The Geezer’s Dirty Dozen on Delirium Lecture with Video

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This is one of those videos I promised to inflict on you and, of course, its about delirium.  The nurse on our delirium Quality Improvement project asked for volunteers to give a CEU talk to nurses in the hospital because she’s planning to roll out the Delirium Observation Screening Scale (DOSS) to the rest of the hospital.

I’m pretty cheap so I made this video in two stages, the video and the slides. I uploaded to YouTube and the slides I made separately, so the viewer needs to come to my blog site to see the complete show.

Here are the slides with relevant data with hyperlinks:

Slide 3. Delirium Resource Materials

• The blog site, The Practical Psychosomaticist

1. The Practical Psychosomaticist: James Amos, M.D.

1. Geriatric Nursing Resources for Care of Older Adults :: need help stat

1. ICU Delirium and Cognitive Impairment Study Group

1. CG103 – Delirium – National Institute for Health and Clinical Excellence

1. Welcome to the Hospital Elder Life Program (HELP)

1. American Delirium Society

1. European Delirium Association |
2. European Delirium Association | News > Patient Experience of Delirium- Teaching Video

• Raise awareness about delirium in hospitalized medically ill adult patients, especially the elderly and be able to

1. Describe at least 3 risk factors
2. Cite occurrence rates of delirium in the general hospital and in the ICU
3. State 3 outcomes of delirium in the elderly

• Learn how to detect delirium and be able to

1. Describe generally how the CAM and the DOSS are used to detect delirium

• Learn how to manage, treat, & prevent delirium and be able to

1. Describe general pharmacologic and non-pharmacologic treatment and prevention strategies

Slide 5. What is Delirium?

• Acute brain injury, by definition a medical emergency which can mimic many primary psychiatric disorders and in which affect, behavior, and cognition typically fluctuate.
• One definition, “…A symptom of how hospital care is failing older persons….”

1. Inouye, S. K., M. J. Schlesinger, et al. (1999). “Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care.” The American journal of medicine 106(5): 565-573.
2. A few of the systems reasons: multiple room changes, absence of clock and calendar, sensory aids, family members, use of physical & chemical restraints
3. A few hospital cultural reasons: persisting assumption that delirium is: a primary psychiatric problem per se and that it’s the duty of mainly one medical subspecialty (Psychiatry) to manage; a nursing management problem; an unavoidable consequence of severe medical illness

Slide 6. Delirium DSM-IV Diagnosis

• Disturbance of consciousness with reduced ability to focus, sustain, or shift attention
• A change in cognition or the development of a perceptual disturbance that is not accounted for by a pre-existing, established, or evolving dementia
• Develops over a short period of time and tends to fluctuate during the course of the day
• Evidence from history, physical, or labs that the disturbance is caused by

1. General medical condition
2. Substance intoxication or withdrawal, or medication use
3. Multiple etiologies
4. Not otherwise specified

• Though not specified in DSM, subtypes

1. Hypoactive, hyperactive, and mixed

• The ICD-10 definition is “mental disorders due to known physiological conditions” http://www.icd10data.com/ICD10CM/Codes/F01-F99/F01-F09/F05–

• Mimics primary psychiatric disorders

1. Disorders of consciousness: hyperalert to obtunded
2. Disorder of affect, behavior, cognition
3. Disorder of perception: hallucinations, often visual

• Predisposing risk factors

1. Cognitive impairment
2. Age 65 or older
3. Severe illness
4. Dehydration

• Precipitating risk factors

1. >3 new medications added
2. Urinary catheter
3. Any iatrogenic event
4. Physical restraints
5. Malnutrition–Inouye et al, 1993 & 1996

Slide 8. Delirium Prevalence and Outcomes

• 20% prevalence in general hospital
• Range up to 80% prevalence in ICU
• Outcomes

1. Increases LOS, admit to LTC, mortality
2. Post-discharge decline in ADLs & cognitive function

• Health care system quality & outcomes

1. Total one year direct costs attributable to delirium might be $38-152 billion nationally
2. $6.9 billion in Medicare expenditure (2004 dollars)
3. National Quality Measures Clearinghouse of Agency for Healthcare Research says delirium is a marker of quality of care & patient safety
4. Delirium prevention would reduce acute & long-term costs in U.S.

