The Chicken or the Egg: Delirium and TBI in the Elderly

Brecken Hentz MS CCC-SLPLindsay Dutko MA CCC-SLP

Chicken or Egg?

Fall

TBI

Hospital

Delirium

Traumatic Brain Injury in the Elderly

• “A blow or jolt to the head or a penetrating head injury that disrupts normal

function of the brain”

• TBI can occur in absence of positive Head CT

• Unintentional Falls are #1 cause (51%) with MVC next (9%)

• Older age is associated with higher mortality after severe TBI

• Recovery after TBI is more limited for older than younger survivors

– Less capacity for compensation

– Reduced cognitive reserves

 

Differences in the Aging Brain

Older adults who experience an apparently trivial event in which there has been a minor trauma to the head….often present with more insidious and delayed symptom onset of undiagnosed TBI

• Unique pathophysiology of the older brain• Slowly expanding SDH

• “late onset TBI”• May be easily confused with delirium

Flanagan, et al., 2006

TBI vs. Delirium

TBI– Onset immediately following

accident USUALLY – except in the elderly when a SDH is slowly expanding

– Attention– Orientation– Awareness– Memory– Judgment– Reasoning– Problem Solving– Executive Functioning– Initiation/Impulsivity– Behavior (agitation)

Delirium-Onset is generally not until after pt arrives at hospital; can occur as early as in the ED or even prior to hospitalization, though - Attention- Orientation- Memory of recent events- Difficulty speaking- Rambling, nonsense speech- Visual hallucinations- Withdrawn behavior- Restlessness/agitation- Disturbed sleep patterns- Extreme emotions

Case Study

• 92 yo male s/p fall down carport stairs• +LOC (?LOC prior to fall d/t dehydration from stomach virus);

GCS 13 in ED• Brain CT: L parieto-occipital SDH; L subarachnoid

hemorrhange; L anterior temporal lobe cerebral contusion• PMH: DM II, HTN, h/o multiple TIAs, chronic dysphagia

secondary to esophageal strictures last dilated 7/2012, GERD, recently diagnosed follicular lymphoma, hearing loss

• NPO for several days prior to placement of NG tube with eventual placement of PEG tube secondary to very high aspiration risk and poor secretion management

• D/c’d to SNF after a 9-day hospitalization with re-admission for AMS suspected for metabolic changes after 17 days

• D/c’d back to SNF

Mental Status on First Admission

• Baseline:– Mostly independent but does not drive– Primary caregiver for wife with dementia– Supportive family

• In ED:– Nonverbal– Not following commands– Minimal eye opening

• Throughout hospitalization– Gradual improvement (Rancho Level 3 – 5) across hospitalization but

with significant variability in LOA/MS throughout each day– No agitation

• Mental status on d/c was still confused, but appropriate with deficits in recall, processing, and attention.

Mental Status on 2nd Admission

• Per family report, at SNF improved to at least a Rancho Level 6

• Increased impairments from prior hospitalization – Poor orientation– Limited auditory comprehension– Poor topic maintenance– Tangential– Impaired safety awareness/insight (attempting to get out of bed) – Extremely agitated (grabbed granddaughter and clinician’s wrists – Calmer with no one present in the room

• No changes in head CT (wanted to ensure no evolution of previous findings)

Discussion

• What are this patient’s risk factors for delirium?

Common Risk Factors for Delirium

Predisposing• Advanced age• Preexisting dementia• History of stroke• Parkinson’s disease• Multiple cormorbid conditions• Impaired vision• Impaired hearing• Males• History of alcohol abuse

Precipitating• Acute medical problem• Exacerbation of chronic medical

problem• Surgery/anesthesia• New phsychoactive medication• Acute stroke• Pain• Environmental change• Urine retention/ fecal impaction• Electrolyte disturbances• Dehydration• Sepsis

Discussion

• Does this patient have delirium?– If so, on which admission (s)?

Criteria for Delirium

• Disturbance of consciousness with attentional impairment

• Change in cognition or development of a perceptual disturbance not attributable to dementia

• Disturbance develops over a short time and fluctuates during the course of the day

• Disturbance is caused by a general medical condition

Discussion

• What could have been done to prevent this patient’s delirium?

• Now that he has delirium, what can we do to manage it?

Prevention/Management• TBI

– Limit stimulation (no tv, radio, limit visitors)

– Calm environment (lights low, door closed)

– Brief periods of appropriate stimulation with majority of the day/night for rest

• Both– Frequent orientation– Allow movement as

physically able and safe

– Appropriately address vision/hearing impairments

• Call PVR 681-2020

– Engage pt in appropriate cognitive stimulation

– Allow for uninterrupted sleep at night

– Hydration– Bring personal items

from home– Have a routine– Minimize restraint use

• Delirium– Lights on during the

day (allow for TV and radio per pt’s preference)

– Frequent engagement by visitors/staff

– Therapeutic activities (i.e. word searches, newspapers, conversations, etc)

Strategies

• Orientation:– Verbal re-orientation– Written re-orientation

• Safety Awareness:– Active bedside attendant– Verbal cues– Written cues

More Strategies

• Attention/Receptive Language– Eliminate distractions

• Close the door• Turn off the TV, radio, etc• Limit # of people in the room when having conversations• For delirium, even though you want family present and familiar

background noise to keep pt oriented and awake, when you are communicating with pt, environment needs to be quiet

– Sit directly across from the pt– Sit pt upright and comfortably – Provide multimodal communication as able

• i.e. Use gestures, pictures, and written key words to supplement verbal information

More Strategies

• Expressive Language– Simplify language; ask 1 question at a time

• i.e. say “Do you hurt?” instead of “Are you ready for more pain medicine?”

• i.e. say “You fell and hit your head. You are at Duke Hospital” instead of “You fell and sustained a brain hemorrhage, so your family brought you into Duke Hospital.”

– If not verbal or minimally verbal attempt to elicit nonverbal yes/no responses

• Verify responses with opposite question– i.e. Ask both “Are you hot?” and “Are you cold?”– i.e. Ask both “Are you in pain?” and “Are you comfortable?”

– Provide tangible choices• i.e. show the pt both orange juice and apple juice

– Provide written choices

In Conclusion…

• Delirium can co-occur with other cognitive and communication impairments, like TBI.

• Management of delirium in these patients may have to be modified to best fit the patient.