The Chicken or the Egg:
Delirium and TBI in the Elderly
Brecken Hentz MS CCC-SLP
Lindsay Dutko MA CCC-SLP
Chicken or Egg?
Fall
Delirium
TBI
Hospital
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- Withdrawn behavior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
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
Advanced age
Preexisting dementia
History of stroke
Parkinson’s disease
Multiple cormorbid conditions
Impaired vision
Impaired hearing
Males
History of alcohol abuse
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 6812020
– 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.