oct 6 - postop delirium in the older person (brymer)
TRANSCRIPT
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
1/70
Post-operative deliriumin the Older Person
Presented by: C. Brymer, M. Dasgupta, L. VanBussel & H. Park
(Slides prepared by: M. Dasgupta, MD, FRCP,Laurie McKellar RN(EC), BScN, GNC(C)
Lisa Van Bussell, MD, FRCP(C))
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
2/70
Frequent duties of a clinical clerkrotating through surgery:
Do an admission Hx and PE on an elderlyindividual about to go through a surgicalprocedure: This should help in determining the risk for
future problems that may develop (e.g. post-op complications, including delirium)
Being paged to manage a confusedperson who has had a surgical procedure(all the residents are busy in the OR)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
3/70
Case Scenario
You are called (at 3:00 AM) to assess a
confused patient who is post-op day # 3following a hip fracture repair
Staff insist that he is a danger to himself andneeds something now
How to approach this all-too-commonscenario? Could this have been prevented?
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
4/70
Basic objectives
To be aware of how to diagnose delirium
To be able to appreciate when someone is
at risk for developing post-op delirium
To have an approach to management of thedelirious patient
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
5/70
Outline - delirium (peri-operative): Epidemiology: frequency, pathophysiology, impacts/ consequences
Diagnosis: definition and manifestations, collateral history, needfor inter-Disciplinary Team (IDT) approach
Risk factors for surgical patient: Patient factors operative/anesthetic factors post-operative/medical factors
Delirium prevention
Management of the delirious patient: Non-pharmacologic interventions Pharmacologic interventions
Discussion of cases
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
6/70
Surgery in the older adult: Older people account for about 40% of elective
surgeries and 50% of emergent surgicalprocedures
Older people are at increased risk for post-
operative medical complications (e.g. cardiaccomplications, etc..)
Delirium is in the top three most common post-operative complications (Seymour and Vaz,1989; Liu et al.,2000)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
7/70
Delirium Unlike other typical medical/post-operative
syndromes:
There is no unifying pathophysiologic explanationunderlying the delirious state
It represents a common set of symptoms that canaccompany virtually any acute condition (etiologicallynon-specific)
Brain malfunction in response to multiple factors
Occurs in medical, surgical & psychiatric patients-EXTREMELY COMMON
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
8/70
Pathophysiology of Delirium- We really dont know why delirium happens
BUT.. (Van der Mast, Neurol 1998; Marcantonio et al., 2006): It is associated with neurotransmitter alterations
(e.g. anticholinergic activity, altered serotonin
synthesis, catecholamine, ie dopamine activity)
Also implicated: altered melatonin levels, post-oppain and endorphins, cortisol
Neurotransmitter abnormalities may result frommultiple pathophysiologic processes
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
9/70
Associated with bad consequences:
Immediate impacts of delirium:
Difficult to care for
People can get more sick (due to abovefactors)
length of hospital stay, cost
Highly distressing for patients who recall it.(Breitbart et al ( 2002 )
risk for short and long-term
functional decline, dementia,institutionalization and death (Dolan et al.,2000; Marcantonio et al., 2000; Lundstrom et al., 2003)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
10/70
Delirium- What is it? DSM- IV-TR (Diagnostic and Statistical
Manual of Mental disorders, 2000) diagnostic
criteria for delirium (clinical diagnosis): Disturbance of consciousness or awareness (reduced ability
to focus/ sustain or shift attention)
Change in cognition (e.g. memory, disorientation, language)
or development of a perceptual disturbance that is notbetter accounted for by a preexisting, established orevolving dementia
Disturbance develops over a short time period (usuallyhours-days) and fluctuates during the day
Evidence from history, physical examination or laboratoryfindings that the disturbance is caused by the directphysiological consequence of a general medical condition
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
11/70
Delirium- What is it? Confusion Assessment Method (CAM) is a
bedside diagnostic tool
CAM algorithm includes 4 key features of delirium:
1) acute onset and fluctuating course
2) inattention
3) altered LOC
4) disorganized thinking
Delirium should be suspected if features1 and 2 and either 3 or 4 are present
Inouye, S. et al (1990). Annals of Internal Medicine, 113(12)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
12/70
Delirium- Clinical Manifestations
Hyperactivity and/or Hypoactivity
NOTE: Delirium is often misdiagnosed
as dementia &/ or depression
Resistive to medical and care needs
e.g. refusing physical exam, tests, medications,pulling out IV/central lines/foley catheters/chest
tubes, removing leads, oxygen, etc. Refusing bathing, eating, drinking, ambulation,
OT/PT interventions
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
13/70
Delirium- Clinical Manifestations
Behavioural changes:
calling out, moaning, crying, physical aggression,hallucinations/paranoia, attempting to escape (highrisk for falls), altered sleep
Cognitive changes: disorientation, non-sensical speech, not following
commands, etc.
