Susan Schumacher MS GCNS Objectives Identify 3 differences in clinical presentation of delirium versus underlying dementia Explain how to perform the Confusion Assessment Method CAM Identify at least 3 factors contributing to the development of delirium ID: 776409
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Slide1
Delirium Prevention, Assessment and Management
Susan Schumacher, MS, G-CNS
Slide2Objectives
Identify 3 differences in clinical presentation of delirium versus underlying dementia.
Explain how to perform the Confusion Assessment Method (CAM).
Identify at least 3 factors contributing to the development of delirium.
Identify appropriate interventions to prevent or shorten the course of delirium.
Describe pharmacological treatment of delirium.
Slide3What is Delirium?
A transient state of cognitive impairment manifested by simultaneous disturbance of behaviors that develop abruptly and fluctuate diurnally (daily)
Slide4Changes Observed in Delirium
Level of consciousnessAttentionPerceptionMemoryThinkingOrientationPsychomotor behavior
Slide5Perceptions from Patients
“I thought there were some photographers and things around taking advantage of people.”
Felt like “someone had pulled a curtain.”
Felt like “hospital staff were plotting against me.”
McCurren
,
Cronen
(2003)
Slide6How Common is Delirium?
Incidence within hospital 4-53.3%
Complicates hospital stay for more than 2.3 million older persons annually
Occurs in 5-61% of orthopedic patients, especially those with hip fractures
Between 22-89% of patients with delirium have underlying dementia.
Prevalence in patients receiving mechanical ventilation is as high as 83%.
Slide7Differentiating Delirium and Dementia
Delirium
Dementia
Onset
Acute, abrupt
Insidious
Duration
Hours to days, may last months
Months to years
Course
Fluctuating course which tends to be worse at night
Steady decline; can be stepwise decline with vascular dementia.
Attention
Inattention present
No change
Slide8Differentiating Delirium and Dementia
Delirium
Dementia
Consciousness
Changes- vigilant to lethargic
No change until late in the illness
Hallucinations/Delusions
Visual and auditory hallucinations and delusions
Delusions
Visual hallucinations with
Lewy
body dementia
Sleep/wake cycle
Impaired, sleep schedule can become reversed
Fragmented; may awaken frequently
Mood/Affect
Rapid swings; paranoid
Apathetic, depressed
Psychomotor behavior
Hypoactive, hyperactive or mixed
No change
Slide9Outcomes Related to Delirium
Length of stay
Higher level of care at discharge
Increased mortality after discharge
Increased risk of adverse events
Slide10Investigating the factors leading to Delirium (Multi-factorial)
Underlying risk factors
: Factors that cannot be changed which impact delirium.
Precipitating factors:
Factors that contribute to development of delirium which can be changed.
Slide11Underlying Risk Factors
DementiaSubstance abuseParkinson’s diseaseSensory deficitsAgeTraumatic brain injuryChronic kidney disease
Slide12Precipitating Factors
Hypoxia
Infections
Electrolyte imbalancesAnemiaMedicationsUncontrolled painConstipationTethers (catheters)
Slide13What is Confusion Assessment Method(CAM)?
Diagnostic assessment tool for delirium developed by Sharon Inouye (Yale)
Assesses 4 features of delirium:
Acute onset and fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Slide14Completion of CAM
On admission for all patients greater than 70 years
Every 8 hours for patients greater than 70 years
Supportive information:
Hours of sleep
Agitation score
Behaviors
Nursing interventions
Slide15CAM Assessment on Admission
Completed and documented within 4 hours of admission
Baseline Cognitive Status
Impairment (dementia, traumatic brain injury, other neurologic diseases impacting cognition)
Admission Cognitive Status
CAM completed by Surgery Center RN for surgical patients (documented in PICIS)
Slide16Criteria for Patients Unable to Complete the CAM
Language Barrier (unable to speak
english
)
Receptive/Expressive Aphasia
Unconscious or sedated (Use CAM-ICU)
Severe stage of dementia or brain injury
Slide17What makes a positive CAM?
