delirium in older patients admitted to a community based...

Geriatric Grand RoundsGeriatric Grand RoundsGeriatric Grand Rounds

Tuesday, October 27, 2009 12:00 noonTuesday, October 27, 2009 12:00 noon

Dr. Bill Black AuditoriumDr. Bill Black AuditoriumGlenrose Rehabilitation HospitalGlenrose Rehabilitation Hospital

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Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care

Hospital

Dr. Lotje Wasilenko, CCFPCare of the Elderly Resident

October 27, 2009

Disclosure

I have no relationship that could be perceived as placing me in a real or apparent conflict of

interest in the context of this presentation

Outline• Background

• Research questions

• Methodology

• Results

• Conclusion

• Limitations

• Recommendations/Future directions

Background on Delirium

Definition Delirium (DSM-IV-TR)1

• Acute alteration in consciousness

• ↓ Ability to focus, sustain, or shift attention

• Develops over hours to days

• Results in cognitive and perceptual

disturbance

Prevalence and Risk Factors of Delirium in Older Patients Admitted to a Community Based Acute Care HospitalLotje Wasilenko, MD, CCFP

Geriatric Grand Rounds Glenrose Rehabilitation Hospital, Alberta Health Services, AB, Canada October 27, 2009

Definition Delirium (DSM-IV-TR)1

• Fluctuates throughout the day

• Caused by medical conditions, medication

side effects, substance intoxication

Prevalence of Delirium

• Delirium can be found wherever there are sick patients

• Prevalence in hospitalized older adults is 25% to 56% 2,3

Prevalence of Delirium

• Highest prevalence: 4,5,6

- Older patients post-op 15-53%- ICU 70-87% - Near death 80%

• Unrecognized in up to 65%7 (age, dementia, other mental disorder)

Risk Factors and Precipitants8

• Delirium is a multi-factorial disorder

• Risk factors that increase baseline

vulnerability

- Underlying brain diseases (dementia/stroke)

- Advanced age

- Sensory impairment

Risk Factors and Precipitants8

• Precipitants are factors that precipitate the

disturbance

• Precipitants alone do not cause delirium

• Precipitants interact with underlying risk

factors

Precipitating Factors

• Drugs and toxins

• Infections

• Metabolic derangements

• Brain disorders

• Systemic organ failure



Precipitating FactorsOthers:• Immobility (restraint use)• Dehydration• Malnutrition• Use of bladder catheters• Constipation• Urinary retention• Pain• Sleep deprivation

Vulnerability9

• Highly vulnerable patients have many risk factors - Delirium due to relatively benign precipitant- For example: change in medication

• Less vulnerable patients have few risk factors- Require major insult to trigger delirium

Diagnosis

• Most important:- Delirium is a medical emergency- Recognize that delirium is present- Uncover the cause for delirium

• Evaluation: history (including meds), physical exam, CAM, investigations

CAM10

• Confusion Assessment Method1) Acute onset and fluctuating course2) Inattention3) Disorganized thinking4) Altered level of consciousness

• Diagnosis of delirium requires 1 and 2, plus either 3 or 4

• CAM Scores predicting Delirium (Sensitivity of 94-100% and Specificity of 90-95%)

Consequences of Delirium11

• Prolonged hospital stay

• Functional and cognitive decline

• ↑ Risk of institutionalization

• ↑ Morbidity and mortality

• ↑ Financial burden

Prevention of Delirium

• Managing modifiable RF/Precipitants reduces risk of delirium




• Managing modifiable RF/Precipitants reduces risk of delirium


• This study used protocols to screen and control for 6 RF:

- Cognitive impairment - Visual impairment- Sleep deprivation - Hearing impairment- Immobility - Dehydration


• Significant reduction in number of delirium episodes compared with usual care (62 versus 90)

• Significant reduction in the total number of days with delirium (105 versus 161)

• No effect on delirium severity or recurrence rate

Seniors’ Delirium Protocol

• Implemented in August 2008

• To improve identification and management of

delirium in the acute care setting

• Early recognition and intervention of delirium

to improve patient outcome

Seniors’ Delirium Protocol

• Guides assessment for delirium

• Includes CAM, guidance of opioid use, and medication management of disturbed behaviour

• 3 pages of patient care orders

Research Questions



Research Questions

1) What is the prevalence of delirium in patients 65 years of age or older, admitted to a Family Medicine unit at a community based Acute Care Hospital?

2) What are the most common risk factors and precipitants in older hospitalized patients with delirium?

Research Questions

3) Is the Seniors’ Delirium Protocol being utilized in patients with a change in behaviour or cognition?

- Delirium- Acute confusion- Agitation (new onset)

Methodology

Methodology

• Literature review

• Ethics and site approval

• Chart retrieval from medical records– Patients ≥ 65 years old admitted to Family Medicine Unit

in an acute care facility between November 1, 2008 and February 28, 2009

• Retrospective chart review and data extraction

Methodology Data Extraction



Results

Age/Gender of Sample Population

n = 250

AgeMean (yrs) 83.04SD 7.83Range (yrs) 65-103

Research Question #1

What is the prevalence of delirium in patients 65 years of age or older, admitted to a Family Medicine unit at a community based Acute

Care Hospital?

Prevalence of Delirium/Acute Confusion/Agitation

n = 250

Prevalence of Delirium/Acute Confusion/Agitation

n = 78


What are the most common risk factors and precipitants in older hospitalized patients with

delirium?