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
14/70
Delirium- complexity of diagnosis Overlapping features between delirium, dementia
& depression, and all 3Ds can co-exist
If person has altered mental status, alwaysassume delirium until proven otherwise.Delirium is a medical emergency.
Differentiating the 3Ds clinically : onset, course,progression, duration, awareness, alertness,attention, orientation, memory, thinking &
perception (New Zealand Guidelines Group (1998). Guidelines for theSupport and Management of People with Dementia.)
Slide is content from the London 3Ds 2008 Workshop (Screening)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
15/70
Assessment of Clinical features of delirium, dementia & depression
(adapted in RNAO BPG Screening for Delirium, Dementia and Depression in Older Adults( 2003)from: New Zealand Guidelines Group (1998) Guidelinefor the Support and Management of People with Dementia.)
Feature Delirium/ Acute Confusion Dementia Depression
Onset Acute/subacute depends on cause, often attwilight
Chronic, generally insidious,depends on cause
Coincides with life changes, oftenabrupt
Course Short, diurnal fluctuations in symptoms;worse at night in the dark & on awakening
Long, on diurnal effects,symptoms progressive yetrelatively stable over time
Diurnal effects, typically worse in themorning; situational fluctuations butless than acute confusion
Progression Abrupt Slow but even Variable, rapid-slow but uneven
Duration Hours to less than 1 month, seldom longer Months to years At least 2 weeks, but can be severalmonths to years
Awareness Reduced Clear Clear
Alertness Fluctuates; lethargic or hypervigilant Generally normal Normal
Attention Impaired, fluctuates Generally normal Minimal impairment but distractible
Orientation Fluctuates in severity, generally impaired May be impaired Selective disorientation
Memory Recent & immediate impaired Recent & remote impaired Selective or patchy impairment,islands of intact memory
Thinking Disorganized, distorted, fragmented, slow oraccelerated incoherent
Difficulty with abstraction,thoughts impoverished, makepoor judgments, words difficult tofind
Intact but with themes ofhopelessness, helplessness or self-deprecation
Perception Distorted; illusions, delusions &hallucinations, difficulty distinguishingbetween reality & misperceptions
Misperceptions often absent Intact; delusions & hallucinationsabsent except in severe cases.
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
16/70
Obtain Collateral History- tosort it out
Determine baseline functional & cognitive status byseeking out a reliable informant.
Possible questions to ask: Is he/she thinking, behaving & taking care of
themselves differently than they normally do?
Can you give me some examples of how he/shethinking, behaving & taking care of themselvesdifferently than they normally do?
When did this change start?
Was the change gradual or abrupt?
