Concept Mapping
Caroline Harada, MD
Concept Map
• A concept map is a diagram showing the
relationships among concepts. It is a
graphical tool for organizing and
representing knowledge.
• We plan to use them here to:
– Provide an initial conceptual frame for
subsequent information and learning
– Increase meaningful learning
– Enhancing metacognition (thinking about what
you know and what you need to learn)
Wikipedia, “Concept map” Accessed Sept 4, 2009
Example of a Concept Map
Applies to
geriatrics
fellowship
Accepted to
geriatrics
fellowship
Spends a year
learning
geriatrics
Becomes a
geriatrician
Example Concept Map
Tired person
Skips exercise
Drinks lots of
coffee
Eats muffins
Doesn’t sleep
well at night
Gains weight
Patient: Mrs. T
• 75 year old woman with a history of hemorrhoids and
depression admitted for blood in stools on Monday
evening
• She is very weak and there is concern she will fall, so
she is put on bedrest and a foley is placed
• She is made NPO, IVF are started, she gets prepped for
colonoscopy by drinking a gallon of GoLytely
• She has a colonoscopy on Tuesday afternoon
• Tuesday evening she becomes very agitated, she
starts fighting caregivers, pulling out her IV and foley
• She is placed in restraints
• She is now extremely confused. How did this happen?
Is this confusion delirium?
Delirium
& the Hospitalized
Older Patient
Learning Objectives
• Recognize delirium in hospitalized older
adults
• Describe hospitalized older adults who are at
risk for delirium
• Identify common causes of delirium in the
hospitalized older adult
• Develop strategies to prevent or manage
delirium
What is Delirium?
What is Delirium?
• Acute confusional state
• Acute decline in attention and cognition
• Usually there is evidence of an underlying
physiologic or medical condition
Inouye SK, NEJM 2006
DSM V criteria
A. Disturbance in level of awareness and
reduced attention
B. A change in cognition
C. There is evidence from the history, physical
examination, or laboratory findings that the
disturbance is caused by the direct
physiologic consequences of a general
medical condition
D. The disturbance develops over a short
period of time (usually hours to a few days)
and tends to fluctuate in severity
http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=32
Common Symptoms
• Thinking is slow and muddled but content
can be complex
• Hallucinations/delusions (30%)
• Sleep wake reversal
• Labile affect
• Psychomotor disturbances: 2 characteristic
forms
– Hyperactive- agitation, picking behaviors
– Hypoactive- lethargy
Inouye SK. NEJM 2006
Confusion Assessment Method (CAM)
Does your patient have:
1. Acute change in mental status with fluctuating
course
2. Inattention
PLUS, either
3. Disorganized thinking
4. Altered level of consciousness
Inouye SK et al. Ann Int Med 1990
Do you hear the term
“DELIRIUM” used often?
• Delirium is often called something else:
–
–
–
–
–
–
Altered mental status
Dementia
Confusion
Agitation
Sundowning
Loopy
Delirium recognition is
particularly poor in patients
with dementia
• If person has dementia it is assumed they are
“at baseline”
• Delirium gets confused with dementia
– Dementia patients are at HIGH risk for delirium
when in the hospital
– Anyone can get delirious (even if they don’t have
dementia)
Fick, DM et al JAGS 2002
Delirium
OR
Dementia?
• Confused, inattentive
• New, acute onset
• Confused but attentive
• No different from baseline
• Fluctuating course
• Reversible
• Caused by MANY
triggers
• Minimal fluctuations
• Irreversible
• Caused by one disease
• Normal level of
• Altered level of
consciousness (sleepy,
consciousness (alert)
hyperalert)
• Sometimes preventable • Not preventable
Epidemiology
How common is it?