Slide 9. Etiology and Pathophysiology of Delirium

• Etiology

1. Underlying medical cause(s)

• Acetylcholine

1. Involved in attention, arousal, memory
2. Decreased activity causes deficits

Metabolic insults, thiamine deficiency & anticholinergic medications can cause delirium through decreasing cholinergic activity

• Dopamine

1. Excess can cause agitation, delusions
2. Inverse relationship between dopamine and acetylcholine
3. Dopaminergic agents can induce delirium; dopamine antagonists like antipsychotics  can treat delirium symptoms

Slide 10. Delirium Screening and Detection

• Link to delirium screening instrument blog post by Dr. Amos

1. https://jajsamos.wordpress.com/2011/04/25/delirium-screening-scales-pounding-down-the-home-stretch-the-delirium-observation-screening-scale-and-the-nursing-delirium-screening-scale-nose-to-nose/

• Link to video Geriatric Nursing Resources at https://jajsamos.wordpress.com/delirium-video/
• How to do the Mini-Cog to increase the sensitivity of the CAM at https://jajsamos.wordpress.com/2011/09/28/lightning-fast-mini-cog-video-featuring-drs-paul-thisayakorn-and-alex-gamble/
• The Confusion Assessment Method (CAM) developed by S.K. Inouye rated in around 5 minutes

1. Acute change in mental status/fluctuating course and inattention; either disorganized thinking or altered level of consciousness

• The Delirium Observation Screening Scale (DOSS) 25 item scale (shortened to 13) developed by Schuurmans et al rated in about 5 minutes, score zero=normal, highest 13=delirium, cut-off is 3 points

Slide 11. Preventing Delirium: Non-Pharmacologic Strategy

• Frequent orienting and familiar objects available
• Consistent nursing staff & family involvement
• Encourage normal sleep-wake cycle, preferably with non-drug intervention
• Encourage mobility
• Hearing aids, eyeglasses available
• Prevent organic drivers: hypoxia, acidosis, infection
• Avoid or minimize exposure to anticholinergic and sedative-hypnotic medications
• Multicomponent strategies

1. Comprehensive assessments & strategies target risk factors appear to be effective for preventing delirium in older patients
2. Example: Hospital Elder Life Program (HELP) started at Yale (S.K. Inouye)

• First and foremost treat the underlying medical cause(s) and avoid drugs that contribute to delirium
• Haldol is the non-FDA approved drug of choice for managing disruptive behaviors, hallucinations and delusions

1. Cardiac monitoring needed if given IV; can prolong cardiac conduction and contribute to arrhythmias

• Atypical antipsychotics also effective; caveat is FDA Black Box Warning in demented elderly: can increase mortality risk
• Avoid benzodiazepines unless alcohol withdrawal causing delirium
• Prevention studies with antipsychotics suggest that it may be possible to prevent delirium with this class of medication

1. Results  so far preliminary , sometimes inconsistent, and  not recommended as  standard care
2. Antipsychotics have side effects

• Prevention using sleep-wake cycle regulators like Melatonin suggest it might be helpful; results preliminary, low incidence of side effects; see link https://jajsamos.wordpress.com/2011/11/01/melatonin-for-a-more-mellow-formulary/

Delirium Post-Workshop Quiz

 

By Drs. James Amos & Ravneet Dhaliwal

 

1. Clinical risk factors for delirium include all except:

    a) hypoxia

    b) age <25

    c) multiple drugs

   d) sensory impairment

   e) infection

 

2. Which of the following is the most appropriate screening tool for delirium?

    a) Confusion Assessment Method

    b) Folstein Mini-Mental Status Examination

    c) The clock drawing task

    d) Montreal Cognitive Assessment

 

3. The following can cause or aggravate delirium:

     a) Polypharmacy: medications as Opioids, anticholinergics etc.

