Download - Delirium: Recognition Assessment Prevention Management WRHA Surgical Program Delirium Guidelines
Delirium: Recognition Assessment Prevention
Management
WRHA Surgical ProgramDelirium Guidelines
Delirium
Definition: A disturbance of
consciousness with inattention that develops over a short time & fluctuates
What is Delirium?
• An acute confusional state
• Usually has a reversible cause
• Characterized by:– Inattention– Sudden onset– ………………..
Why Should We Use Delirium Guidelines ?
• Delirium can result in:– morbidity and mortality – length of stay – rates of admission to long term care
facilities– 20% of patients discharged post hip # still
had evidence of delirium (Journal of American Geriatric Society 2001 May;49(5):678-9).
40%
25%
35%
Recovery Permanent Cognitive Impairment Mortality
Outcomes of Delirium
(even with complete recovery, 30% dementia within 3 years = decreased brain reserve)
Recognition of Delirium
• Previous studies 32%-66% of cases are
unrecognized by Medical Staff
Yale- New Haven study (Inouye S. Ann Intern Med 1993: 119-474)
– 65% unrecognized by Physicians
– 43% unrecognized by Nurses
Top 4 Independent Risk Factors for Delirium
Vision impairment:
Any severe illness: Cognitive impairment:
High Urea/Creatinine ratio:
Inouye S. Ann Intern Med 1993: 119-474
4 Independent Risk Factors for Nurse Under-Recognition
• Hypoactive Delirium
• Age 80 yrs and over
• Visual Impairment
• Dementia
Types of Delirium
• Hyperactive
• Hypoactive
• Mixed
Causes of Delirium?
• Anything that hurts the brain or impairs its proper functioning can provoke a delirium!
• Brain’s way of demonstrating “acute organ dysfunction”
Causes of Delirium:
1. Drugs2. Infection3. System failure/events 4. Metabolic Imbalance 5. Dehydration/Poor Nutrition 6. Surgery or general anaesthetic within the
last 5 days
Causes of Delirium:
7. Pain
8. Uncorrected sensory or
language impairment
9. Fecal Impaction
10. Urinary Retention/Catheter
11. Restraints
12. Sleep disruption
13. No factors can be identified
20% of the time
14. Recent severe illness or event
involving hypoxia
Causes of Delirium Related to Surgery
Risk FactorsPredisposingPrecipitating
ComorbiditiesDiabetes
MIEtc…
Perioperative DrugsAnesthetics Opioids
BenzodiazepinesEtc…
Theories for Post Op Delirium
• Acetylcholine interaction with medications used during surgery
• Increase of neurotransmitters, serotonin and dopamine during surgery
• Previous abnormality levels of melatonin• Damage to neurons by oxidative stress or
inflammation caused by a surgical procedure• Post op abnormal brain waves
• Any drug can potentially cause confusion
• Take a careful history of any new drug STARTED or any old drug STOPPED recently
Medications Associated with Delirium
Medications Associated with Delirium
• Over the counter drugs– Cimetidine– Cough/Cold Remedies– Gravol/Maxeran– Sleeping medications – Herbal meds
Reference List of Drugs with Anticholinergic Effects
• Antidepressants• Antipsychotics• Antihistamines/
Antipruritics• Antiparkinsonian• Antispasmotics• Antiemetics
• Opioids• Anticonvulsants• Antibiotics• Corticosteroids• Anticholinergics
StudiesIn studies, drugs with anticholinergic side effects have been
shown to:• Lower cognitive scores in elderly subjects• Cause/worsen severity of delirium• Associated with more ADL decline in patients with dementia• Associated with faster MMSE decline in patients with
dementia• If drugs reduced, be associated with improvements in
dementia and delirium.
Full List of Safe Medications for the Older Adult
Please see attachment at the end of this presentation
Assessing for Delirium
Pre-Admission Assessment
• Decision Tree
CAM – Confusion Assessment Method– Sensitivity (94 to 100%), specificity (90 to 95%)
Requirement for delirium = 1, 2 AND either 3 OR 41. Abrupt change?
2. Inattention, can’t focus?
3. Disorganized thinking? Incoherent, rambling, illogical?
4. Altered level of consciousness? (Hyper-alert to stupor?)
AND
Trigger Questions
1. Acute change in behaviour?
2. Changes in function?
3. Changes in cognition? MMSE
4. Changes in medications?
5. Physiologically stable?
How Do We Assess for Inattention
• Recite the months backwards or days backwards
• Have the patient count backwards from 20 to 1.
• Use the CAM
Once You Identify Delirium, Now What?
• Identify the acute medical problems that could be either triggering the delirium, or prolonging it!
• Clarify pre-morbid functional status, sequence of events and previous admission cognitive baseline
• Identify all predisposing and precipitating factors, and consider the differential
Physical Exam– Vitals: normal range of BP, HR, Temp and
pain – Good physical exam: particular emphasis
on Cardiac, pulmonary and neurologic systems
– Hydration status
– Also rule out • fecal impaction• urinary retention • Infected pressure ulcer, UTI or pneumonia
Delirium workup: Lab testing• Basic labs most helpful!
– CBC, lytes, BUN/Cr, glucose,CO2, Ca+, Mg, PO4
– TSH, B-12, LFTs & albumin
• Infection workup (Urinalysis, CXR) +/- blood cultures
• EKG
• O2 sat/ABG
What About Prevention?
Yale Delirium Prevention Trial Risk Factors Intervention
Cognitive Impairment Reality orientation / therapeutic activities program
Vision/Hearing impairment Vision / hearing aids / adaptive equipment
Immobilization Early mobilization / Reduce immobilizing equipment
Psychoactive medication Non pharmacologic approaches to sleep / anxiety / Restricted use of
sleeping medicationDehydration Early recognition / Volume
expansionSleep deprivation Noise reduction strategies/sleep
enhancement programRef: Inouye SK, NEJM. 1999;340:669-676
Prevention and Pre-Op Assessment
• Pre-op Clinic Form• Pre- op- Questionnaire
What about Management?
Non Pharmacological Interventions
• Always apply non-pharmacological interventions in your Care Plan. Examples– Initiate toileting routines– Mobilize ASAP– Quiet room, soothing music
Pharmacological Interventions
• Only use medication if:– Non-pharmacological interventions are not
successful– The patient is a danger to themselves or others
• You may see the physician order or a pharmacist suggest the following medications:– Low dose Haloperidol or– Low dose Risperidone or– Low dose Olanzapine – ** Avoid the use of benzodiazepines
Pharmacological Interventions
• It is important to remember that:– Dosing is best given prn
when agitation becomes a concern or becomes a safety issue
– Medications must be discontinued once the agitation from the delirium is resolved
Delirium Pamphlet
• This is to be given to Families so that they may better understand what their family member is going through.
• It is also recommended that it be displayed in any Pamphlet Holders for Patient and Family Education.
• A copy of the pamphlet is found at the back of the presentation
Pre-Admission Clinic Forms
Questions ??????