Speak with other involved healthcare professionals
(nursing, PT, OT, etc..)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
17/70
Diagnosing & preventing:
To summarize- delirium: is an acute change in cognition and alertness
is one of the most common peri-operativecomplications
makes providing care difficult and is associatedwith bad outcomes
Preventing delirium (pro-active approach)is more effective than managing thealready delirious individual
Preventing it also implies recognizing whois at risk
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
18/70
Management- assessing risk:
In the surgical setting, always consider the individuals baseline inherent risk for
developing peri-operative delirium the nature of the surgery and post-op complications/events
Proactively assess risk preoperatively withvalidated risk indices
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
19/70
Determining risk for post-op
delirium:
In the non-cardiac elective surgery setting,
patient risk-factors include (Marcantonio et al., 1994) Age > 70, cognitive impairment, functional dependence,
self reported alcohol abuse, markedly abnormallaboratory values (130>Na>150,3.0>K>6.0, or3.3>glucose>16.7) (1 point assigned for each)
Type of surgery also important (AAA repair- 2 pointsand non-cardiac thoracic surgery-1 point)
Patients with 0, 1, 2 & >2 points had 2 %, 8%,13%, and 50% chance respectively of becoming
delirious
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
20/70
Risk for Post-op deliriumPatient-centered risk in hip (elective and
emergent) surgery:
Scale originally derived in the medical population(Inouye et al.,1993) has been validated in the hip surgerysetting (Kalisvaart et al.,2005).
Identified risk factors were: cognitive impairment,dehydration, severity of illness (APACHE II score >15), visual impairment (20/70 or worse) 0 points had ~4% (3.8 %) chance of delirium
1-2 points had ~10% (11.1%) chance of delirium 3-4 points had ~ 40% (37.1 %) chance of developing
delirium
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
21/70
Risk for Post-op deliriumOther risk factors in the non-cardiac surgery
setting:
Multiple studies have looked at risk for developingincident (new) delirium in the non-cardiac ORsetting: Risk factors include: increasing age, cognitive
impairment (****), psychotropic drug use, increasingmedical co-morbidity, dependent functional status,nature of the surgery, visual impairment, depression,residence in assisted-living homes
****Strongest and most consistently found risk factor-Important to do mental status screening before the surgical
procedure
Medical illness should also be treated/ controlled
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
22/70
Risk for Post-op deliriumPatient-centered risk in cardiac surgery: Risk scale in cardiac surgery (Rudolph et al.,2009), in
patients at least 60 yrs old:
prior history of CVA/ TIA (1 point) Mini Mental Status Exam (MMSE) score (4: 1 point)
Increasing points- increased risk for delirium: 0 points (~10-20 %); 1 point (40-50%); 2 points (60-
70%); 3 or more points (80-90%)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
23/70
Surgical risk factors:
The procedure matters:
Highest reported rates in post-hip fracture andemergent surgery (20-70%), bilateral kneereplacements (Williams Russo et al, 1992) & vascularprocedures (25-50%); close to 50% incidence in
AAA repair (Schneider at al., 2002)
Post CABG- earlier studies report higher rates, butrecent studies report 10-30% incidences (Van derMast et al., 1996)
Occurs in minor surgery as well (1-4% in cataractsurgery; 7% in urologic- Summers et al., 1979; Chaudhuri etal, 1994; Milstein et al., 2002; Hamann et al., 2005;)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
24/70
Surgical risk factors:Other surgical factors:
blood loss and length of surgery associatedwith risk for delirium (Knill et al., 1991; Hofste et al., 1997;Marcantonio et al., 1998; Bucerius J et al., 2004; Yamagata et al., 2005;
Hamann et al., 2005))
waiting time for hip fracture surgery isassociated with delirium rates (Edlund et al., 1999;Duppils and Wikblad, 2000)
Controversy exists about other surgical factors: Intra-operative BP changes Effect of off-pump by-pass or hypothermic techniques in
cardiac surgery
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
25/70
Anesthetic risk factors:Anaesthetic and other considerations:
Little evidence to suggest that either general or localanesthetics affect a persons chance of having delirium(Williams Russo et al., 1995), although there may be fewer othercomplications with use of local anesthetics (Rodgers et al., 2000)
Peri-operative pain has been found to correlate with post-
operative delirium (Lynch et al.,1998; Vaurio et al., 2006, Morrison et al.,2003)
Delayed ambulation associated with delirium risk(Kamel etal., 2003)
This continues to be an evolving field of research and newsedating agents (e.g. dexmedetomidine, an alpha2 agonist)may decrease delirium (Maldonado et al., Psychosomatics 2009; 50(3): 206-17
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
26/70
Post-op factors:Non-operative, post-operative factors:
Surgical patients can also have medical problems,which need to be ruled out- e.g. post-op MI,infections, reactions to drugs, etc..