Feature I: Acute Onset of mental status changes
AND
Feature II: Inattention
Feature III: Disorganized Thinking
Feature IV: Altered Level of Consciousness
ONE
abnormal finding for each feature = a positive result for that feature
AND
AND/ OR
Slide18Confusion Assessment Method(CAM)
Criteria 1
(Acute onset and Fluctuating Course)- Has patient changed from their baseline cognitive status? Does the behavior fluctuate during the day, such as worse in the evening or night?
Slide19Case Study- Criteria 1
An 88 yr old woman who is admitted with an intracranial bleed and has underlying mild cognitive impairment. She has been alert and oriented to person, place and time. She is cooperative with cares, but has a difficult time remembering to use the call light. At 3am she wakes up and cries out for help, pulls out her IV line, tries to push nursing staff away and is paranoid about what the staff are trying to do with her.
Slide20Case Study- Criteria 1
A 79 yr old man admitted for total hip is POD #3. He has underlying dementia (mild), CAD, Type II diabetes, and osteoarthritis. Patient’s bed alarm is going off 2-3 times/ shift, as he tries to get out of bed to use bathroom and he forgets to use the call light. He is alert and oriented to person and place, slept well during the night and cooperates with nursing cares. He asks the staff about calling his wife several times every shift.
Slide21Confusion Assessment Method (CAM)
Criteria 2-Inattention
Does the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?
Slide22Case Study- Criteria 2
Talking with a patient about his hospital stay, patient gives eye contact to the nurse initially, but when an x-ray machine moves past his door, his focus shifts to the hallway. Also, patient unable to follow the directions that nurse has provided about using call light when needing assistance.
Slide23Confusion Assessment Method(CAM)
Criteria 3
(Disorganized Thinking) Is the patient’s speech disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
Slide24Confusion Assessment Method(CAM)
Criteria 4
Overall, how would you rate this patient’s level of consciousness?
Levels of Consciousness
Alert (normal)
Vigilant (
hyperalert
)
Lethargic (drowsy, easily aroused)
Stupor (difficult to arouse)
Coma (
unarousable
)
Slide25ScoreTermDescription+4CombativeOvertly combative, violent, immediate danger to staff+3Very agitatedPulls or removes tubes or catheters, aggressive+2AgitatedFrequent non-purposeful movement, fight ventilator+1RestlessAnxious but movements not aggressive, vigorous0Alert and calm-1DrowsyNot fully alert, but has sustained awakening (eye opening/eye contact) to voice (> 10 seconds)-2Light SedationBriefly awakens with eye contact to voice (< 10 seconds)-3Moderate SedationMovement or eye opening to voice (but no eye contact)-4Deep SedationNo response to voice, but movement or eye opening to physical stimulation-5UnarousableNo response to voice or physical stimulation
Richmond Agitation Sedation Scale (RASS)
Slide26What makes a positive CAM?
Feature I: Acute Onset of mental status changes
AND
Feature II: Inattention
Feature III: Disorganized Thinking
Feature IV: Altered Level of Consciousness
ONE
abnormal finding for each feature = a positive result for that feature
AND
AND/ OR
Slide27Let’s Practice!
Slide28E-paging a new Positive CAM
Delirium is an urgent medical condition. A positive CAM test should be reported immediately so the patient can be evaluated for delirium quickly.Have this information ready when you page:BGMLast void/is patient retaining urineOxygen saturationLast BMPain statusTemperature & Blood PressureI & O balanceLatest labs if available (serum K, Na, Mg, Cr, etc)Agitation ScoreConfirm your CAM POSITIVE result with the Charge Nurse before paging.
If no response within 10
mins
, call an RET
Slide29Interventions to Prevent and Manage Delirium
Delirium Prevention Trial (Inouye)
Patients in the highest adherence group demonstrated an 89% reduction in delirium risk compared with patients in the lowest group.
Protocols for orientation, therapeutic activities and mobility make a significant difference when implemented consistently!
