Brain Failure: Prevention,
Assessment, and Management of
Delirium in Older Hospitalized
Individuals
Matthew J. Beelen, MD
Geriatric Specialists
Lancaster General Health
June 18, 2013
Case



79 year old man, baseline mild cognitive
impairment (MCI)
CABG in July 2012
Post-operative delirium
 “mild
bouts of confusion” post op
 “confusion, delusions, and hallucinations”
 “impulsive”

To rehab facility
 Confusion
gradually improved
Case, continued

Returned home – since then:
 No
longer able to manage finances
 No longer able to manage medications
 Confusing dates and appointments
 Failed driving test (wife does not drive)
 Unable to continue working part time
 Depressed
 Wife distressed about his decline, his repeating, his
depression

Almost 1/3 of hospitalized elderly will develop delirium
Learner Objectives




Articulate the significance of delirium
Recognize and identify delirium promptly as it
occurs
Describe approaches to delirium prevention and
incorporate these into
Compare approaches to delirium management and
incorporate these into practice.
What is Delirium?

A disturbance in consciousness that:
 Has
acute onset (hours to days) and fluctuates over the
course of the day
 Involves reduced ability to focus, sustain, or shift
attention
 Involves a change in cognition (memory, orientation,
language, etc) or perception (hallucinations)
 Is associated with an underlying medical etiology
APA; DSM-IV, 1994
Inflammatory Model of Delirium
Marcantonio ER, JAMA . 2012;308:73-81.
Delirium Subtypes

Hyperactive
 Agitation
 Increased
vigilance
 Hallucinations

Hypoactive
 Somnolent,
lethargic,
stupor, coma,
decreased
psychomotor activity
 Often unrecognized
 75%
of cases in the
elderly
 Associated with higher
mortality
Delirium or Dementia?
Delirium
Dementia
Time Pattern
Acute changes and
fluctuation during the day
Chronic and gradual,
possible changes in response
to environment, fatigue
(“sundowning”)
Level of Consciousness
Often altered
Alert
Attention
Impaired
Usually intact unless severe
dementia
Speech
Incoherent, disorganized
Ordered, anomic/aphasic


Dementia and delirium often coexist
What is the patient’s baseline?
Identification: Confusion Assessment Method
Feature 1: Acute change and
fluctuating course of mental
status
And
Feature 2: Inattention
And
Feature 3: Altered level of
consciousness
Inouye, et. al. Ann Intern Med 1990; 113:941-948.1
Or
Feature 4: Disorganized
thinking
Confusion Assessment Method (CAM)




86-94% sensitive, 89-93% specific
Validated in over 1000 patients
Used in over 250 original published studies
28 page training manual…
 Improved
accuracy with formal training
 Improved accuracy when using a standard cognitive
screen as part of the CAM (Modified Mini-Cog)

Takes about 5 minutes to perform
http://hospitalelderlifeprogram.org
Modified Mini-Cog Assessment

Orientation



1. Time: Day, Year, day/night, last meal, how long in hospital.
2. Place: City/State, Hospital, Floor
Registration

3. Name 3 objects: (apple, watch, penny)


Clock-drawing


Ask the patient all 3 after you have said them. Repeat until all 3 are
learned
4. Draw a circle, draw numbers, and place hands at “ten past eleven”
Recall

5. Ask for 3 objects in question 3
http://hospitalelderlifeprogram.org
Identification in the ICU: CAM-ICU

Assesses same domains as CAM
 Different
questions/methods of assessment used
 Ideal for non-verbal patients

Incorporates the Richmond Agitation and Sedation
Scale (RASS)
 To
decide if patient can be assessed for delirium
 To assess level of consciousness
www.icudelirium.org; Ely EW et al, JAMA. 2001;286:2703-2710.
CAM-ICU: RASS
www.icudelirium.org
Identification Using CAM-ICU





93-100% sensitive, 89-100% specific
Validated for ventilated and non-ventilated
critically ill patients
28 page training manual…
Takes about 5 minutes to perform
Recommended to be done every shift
 Evidence
of benefit?
www.icudelirium.org; Ely EW et al, JAMA. 2001;286:2703-2710.
The Role of CAM and CAM-ICU



Evidence of benefit of
screening is lacking
“We cannot manage
delirium or decrease its
complications unless we
recognize it”
Useful as a means to
monitor for delirium as
part of QI process
Delirium is Common
100%
90%
80%
70%
60%
Maximum
Minimum
50%
40%
30%
20%
10%
0%
ED
Admission
Gen Med
Post Op
ICU
DC to ECF
Prevalence of Delirium at Various Points of Hospitalization
Delirium Has Significant Impacts