Pain or lack of pain medications, narcotics
Post-op MIs often do not present with pain
Unfortunately delirium is etiologically non-specific(can accompany virtually any condition)
Urinary retention, constipation
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
27/70
Possible post-op factors:
Precipitating factors:
Precipitating agent- MULTIFACTORIAL- Can be caused by any of multiple noxious stimuli- non-specific:drugs, ANY medical illness, change of environment,
catheter and restraint use, ICU setting, surgical setting,sleep deprivation, pain, constipation, urinary retention,environmental change, etc..)
In 10-25% of cases there may not be an
underlying offender found (Dubos et al., 1996; Rudberg etal., 1997); this may be even higher in the hipfracture setting (Brauer et al., 2000)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
28/70
Possible Causes of delirium
I Watch Deathmnemonic for possible causes of delirium:
I : Infections
W : Withdrawal A: Acute Metabolic T: Toxins, drugs C: CNS pathology
H: Hypoxia
D: Deficiencies E: Endocrine A: Acute Vascular T: Trauma H: Heavy Metals
( American Psychiatric Publishing, Inc., www.appi.org. Adapted from Wise (1986)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
29/70
Delirium Prevention Hard facts: we dont know how to decrease the
complications related to delirium (e.g. functional
decline, LTC, death), once it has occurred, andstudies related to managing delirium are scarce
Once delirium occurs, interventions are less
effective & efficient.(Cole, M., Dementia and Geriatric CognitiveDisorders(1999), p. 406- 411; Cole, M. et al, CMAJ ( 2002), p. 753-759; Inouye, S.,Annals of Medicine (2000), p. 257-263, Holroyd-Leduc JM et al, CMAJ (2010); 182(5):465)
Consider preventative measures from thebeginning (especially if at high risk)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
30/70
Prevention of Delirium
Systematic reviews suggest multifaceted geriatricassessment programs (largely non-pharmacological)may new delirium or delirium length although
most trials are not RCTs (Cole et al., 1998, Tabet N et al., 2009, Holroyd-Leduc JM et al, 2010)
Before-after trials of nursing-based detection andprevention programs suggest they may be effective
in cognition and functional outcomes(Lundstrom et al, 1999; Milisen et al., 2001)
In a recent RCT there was a in incidence andduration of delirium in the group randomized to a
multi-factorial intervention program (Lundstrom et al., 2007)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
31/70
Prevention of delirium Hospital Elder Life Program targets risk
factors for delirium (Inouye, S. et al, NEJM (1999), p. 669-676):
Cognitive impairment e.g. orient patients
Sleep deprivation e.g. keep environment quiet at night
Immobility- e.g. mobilize
Visual impairment e.g. provide glasses Hearing impairment e.g. provide hearing aids
Dehydration watch for and treat dehydration
Other studies also support the benefit ofnon-pharmacologic approaches (Vidan et al., J AmGeriatr Soc 2009; 57: 2029-36)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
32/70
Management of Delirium
First line intervent ions are non-pharmacolgical
Identify and treat the medical cause(s) of thedelirium
Modify the environment & use behaviouralstrategies to address responsive behaviours suchas:
Re-orientate and reassure patient that s/he is safe Talk slowly and calmly, use short simple sentences and
instructions
Distract to a topic s/he likes
Keep patient safe from self harm or harm to others
Educate the patient and family about their delirium
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
33/70
Assessment & Management of Delirium
Determine and treat the underlyingprecipitant:
Multiple studies suggest that plurality of causation is commonin delirium- often 3 causes found (Francis et al., 1990; Rudberg et al.,1997)
Contributing factors can include:
on-going acute medical conditions- e.g. hepatic or renalfailure, adverse drug reactions, dehydration (Lawlor et al.,2000)
less medically acute, care-related, potentiallymodifiable causes (Francis et al.,1990; Inouye 1999; Brauer et al.,2000):
E.g. urinary retention, constipation, foley catheters, the useof restraints, sensory deprivation, excessive immobility, andenvironmental disturbances
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
34/70
Assessment & Management of Delirium
Delir ium the medical work-up:
The work up of delirium is largely empiric
American Psychiatric Association PracticeGuidelines, 1999- consensus basedmanagement approach (Am J Psychiatry May 1999; 156(5): 1-20)
Recommend delirious individuals undergo basiclaboratory work-up: lytes, glucose, calcium, albumin,BUN, Creat, AST, ALT, bili, alk phos, Mg, PO4, CBC,EKG, CXR, ABGs (O2 sats), U/A (?Troponin in ORsetting?)