•
•
•
•
One fifth of hospitalized patients over 65
One third of hospitalized patients over 70
One third of older ER patients
70-87% of older ICU patients
Geriatrics Review Syllabus 6th Ed; Inouye SK. NEJM 2006
Impact of Delirium
Cost
• Adds $2,500 to the hospital
cost per patient
• $6.9 billion of Medicare
expenditures due to delirium
Inouye SK. NEJM 2006
Patient Outcomes
• Patients with it die often and quickly
– Mortality for hospitalized patients with delirium
is 22-76% (similar to AMI or sepsis)
– One year mortality 35-40%
•
•
•
•
Deconditioning
Longer hospital stays
3-5 times risk for nosocomial complications
Increased risk of nursing home placement
after discharge
Inouye SK. NEJM 2006; Geriatrics Review Syllabus 6th Ed
What causes
delirium?
Vulnerable patient:
a house of cards
Old age
Male
Dementia
Functional dependence
Visual/Hearing
impairment
• Dehydration
• Multiple drugs or
coexisting conditions
• Depression, alcoholism
•
•
•
•
•
Inouye SK. NEJM 2006
A trigger: the fan gets turned on your
house of cards…
Drugs
Neurologic disorders
Illness
Surgery
Environmental triggers
(hospitalization, ICU, restraints,
Foley, sleep deprivation)
• Pain, malnutrition/dehydration
• Constipation, urinary retention
•
•
•
•
•
Inouye SK. NEJM 2006
What can we do to
prevent delirium?
Prevention
Yale Delirium Prevention Trial
• Targeted common risk factors:
–
–
–
–
–
–
Cognitive impairment
Immobilization
Psychoactive drugs
Sleep deprivation
Vision/hearing impairment
Dehydration
Inouye SK, NEJM 1999
Yale Delirium Prevention Trial:
Interventions
– Cognitive impairment
Frequent
reorientation- white
boards, volunteers
– Immobilization
Out of bed earlychair is better than
bed
– Psychoactive drugs
Nonpharmacologic
approaches to
agitation
Inouye SK, NEJM 1999
Yale Delirium Prevention Trial:
Interventions
– Sleep deprivation
Herbal tea,
massage, music
– Dehydration
Feeding volunteers,
early IV fluids
– Vision/hearing impairment
Hearing aids,
magnifying glasses
Inouye SK, NEJM 1999
Results
• Delirium developed in:
– 9.9% of patients in the intervention group
– 15% in the normal care group
• Delirious episodes were shorter in the
intervention group
• But… the intervention did not affect severity
of delirium or recurrence rates
Inouye SK, NEJM 1999
Case
• Ms. Z is 87 years old with mild stage Alzheimer’s
disease
• She is in the hospital after a fall down the stairs
with C-2 and humerus fracture
• She is mildly confused, but alert and pleasant. She
is able to pay attention to you when you ask her
questions, but her answers usually don’t make
sense.
Is this delirium or just her underlying dementia?
Delirium
OR
Dementia?
• Confused, inattentive
• New, acute onset
• Confused but attentive
• No different from baseline
• Fluctuating course
• Reversible
• Caused by MANY
triggers
• Minimal fluctuations
• Irreversible
• Caused by one disease
• Altered level of
consciousness (sleepy,
hyperalert)
• Sometimes preventable
• Normal level of
consciousness (Alert,
awake)
• Not preventable
What do you need to know to help
prevent delirium in this patient?
• Geriatric assessment is the first step
– Assess hearing, vision, cognition, mobility/fall
risk, pressure ulcer risk
• Look for hospital hazards
– Foley, restraints, O2, Telemetry
What was done for Ms. Z?
Nursing interventions
– Cognitive impairment
Family encouraged
to stay, educated on
reorientation
– Immobilization
OOB to chair daily,
Foley out, O2 off
– Vision/hearing impairment
– Dehydration
– Sleep deprivation
Put on her glasses
D/c low cholesterol
diet, RN educated on
signs of dehydration
See next slide
Avoiding Sleep Deprivation
• Nursing interventions for daytime
– Keep lights on, curtains open
• Nursing interventions for nighttime
– Keep lights in hallway low
– Keep lights low and TV off in patient rooms
– Keep hallway noise down at night
• Stop waking the patient up
– Check labs BEFORE bedtime
– No vital sign checks between 11pm and 6am
– No nebs at night
Create an Action Plan
List 3 things that increase the risk of delirium
where you work
THAT COULD REALISTICALLY CHANGE
RIGHT NOW
Create a Wish List
List 3 things you would like to make available
to your patients to reduce delirium where
you work
Practice Audits
Summary: Delirium Prevention
Frequent reorientation
Out of bed as much as possible
Keep the environment calm and non-stressful
Minimize sensory impairments
Avoid dehydration
Promote nighttime sleep
PAIN control
Avoid irritants- TAKE OUT THE FOLEY, unneeded
IVs, Tele, O2, braces & cervical collars
• Avoid constipation, look for urinary retention
•
•
•
•
•
•
•
•
The case continues…
• Mrs. Z does NOT develop delirium for the first 5
days of hospitalization.