For patients while in the hospital

For patients after they leave the hospital

For society
 Population
management
Impact in the Hospital





 physical function
 nutrition
 post-op complications
(2-5x risk)
 self-extubation or
removal of lines
 death: 22-76%
mortality rate (10-fold
risk)
Inouye SK. N Engl J Med 2006;354:1157-65
Marcantonio ER. JAMA 2012;308:73-81






 pneumonia
 falls
 pressure ulcers
 exposure to physical
and chemical restraints
 family distress
 burden on nurses and
patient care staff
Impact Post-Hospitalization



3-fold increased risk of institutional placement at
discharge
2-fold  risk of 30-day readmission from ECF
Death
3
fold risk of death at 6 months
 Every day an ICU patient spends in delirium increases
risk of death at 6 months by 10%
 1 year mortality rate is 35-40%
 Risk of higher mortality persists for up to 2 years
Inouye SK. N Engl J Med 2006;354:1157-65
Marcantonio ER. JAMA 2012;308:73-81
Ely EW et al. JAMA 2004;291:1753-1762
Marcantonio ER et al. J Am Geriatri Soc 2005;53:963-969
Impact Post-Hospitalization


Worsening cognition in those with pre-existing
cognitive impairment
Patients with Alzheimer’s who develop delirium:
 Rate
of cognitive decline is doubled in the year after
delirium compared to those without delirium
 More
rapid rate of decline persists for 5 years
Gross AL et al. Arch Int Med 2012;172:1324-1331
Fong TG et al. Ann Int Med 2012;156:848-856
Fong TG et al. Neurology 2009;72:1570-1575
Delirium and Cognitive Decline
Saczynski JS et al. N Engl J Med 2012;367:30-39
Impact Post-hospitalization

New cognitive impairment:
 Greater
then 10-fold increase risk in new
development of dementia over the next 4 years
 Cognitive
reserve theory
Witlox J et al. JAMA 2010;304:443-451.
Cognitive Reserve and Delirium
delirium
Impact on Society

Increased length of stay
 2-5
days longer than those without delirium
 Increased ICU and ventilator days

Increased costs of care
 $60,000
incremental costs over the following year
 $6.9 billion annual cost to Medicare to treat delirium

Impact on caregiver burden
 Assistance
with activities of daily living
 Emotional impact
Marcantonio ER. JAMA 2012;308:73-81.
O’Mahony R et al. Ann Intern Med 2011;154:746-751.
Delirium - Cost to Society
Monthly Health Care Costs After Discharge from Hospital
Leslie DL. Arch Int Med 2008;168:27-32
Approach to Delirium Prevention
Recognize Risk
Reduce Risk
Prevention of Delirium



“At least 30-40% of cases may be preventable.
Prevention is the most effective strategy for reducing
delirium frequency and complications.” (Inouye, 2006)
“We should not wait for delirium to happen but must
work to implement proven interventions that prevent
delirium” (Ely, 2012)
“Effective strategies that prevent delirium should be a
high priority for health care systems.” (O’Mahony,
2011)
Risk Factors for Delirium
Inouye SK. J Geriatr Psychiatry Neurol 1998;11:118-125.
Predisposing Factors






Baseline cognitive
impairment***
Vision Impairment
Hearing Impairment
Older age
Low educational level
ADL impairment
 From
ECF





Depression
Alcohol abuse
Multiple significant
chronic conditions
High numbers of home
medications
Use of opioids or
benzodiazepines prior
to admission
Predisposing Factors


Dehydration

 Bun/Cr

> 18
Severe Illness on
Admission
 Sepsis/SIRS/infection
 Acute
organ failure
 Electrolyte/metabolic
 Acute cardiac event
 Stroke/seizures
Malnutrition
Surgical patient
 Hip




fracture
Fracture/trauma
Prior stroke
Parkinson’s
Prior delirium*
Predictive Value of Risk Factors

4 predisposing risk factors (low vision, cognitive
impairment, dehydration, severe illness)
Initial
Initial
Validation
Validation
# of RFs
Risk Group
Rate (%)
RR
Rate (%)
RR
0
Low
9
1.0
3
1.0
1-2
Intermediate 23
2.5
16
4.7
3-4
High
9.2
32
9.5
83
“Primary prevention of delirium should address important delirium risk factors
and target patients at intermediate to high risk for delirium at admission.”
Inouye SK. J Geriatr Psychiatry Neurol 1998;11:118-125
Precipitating Factors
Derangements in Normal
Functions:
 Fluid intake
 Bladder