If clinical uncertainty persists consider: Urine C &S,Urine drug screen, VDRL, heavy metal screen, B12 andfolate, ANA, urinary porphyrins, NH4, HIV, blood C & S,serum drug levels, LP, CT/MRI, EEG
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
35/70
Assessment and Management of Delirium
Determine underlying precipitant:
Use I WATCH DEATH mnemonic
Easy things to check for: Have they moved their bowels? Have they been toileted (is there urinary retention)? Are they on restraints, or other invasive devices
(catheters)? Check their MARS for drugs potentially causing delirium
Drugs: Anticholinergics, psychotropics: TCAs, gravol,
benzodiazepines, even neuroleptics (e.g. Olanzepine),antidepressants, narcotics (never give Demerol)
Case reports suggest diverse drugs can be associatedwith delirium (e.g. quinolones, digoxin)- so considerd/cing what you dont need
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
36/70
Assessment and Management of Delirium
Determine underlyingprecipitant:
Studies suggest CNS causes rarelycause for delirium (Francis J et al., JAMA 1990;263: 1097-1101)
Advanced cancer may an exception(without known CNS mets) where
meningeal involvement has beendescribed in 5-20% of cases (Lawlor etal., 2000; Olofsson et al. 1996; Tuma et al., 2000)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
37/70
Assessment and Management of Delirium
Modify the environment and behaviouralapproaches: bedside manner matters-
Try to re-orient delirious person
Talk calmly and slowly. Give one step requests to avoidoverwhelming person.
Provide glasses and hearing aids
Place familiar objects in room
Too much/too little sensory stimulation?
Modify your approach. Try to do task later when patient not
resistive.
Encourage family to spend time with delirious individual(unless this worsens things)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
38/70
Non-pharmacologic management
Keeping patients safe- preventcomplications:
Are they eating/ drinking/ aspirating?
Consider hydration with IVFs, prevent renal compromise/failure & electrolyte imbalance, watch for aspirationpneumonia (?SLP consult?)
Are they mobilizing- will prevent deconditioning & pressureulcers and will help with lung status
Consult PT prn If not contraindicated, mobilize and get up in chair TID
Are they restrained? Do they have unnecessary foleycatheters? (both can aggravate their delirium)
Consider discontinuing. Follow Restraint policy if restrained.
Are they a fall risk? Use fall prevention strategies & monitor for falls
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
39/70
Non-pharmacologic management
Non-pharmacologic approaches canduration of, or complications of delirium:
A RCT done in the ICU showed early mobilizationdecreased the duration of delirium (Schweickert et al.,Lancet 2009; 373: 1874-82)
Multifaceted intervention studies suggest that
complications can be prevented: e.g. fewer days of delirium, less delirium, and fewer
falls, in both delirious and non-delirious individuals,lower post-op LOS (Lundstrom M, et al. Aging-Clinical &Experimental Research, 2007; 19 (3): 178-86)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
40/70
Other management approaches (drugs):
Pharmacological treatments - Not alwaysrequired:
No evidence that medications alter complications relatedto delirium
No RCTs demonstrate the benefit of psychotropics innon-alcohol withdrawl delirium (Crit Care Med 2010; 38: 428-37)
Benzodiazepines can cause paradoxical agitation Other psychotropics can contribute to delirium and can
have other significant side effects.
