal Medicine, 135(32), 40.
• National Library of Medicine (NLM). (2020). Melatonin. Access via: https://pubchem.ncbi.nlm.nih.gov/compound/Melatonin
• Zhou, Y, et al., (2020, November 6). A network medicine approach to investigation and population-based validation of disease manifestations and drug repurposing for COVID-19. PLOS Biology. DOI: 10.1371/journal.pbio.3000970. Retrieved from https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.3000970
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References for Delirium & Dementia
• Tahir, T. A., Eeles, E., Karapareddy, V., c, Muthuvelu, P., Chapple, S., Phillips, B. , Adyemo, T., & Farewell, D., Bisson, J. I. (2010). A randomized controlled trial of quetiapine versus placebo in the treatment of delirium. Journal of Psychosomatic Research, 69(5), 485-490. http://dx.doi.org/10.1016/j.jpsychores.2010.05.006
• Marcantonio, E. R., Jonathan M. Flacker, J. M., R. John Wright, R. J., & Neil M. Resnick, N. M. (2003). Reducing Delirium After Hip Fracture: A Randomized Trial. Journal of the American Geriatrics Society, https://doi.org/10.1046/j.1532-5415.2001.49108.x
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