 Acid/base
emptying
 Electrolyte
Nutrition intake
 Bowel

New Acute Conditions:
 Metabolic
movements
 Glucose

Oxygen intake

 CO2

release
Sleep/wake cycle
Mobility


Anemia
Infection/fever
CNS event/condition
Cardiac event/condition
Hypotension/shock
Precipitating Factors
Extrinsic Factors
 Procedures / Surgery
 Ventilators / ICU
 Tubes, lines, catheters,
restraints, devices
 Environment change
Other Symptoms
 Pain
 Emotional Distress
Medications
 >3 added the
previous day
 “polypharmacy”
 Benzodiazepines
 Anticholinergics
 ETOH or drug
withdrawal
 Opioids (+/-)
Prevention Strategies


Prevention should focus on those at intermediate to
high risk
Effective prevention must address the complex
array of precipitating risk factors
 Limited

evidence of benefit for isolated interventions
Prevention requires cooperative interdisciplinary
effort
Multi-Component Interventions

Methods and specific interventions vary widely
Reston JT and Schoelles KM. Ann Intern Med. 2013;158:375-380.
Hospital Elder Life Program (HELP)


Age ≥ 70 on a general medicine unit, ≥1 risk factor
(impaired cognition, elevated BUN/Cr ratio, vision
impairment, severe illness) = medium to high risk
Additional risks assessed in the first 48 hours:
 Sleep
deprivation: interview and nurse input
 Immobility: ADL assessment scale
 Hearing impairment: Whisper test

Initial and daily assessment for delirium: CAM
Inouye SK et al. N Engl J Med 1999;340:669-676
The HELP Team


Elder Life Nurse Specialist – Masters level with
geriatric training and experience
Elder Life Specialist/Volunteer Coordinator
 Performs
screening, develops care plans, oversees and
coordinates volunteers, training, data collection
 Masters level with experience with human services or
healthcare, geriatrics, supervisory experience



Geriatrician
Program Director (may be one of the above)
Volunteers (3-4 hours, 1-2 times per week)
Inouye SK et al. N Engl J Med 1999;340:669-676
HELP - Intervention

What did the HELP Team do?
 Performed
initial and ongoing assessments
 Administered a set of care protocols for at-risk patients
 Targeted
 Provided
6 risk factors for delirium
ongoing staff education
 Led interdisciplinary meetings and rounds
 Led ongoing CQI process
HELP Interventions for 6 Risk Factors
Targeted Risk Factor
Cognitive impairment
Sleep deprivation
Immobility
Visual impairment*
Hearing impairment*
Dehydration*
Standardized Intervention
Orientation & therapeutic activity protocol
(discuss current events, word games, reorient, etc)
Sleep enhancement & nonpharm sleep protocol
(noise reduction, back massages, schedule
adjustment)
Early mobilization protocol
(active ROM, reduce restraint use, ambulation, remove
catheters)
Vision protocol
(glasses, adaptive equipment, reinforce use)
Hearing protocol
(amplification devices, hearing aids, earwax
disimpaction)
Dehydration protocol
(early recognition of dehydration & volume repletion)
HELP Outcomes – Original Study


852 patients
Delirium incidence
 9.9%
intervention
 15% controls

Inouye SK et al. N Engl J Med 1999;340:669-676
Decrease in total
number of days of
delirium
Subsequent HELP Outcomes








Disseminated to sites worldwide
Less functional and cognitive decline, falls, and
pressure ulcers during hospitalization
Little impact on delirium severity once it occurred*
Cost effectiveness has been demonstrated
Cost savings to hospitals has been demonstrated
Improves geriatric education within the hospital
Volunteer use benefits the community
Implementation support is available
Inouye SK et al. J Am Geriatr Soc 2000;48
Rubin FH et al. J Am Geriatr Soc 2011;59:359-365.
General Prevention Recommendations





Early risk assessment
and develop plan to
address risk factors
Plan carried out by
competent interdisciplinary team
Minimize staff and
location changes
Orienting interventions
Familiar visitors
O’Mahony R et al. Ann Intern Med 2011;154:746-751.