Constant observation more effective than restraints, or
sedation to keep patient safe.
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
41/70
Management of Delirium
Pharmacological Interventions:
Avoid psychotropic medications when possible
If agitation occurs: Speak with allied healthcare professionals to identify
(and avoid if possible) triggers Modify environment and/or care approach. Flex care
In absence of psychotic symptoms or causingdistress, or harmful behaviours, treatment ofdelirium with psychotropic medication is notrecommended.
Psychotropic medication to control wanderingis NOT recommended.
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
42/70
When to use drugs? Reserve psychotropic medications for
older persons w ith delirium w ho aredistressed due to agitation orpsychotic symptoms in order:
To carry out essentialinvestigations or treatment.
To prevent delirious older personfrom endangering themselves or
others.CCSMH National Guidelines for Seniors Mental Health:The Assessment and Treatment of Delirium (2006), p.16)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
43/70
Management of Delirium
Pharmacological Interventions:
When psychotrophic medication used:
Aim for monotherapy, lowest effective dose andtaper as soon as possible
Monitor for any side effects- (CCSMH National Guidelines forSeniors Mental Health: The Assessment and Treatment of Delirium (2006),
p.16)
e.g. arm/leg tone, neuroleptic malignant syndrome,postural BPs drops (seroquel) and QTc interval
Use medication with low side-effect profile.
Titrate with very small increments
Trial for short periods, re-evaluate need for drugsregularly
Management of Delirium
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
44/70
Management of Delirium
Pharmacological Interventions: Few studies to determine optimal doses of anti-psychotics in
treatment of delirium.
Anti-psychotics drug of choice in treatment of delirium (Ozbolt et al.,2008).
No RCTs to show us that psychotropics improve outcomes fordelirium
Haloperidol (typical antipsychotic) suggested as anti-psychotic ofchoice and continues to be first line agent for treatment ofsymptoms of delirium.
Starting dose of Haldol: 0.25-0.5 mg PRN, increase gradually asneeded
Use of benztropine and related medications should be avoided indelirium due to anti-cholinergic effects, and should not be started asprophylaxis with haloperidol. (CCSMH National Guidelines for Seniors MentalHealth:The Assessment and Treatment of Delirium(2006), p.42)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
45/70
Management of Delirium
Pharmacological Interventions-
Neuroleptics:
A recent RCT suggested that haldolprophylaxismay delirium duration and length of hospital stay in individualswithout delirium pre-operatively, prior to hip surgery, if theyare at increased risk for delirium (Kalisvaart et al., 2005)
Given the possible toxicity of neuroleptic use, caution should beexerted, and these results should be verified beforeprophylactic use becomes recommended
The effect on long or short term functional outcomes is
unknown
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
46/70
Management of Delirium
Pharmacological Interventions:
Atypical anti-psychotics: reasonable alternative agents for older persons
with delirium due to fewer EPS side effect(consider especially for individuals sensitive to
dopamine- e.g. Parkinsons disease, Lewybody dementia).
Slight increase risk of stroke and all-causemortality with atypical anti-psychotics in
persons with dementia.(CCSMH National Guidelines for Seniors Mental Health: The Assessment and
Treatment of Delirium (2006), p.43)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
47/70
Management of Delirium
Pharmacological Interventions:
Atypical anti-psychotics (contd)
Clozapine for delirium not recommended because ofpossible serious hematologic side effects.