Slide30Intervention Protocols
Protocols:
OrientationTherapeutic activitiesMobility
Slide31Interventions for Delirium
Medication managementReview for culprit medicationsPharmacy consultAdminister medications for delirium per order set Pain Management
Slide32Interventions for Preventing and Resolving Delirium
A2 Evidence Promotion of nutritionRemoval of urinary catheter and other tethersEarly mobilizationGlasses and hearing aidesPain managementBowel and bladder needsFluids and electrolyte balanceAdequate 02
Slide33Patient and Family Education
Brochure/BookletWhat is Delirium?Why is it occurring ? What can be done to treat and resolve it?What can family members do to help?
Slide34Comfort Measures and patients with Dementia
Temperature (hot or cold?)Hungry or thirstyOver or under- stimulatedBowel or bladder needsProvide reassurancePersonal items such as family pictures
Slide35Hospital Elder Life Program (HELP)
A comprehensive program of care for hospitalized older patients, designed to
PREVENT
delirium and functional decline.
Target patient =>70 years old with a LOS > 2 days.
HELP® Goals
Maintain physical and cognitive functioning throughout hospitalization (through daily interventions)
Maximize independence at discharge
Assist with the appropriate transition from hospital to home or step-down setting
Improve geriatric skills of staff throughout the general medicine units.
Slide36Hospital Elder Life Program (HELP)
Trained program volunteers: 100Patient visits permonth: 400!!
Slide37Hospital Elder Life Program (HELP)
Key interventions of the program
Daily visitor program with structured cognitive orientation
Therapeutic activities program
Early mobilization
Non-pharmacologic sleep protocol
Hearing and vision protocol
Feeding and fluid assistance
Geriatric patient care education for unit nursing staff
How to order a HELP consult
Slide38Delirium Order set- Medications
IV Haloperidol (
Haldol
) (Severe, Moderate Hyperactive Delirium and Hypoactive Delirium)
Scheduled doses of
Haldol
based on RASS score
PRN doses to reduce agitation to 0 on RASS scale or until 8mg given (moderate) 12mg (severe)
Contact provider if
Haldol
every 30 minutes for 2hours is not decreasing agitation.
Weaning off
Haldol
(once pt goes 24 hours without
prn
dose)
Try to avoid in patients with Parkinson’s disease
Risk of prolongation of the QT/
QTc
interval (baseline and daily EKG)
Slide39Why the daily EKG?
Prolongation of QT/QTc interval may occur with any antipsychotic medication (Haldol) and increases risk for Torsades de Pointes.
Slide40Delirium Order set- Medications
QUEtiapine (Seroquel)Used for patients with Parkinson’s diseaseMay give Haldol and Ativan additionally for RASS score of +3. (Combative patient)Watch of orthostatic hypotension LORazepam (Ativan)Given with IV Haldol for very agitated patients ONLY
Slide41Prevention of Delirium is Key!
Slide42References
Inouye,S
., Baker, D., Fugal, P. & Bradley, E. (2006). Dissemination of the hospital elder life program: Implementation, adaptation, and successes.
Journal of
Gerontological
Society,
54:1492-1499.
Inouye,S
.,
Bogardus,S
.,
Williams,C
. & Leo-
Summers,L
. (2003). The role of adherence on the effectiveness of
nonpharmacologic
interventions.
Archives of Internal Medicine,
163: 958-964.
Robinson,S
., Rich, C.,
Weitzel,T
., Vollmer, C. &
Eden,B
. (2008). Delirium prevention for cognitive, sensory, and mobility impairments.
Research and Theory for Nursing practice: An International Journal,
22(2): 103-113.
Sendelbach
, S.& Finch
Guthrie,P
. (2009). Acute Confusion/Delirium. In M.G.
Titler
(Series Ed.),
Series on Evidence-Based Practice for Older Adults
, Iowa City, IA: The University of Iowa College of Nursing Interventions Research Center, Research Translation and Dissemination Core.