Treat pain
Minimize infection risk
Optimize:
 hydration
and nutrition
 bowel/bladder function
 oxygenation
 activity and mobility
 medications
 sensory input
 sleep
Prevention - Interdisciplinary Team
The Health System
Nurses
Pharmacist
Physicians
Patient
Physical
Therapist
Balas MC et al. Crit Care Nurse 2012;32:35-47
Respiratory
Therapist
Barriers to Optimal Prevention


Culture change is needed – proactive vs. reactive
System change is required
To ensure interdisciplinary team coordination
 QI processes related to key components of prevention






Initial assessment
Development of management plan
Completion of individual components of plan
Monitoring for delirium for early detection and for monitoring
effectiveness of program
Institutional support (“buy-in” and resources)
Treatment of Delirium
Management of Delirium


There is little rigorous evidence of benefit
Non-pharmacologic measures show a trend toward:
 Shorter
duration of delirium
 Decreased severity
 Shortened hospital LOS


Medications: as of 2011 there was only one
randomized placebo-controlled trial – it showed no
difference in outcomes
So what can we do?
Flaherty JH. Med Clin N Am 2011;95:555-577.
Management – Team Approach

Communicate the diagnosis
 To
team members
 To family
 In the medical record: “encephalopathy” - $$ irony


Multi-factorial assessment of precipitating factors
Management plan to address these factors
 Sound

familiar?
Brain Failure: serious problem, possible emergency
 Immediate
attention is crucial
Review Precipitating Factors
Derangements in Normal
Functions:
 Fluid intake
 Bladder



 Acid/base
emptying
 Electrolyte
Nutrition intake
 Bowel

Acute Illnesses:
 Metabolic
movements
 Glucose

Oxygen intake

 CO2

release
Sleep/wake cycle
Mobility


Anemia
Infection/fever
CNS event/condition
Cardiac event/condition
Hypotension/shock
Review Precipitating Factors
Extrinsic Factors
 Procedures / Surgery
 Ventilators
 Tubes, lines, catheters,
restraints, devices
 Environment change
Other Symptoms
 Pain
 Emotional Distress
Medications
 >3 added the
previous day
 “polypharmacy”
 Benzodiazepines
 Anticholinergics
 ETOH or drug
withdrawal
 Opioids (+/-)
Management – Focus on Safety

Environment
 Optimize
orientation, comfort, sleep/wake cycle
 1:1 supervision or “sitter”
 Family or friend presence
 Is a room or unit change indicated?
 “Don’t neglect the hypoactive”

For severe distress or risk of harm to self or others
 Consider
medication
 Consider restraints – the least necessary
Treatment With Medications

Limited, small studies
Only 1 with a blinded placebo comparison group
 Underlying dementia either not mentioned or was used as
exclusion criteria in most studies
 Delirium subtypes were not accounted for




No clear evidence that medications decrease severity
or shorten duration
No clear evidence that newer antipsychotics are more
favorable than haloperidol
People with delirium get better without medications…
Seitz DP et al. J Clin Psychiatry 2007;68:11-21.
Campbell N et al. J Gen Intern Med 2009;24:848-853.
Flaherty JH et al. J Am Geriatr Soc 2011;59:S269-S276.
Treatment with Medications


No FDA approved medications for delirium
Haloperidol
 0.25-0.5mg
PO Q4 hours PRN
 0.5-1.0mg IM q30-60min
 IV doses have much shorter duration of action: q60min

Atypical antipsychotics – oral
 Risperidone
0.25mg-0.5mg Q12-24 hours
 Olanzapine 2.5-5.0mg Q12-24 hours
 Quetiapine 12.5-25mg Q12-24 hours
Treatment With Medications

Antipsychotics
 Can
prolong the QT interval (get baseline EKG)
 Can cause parkinson-like symptoms at high doses
 Can cause worsening or irreversible decline in
Parkinson’s or Lewy Body dementia
 Quetiapine
 If

is thought to be best choice for these conditions
used – start with low end of dose range
Benzodiazapines
 2nd
line or last resort (unless alcohol withdrawal)
 Can induce, worsen, or prolong delirium
Final Case


Nov. 2012: 87-year-old woman admitted to hospital
from nursing home with mental status change,
tachycardia, tachypnea, fever. Baseline MCI.
3 day hospital stay
E coli UTI
 New onset Atrial fibrillation, fluid overload / CHF
 NSTEMI
 Confused, lethargic, “encephalopathy”



Discharged to nursing home “comfort care, hospice
consult, NPO”
Now – back to baseline!
Summary






Delirium has significant impacts, especially after
discharge
Watch for the hypoactive subtype
We may be able to prevent 1/3 of cases
Prevention is the best treatment
Effective prevention and treatment requires a
careful assessment for risk factors and a plan to
minimize them – culture and system change
Medications: limited role
Questions?