Studies limited risperidone- most evidence amongatypicals in treating symptoms of delirium in adultpopulation
Risperidone produces less sedation and negligible anti-cholinergic effects
Quetiapine has fewer parkinsonian side effects but cancause drowsiness and postural BP drops
(CCSMH National Guidelines for Seniors MentalHealth: The Assessment andTreatment of Delirium(2006), p.43)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
48/70
Assessment and Management of Delirium
Pharmacological Interventions:
Atypical anti-psychotics (contd)
Olanzapine can produce over-sedation and gaitdisturbances, and may have anti-cholinergic side effects,especially at higher doses (Breitbart et al., 2002)
Concerns about weight gain, glucose dysregulation andhypercholesterolemia likely less with short duration oftreatment; however, use with caution in persons withdiabetes mellitus as there is risk of hyperglycemia
(CCSMH National Guidelines for Seniors Mental Health: TheAssessment and Treatment of Delirium (2006), p.43)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
49/70
Assessment and Management of Delirium
Pharmacological Interventions:
Atypical anti-psychotics (contd)
Suggested initial dosing ranges (start low &go slow approach): Quetiapine:
Start at 6.25-12.5 mg OD-BID, for a few days ifperson is very frail and elderly
Monitor postural BP & P, and if stable, increase slowly
Risperidone 0.25 mg daily to bid
Olanzapine 1.25-2.5 mg daily
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
50/70
Assessment and Management of Delirium
Pharmacological Interventions:
Cholinesterase Inhibitors Increasing interest in use for treatment of
symptoms of delirium.
Case reports support use of rivastigmine in
lithium toxicity induced delirium and inprolonged delirium.
Promising, but more research needed to guide
clinical practice.(CCSMH National Guidelines for Seniors Mental Health: The Assessment and
Treatment of Delirium (2006),p.44)
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
51/70
Assessment and Management of Delirium
Pharmacological Management (contd)
Management of Alcohol Withdrawal Delirium (AWD):
Rule out other concurrent physical causes for delirium(CCSMH National Guidelines for Seniors Mental Health: TheAssessment and Treatment of Delirium (2006),p. 45)
Benzodiazepines as monotherapy are reserved for olderpersons with delirium caused by withdrawl from alcohol/sedative-hypnotics
Shorter acting benzodiazepines (i.e., lorazepam) agentsof choice in the elderly.
Anti-psychotics may be added if psychosis cannot beadequately controlled with benzodiazepines alone.
Taper Benzodiazepines following AWD rather than
abruptly stopping Give Thiamine(CCSMH National Guidelines for Seniors Mental Health: The Assessment and
Treatment of Delirium (2006),p. 17)
Delirium Conclusions:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
52/70
Delirium - Conclusions:
Delirium occurs in all specialties and healthcare sectors Surgical patients are often older with multiple medical
conditions
Delirium is one of the most common post-operativecomplications encountered
Risk/causes of post-op delirium can involve patient,operative, and post-op factors
Must obtain collateral history to obtain baseline mentalstatus, and use an interdisciplinary approach todiagnose and care for a delirious person
Management requires a systematic approach since
anything can contribute to delirium
l l
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
53/70
Delirium - Conclusions: Preventive and non-pharmacologic interventions are
first line before pharmacological therapies
Little evidence presently that psychotropics improve
outcomes Psychotropics have well known side effects
Use psychotropics only when needed
Neuroleptics (haldol or Risperidone) in low doses for
aggression or psychosis; Quetiapine reasonable option Monitor tone & for NMS, postural hypotension, QTc interval
Start with low dose, increase slowly, constantly review needfor psychotropics and wean asap when delirium resolves
Benzodiazepines only indicated in specific cases-alcohol or benzodiazepine withdrawl
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
54/70
Case 1
A 78 year old man is admitted for
elective AAA repair PMH: MI (3 years ago), DM II, OA
Meds: Glyburide, ASA, metoprolol,
tylenol #3 (typically takes 2 beforebed)
What is important to do/ask toassess his risk for post-op delirium?
C 2
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
55/70
Case 2
A 67 year old man is admitted for electiveright knee replacement (arthorplasty)
PMH: AAA repair (with post-op delirium),CAD, MI (3 years ago), heavy EtOH usewith withdrawl, GERD, HTN
Possible h/o depression/ anxiety- startedon Nortryptiline 6 months ago (on 75 mgOD)
Although was independent in ADLs, wiferelays 6 month h/o memory decline (oncehe mistook his grand-dtr for his m-i-l)
C 2
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
56/70
Case 2
Now 8 days post-op, and very
confused, hallucinating, requiringrestraints because of safety concerns(fear of falling)
When we saw him, he was restrainedand thought he was in a gay bar,and his speech was illogical and
nonsensical What would you do next?