RF/Precipitants for Delirium in Sample Population

n = 250

RF/Precipitants in Delirium versus Non-Delirium Group

*

**

**

*

*

*

Age Difference Between Delirium and Non-Delirium Group

n Mean Age (yrs)

SD p-value

Delirium 78 84.6 7.54 0.03No Delirium 172 82.3 7.89

Gender Difference Between Delirium and Non-Delirium Group

Male Femalen % n %

Delirium 28 35.9 50 64.1No Delirium 62 36.0 110 64.0

Differences Not Statistically Significant

Breakdown of Sample Population by Number of RF

for Delirium

Breakdown of Delirium and Non-Delirium Group by Number of RF



Breakdown of Sample Population into Low Risk or

High Risk Groupsn = 250

Prevalence of Delirium in the Low and High Risk Groups

p < 0.001

Age Difference Between High and Low Risk Groups

n Mean Age (yrs)

SD p-value

Low (≤ 3 RF) 92 81.7 7.49 0.04High (≥ 4 RF) 158 83.8 7.96

Gender Difference High and Low Risk Groups

Male Femalen % n %

Low (≤ 3 RF) 31 33.7 61 66.3High (≥ 4 RF) 59 37.3 99 62.7

Differences Not Statistically Significant

Difference in # Medications Between Low and High Risk

Groups

n Mean (# meds)

SD p-value

Low (≤ 3 RF) 92 5.03 2.81 <0.001High (≥ 4 RF) 158 6.41 2.97

Examining the Most Predictive Risk Factors for Delirium

• Logistic regression used to determine the most predictive risk factors for delirium

• First step was to look at correlations between risk factors ( n = 15) and delirium

• Those risk factors found to be positively correlated with delirium were selected for use in the regression equation (10 of the 15 were significant)



Most predictive Risk Factors for Delirium

Risk Factors p-valueHx Dementia 0.001Immobility 0.003Dehydration 0.02Physical Restraints 0.001# Medications <0.001

Bladder Catheter 0.06


Is the Seniors’ Delirium Protocol being utilized in patients with a change in behaviour or

cognition?

- Delirium- Acute confusion- Agitation (new onset)

Seniors’ Delirium Protocol Use Conclusions

• Delirium is very common in our sample population (31%)

• Acute Confusion is documented more often in the chart than the diagnosis of delirium

• Significant predictors of delirium are a history of dementia, immobility, dehydration, use of physical restraints, and # of medications

• Seniors’ Delirium Protocol is underused

Conclusions

• Patients with ≥ 4 RF/Precipitants develop delirium 3 times more often then patients with ≤ 3 RF/Precipitants

Limitations

• Not all RF/Precipitants for delirium were included in data extraction

• Some RF/Precipitants were difficult to assess with retrospective chart review and might have been missed

• Unsure if all delirium diagnosis were correct since CAM score not mentioned in chart



Recommendations

• Since delirium is common and affects patient outcome we should anticipate it in certain patients (hx of dementia/stroke, older age)

• If there is change in behaviour/cognition use Seniors’ Delirium Protocol which addresses most RF and precipitants

Recommendations

• At least address the most predictive RF/Precipitants:

– Hx of dementia– Immobility– Dehydration– Use of physical restraints– Medications that can cause delirium

Recommendations

• If delirium is confirmed use this as diagnosis (instead of Acute Confusion)

• Document delirium in discharge summary

Future Directions

• Staff surveys to find out why Seniors’ Delirium Protocol is not being used

• Regular inservices regarding Seniors’ Delirium Protocol with follow up in 1 year (focus on physicians, residents, students)

• Possibly develop an intervention protocol based on the most predictive RF/Precipitants

Thank You!

• Dr. Bonnie Dobbs and Rhianne McKay• Dr. Jennifer Stickney-Lee and Dr. Namita Rao• Medical Records Staff• Bonnie Launhardt

References1. American Psychiatric Association, Diagnostic and Statistical Manual, 4th ed, Text Revision,

APA Press, 20002. Inouye SK. Delirium in hospitalized older patients. Clin Geriatr Med 1998; 14(4):7456-643. Siddiqi N et al. Occurence and outcome of delirium in medical in-patients; a systematic

literature review. Age Ageing 2006;35:350-644. Inouye SK. Delirium in older persons. N Engl J Med 2006. 354.1157-11655. Pisani MA et al. Cognitive impairment in the intensive care unit. Clin Chest Med 2003;24:727-

376. Casarett D et al. Diagnosis and management of delirium near the end of life. Ann Intern Med

2001;135:32-407. Inouye SK. The dilemma of delirium: clinical and research controversies regarding diagnosis

and evaluation of delirium in hospitalized elderly medical patients. Am J Med 1994;97 (3):278-88

8. Inouye SK, Charpentier PA. Precipitating risk factors for delirium in hospitalized elderly persons: predictive model and inter-relationship with baseline vulnerability. JAMA 1996; 275:852-7

9. Young J, Inouye SK. Delirium in older people. BMJ 2007;334;842-84610. Inouye SK et al. Clarifying confusion: The Confusion Assessment Method, a new method for

detection of delirium. Ann Intern Med 1990; 113:94111. McCusker J, Cole M et al. Delirium predicts 12- month Mortality. Arch Intern Med

2002;162:457-463



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