duke gec delirium what’s in a name? duke geriatric education center 5-16-12
TRANSCRIPT
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
www.interprofessionalgeriatrics.duke.edu
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
www.interprofessionalgeriatrics.duke.edu
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
www.interprofessionalgeriatrics.duke.edu
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