• On hospital day #5, she develops a small bowel
obstruction and requires surgical repair.
• Postoperatively, she is initially very somnolent, but
then develops agitation and confusion, (much
worse than her baseline).
• What do you think was the trigger for her
delirium?
• The doctor orders lorazepam and restraints.
• The patient becomes even more agitated, and
she pulls out her Foley catheter.
Why did the delirium get worse?
• Restraints and benzodiazepines tend to
cause or worsen delirium and agitation.
• What works better?
Management: What
can we do once
delirium occurs?
Management: 3 Components
Eliminate
Triggers
Avoid
Complications
Manage
Symptoms
Management
• Look for and eliminate all possible triggers
–
–
–
–
Infection, Ischemia
Metabolic disturbances
Medications
Restraints
• Avoid complications
–
–
–
–
–
Avoid DVT
Protect airway
Avoid pressure ulcers
Avoid dehydration
Avoid falls- low bed?
Eliminate
Triggers
Avoid
Complications
Management
• Manage symptoms
– Nonpharmacologic
•
•
•
•
Continue delirium prevention
Use sitters, NOT restraints
Encourage sleep at night
Use music, massage, relaxation techniques for agitation
Manage
Symptoms
Inouye SK, NEJM 2006
Pharmacologic Symptom
Management
Manage
Symptoms
• Unclear if these modify the natural
course of disease
• One placebo controlled RCT in the elderly
showed no benefit to quetiapine
• Haloperidol- po if possible
• Atypical antipsychotics
– Lowest possible doses, as infrequently as
possible (0.5 mg risperidone BID, 2.5mg
olanzapine QD, 25mg quetiapine qhs)
• Use standing doses for 2-3 days at most
Flaherty JH, et al. JAGS 2011
Mrs. Z
• You notice that although the patient just had
surgery, she hasn’t asked for any pain meds. The
only pain med ordered is acetaminophen prn.
• Haloperidol prn agitation
• You order scheduled acetaminophen, oxycodone
prn
• Restraints are removed
• Foley is NOT replaced
• Mrs. Z becomes calm and comfortable (and
pleasantly forgetful) the rest of her hospitalization.
Back to Concept
Maps
Patient: Mrs. T
• 75 year old woman with a history of hemorrhoids and
depression admitted for blood in stools on Monday
evening
• She is very weak and there is concern she will fall, so
she is put on bedrest and a foley is placed
• She is made NPO, IVF are started, she gets prepped for
colonoscopy by drinking a gallon of GoLytely
• She has a colonoscopy on Tuesday afternoon
• Tuesday evening she becomes very agitated, she
starts fighting caregivers, pulling out her IV and foley
• She is placed in restraints
• She is now extremely confused
Draw a Concept Map
• How did Mrs. T get so confused?
Blood in stools
Delirium
Summary
• Delirium is an acute state of confusion
• Delirium is different from dementia (because it’s
fixable), but dementia is a risk factor for getting
delirious
• Delirium can sometimes be prevented
• All health care providers can play a role in
protecting patients from getting delirious while in
the hospital
Useful References
• Inouye SK. Delirium in Older Persons. NEJM 2006; 354:115765
• Inouye SK et al. A multicomponent intervention to prevent
delirium in hospitalized older patients. NEJM 1999; 340:66976
• Flaherty JH et al. Antipsychotics in the treatment of delirium in
older hospitalized adults: a systematic review. Journal of the
American Geriatrics Society 2011; 59:S269-276