     b) Infections

     c) Metabolic/electrolyte abnormalities

     d) Brain trauma

     e) All of the above

4. Which of the following interventions should be implemented to address cognitive       impairment?

    a) reorienting

    b) introducing cognitively stimulating activities

    c) providing clock, calendar that are highly visible to the patient

   d) facilitating regular visits from family and friends

   e) all of the above

 

5. The subtypes of delirium based on presentation are

      a) Hyperactive (agitated, hyperalert)

      b) Hypoactive (lethargic, hypoactive)

      c) Mixed

      d) None of the above

      e) All of the above

 

6. The most common diagnosis on inpatient psychiatric consultation  

      service is

     a) Post suicide attempt

     b) Schizophrenia

     c) Delirium

     d) Depression

     e) Anxiety

 

7. Increased morbidity from delirium is mostly related to 

      complications as

     a) Decubitus ulcers

     b) Pneumonias

     c) Seizures.

     d) Permanent cognitive deficits

     e) All of the above

 

8. Which category of medications is least likely to cause delirium?

    a) Analgesics

    b) Multivitamin

    c) Benzodiazepines

    d) Tricyclic antidepressants

    e) Antispasmodics

 

9. Persons with delirium have intact recent and remote memory

   a) True

   b) False

 

10. One nursing intervention to prevent exacerbation of delirium includes:

      a) Discharge patient early

      b) Mobilize patients early after surgery

      c) Keep asking the patient his/her name

     d) Hide sensory aids such as hearing aids and eyeglasses to prevent the patient from     accidentally harming himself with them

      e) Recommend that the physician order Halcion for sleep

 

Use the following case for questions 11-12:

 

Mrs. H. is a 75 year old female who is hospitalized for COPD exacerbation following a recent upper respiratory infection (URI) and urinary tract infection (UTI). She now has a new diagnosis of Diabetes Type 2 with new medications. She also has a history of hypertension and coronary artery disease.

 

11. Mrs. H. experiences weakness and confusion. These symptoms are most likely

due to:

     a) A fracture after a fall

     b) Alzheimer’s disease

     c) Change in environment

    d) Underlying infection or exacerbation of another medical problem

    e) A new onset anxiety disorder

 

12. If Mrs. H. had new onset urinary incontinence associated with weakness and

confusion, which of the following etiologies would be most likely?

 

    a) Inability to get to the bathroom

    b) Overflow incontinence

    c) Recurrent urinary tract infection

   d) Stress incontinence

   e) dementia

 

13. Patient who are delirious can present with the following

     a) Anxiety & Irritability

     b) Fear

     c) Anger

     d) Depression and apathy

     e) All of the above

 

14. While using antipsychotics for management of delirium we should monitor for

     a) EKG for QTc prolongation

     b) Muscle rigidity

     c) Neuroleptic Malignant Syndrome

     d) All of the above

     e) None of the above.

 

15. Mr. C. is an 56 year old male admitted with a large right middle cerebral artery stroke and placed on scheduled Ativan 2mg every 3 hours because he has a history of alcohol abuse. Chronic conditions of HTN and Hypercholesterolemia are well-managed with HCTZ 12.5 mg daily and Lipitor 20 mg daily. Lab tests are all normal. Two days into the hospitalization, the medications are the same and Mr. C. appears more somnolent yet is trying to climb out of bed, staggering about and swearing at everybody in slurred speech, and then take a swing at a physical therapist. Wrists restraints are ordered. As the nurse, you suggest:

 

   a) Ask the doctor to raise the scheduled dose of Ativan because of impending delirium   tremens

   b) Immediately stopping the HCTZ.

   c) Request a companion in the room.

   d) Stop the benzodiazepine.

   e) Transfer the patient to a locked psychiatric unit

 

 

 

 

 

 

 

 

 

 

 

Delirium Post-Workshop Quiz Answer Key

 

1. b

2. a

3. e

4. e

5. e

6. c

7. e

8. b

9. b 10. b

11. d

12. c

13. e

14. d

15. d