C 2
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
57/70
Case 2
MARS review- receiving lorazepam up to 6times per day (EtOH withdrawl initial
indication), on baclofen, tylenol 650 mgqid, nortryptiline 75 mg OD, norvasc,metoprolol
No BM in 8 days
Recent urinary retention
Recent labs otherwise WNL
What would you do now?
C 3
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
58/70
Case 3-
Mrs. P- 76 year old woman on the Plasticsservice (s/p excision of facial SCC, seen 5
days post-op)- RFR- weakness, confusion,falls
Intermittent confusion throughout hospital
stay- e.g. called husband telling him I have to go to
the hospital
e.g. at times thought her husband was her
father C/O severe pain
C 3
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
59/70
Case 3-
Collateral history-
declining STM for one and half years,worse in last 3-4 months (e.g.forgetting what she ate in the AM orwhere she went the day before)
declining ability to do certain IADLs(e.g. meal preparation) largely becauseof back pain
Case 3
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
60/70
Case 3-
PMH: HTN, DM, CRF, severe DDD, h/oright parotid lymphoma (radiated 1999),
prior DVT x 2 Present drugs: tylenol PRN, percocet PRN
(not received in days), bromazepam 6 mg
QHS, ranitidine 150 mg OD, amlodipine7.5 mg, thyroxine 0.1 mg, detrol 1 mgBID, dyazide, multivits, glyburide,
amitryptiline 100 mg OD, metoprolol 75mg BID, coumadin
Case 3
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
61/70
Case 3-
O/E- pleasant, alert and cooperative, notdepressed
Fatigued- with only partial co-operationwith cognitive testing- 7/10 on orientation,1/3 on 5 min recall, -1 on WORLD
backwards (attention), preseverative,problems misplacing hands on clock
Neuro- non-focal except for cognitiveproblems
Qs: What does she have? Would this have been expected?What next?
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
62/70
Selected References: American Psychiatric Association, Diagnostic and statistical manual of
mental disorders, 4th ed. Washington, DC, 1994. American Psychiatric Association. (1999). The American Journal of
Psychiatry, (Supplement), 156(5).
American Psychiatric Publishing, Inc., www.appi.org. Adapted from Wise(1986)
Brauer C, Morrison RS, Silberzweig SB et al. The cause of delirium inpatients with hip fracture. Arch Intern Med. 2000; 160: 1856-60.
Breitbart W., Tremblay A., Gibson C. An open trial of olanzapine for thetreatment of delirium in hospitalized cancer patients. Psychosomatics.43(3)(pp 175-182), 2002
Breitbart W., Tremblay A., Gibson C. The Delirium Experience: Delirium
Recall and Delirium-related distress in Hospitalized patients with cancer,their spouses/caregivers and their nurses. Psychosomatics. 43(3)(pp 183-194), 2002
Bucerius J, Gummert JF, Borger MA et al. Predictors of delirium aftercardiac surgery delirium: effect of beating-heart (off pump) surgery. JThorac & Cardiovasc Surg 2004; 127 (1): 57-64.
CCSMH (Canadian Coalition for Seniors Mental Health) National Guidelinesfor Seniors Mental Health-The Assessment and Treatment of Delirium,2006.
Chaudhuri S, Mahar RS, Gurunadh VS. Delirium after cataract extraction:a prospective study. J Indian Med Assoc 1994; 92 (8): 268-9
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
63/70
Selected References: Cole MG, Primeau FJ & Elie M. Delirium: prevention, treatment, and
outcome studies. J Geriatr Psychiatry Neurol 1998; 11: 126-137. Cole, M. (1999). Delirium: Effectiveness of systematic interventions.
Dementia and Geriatric Cognitive Disorders, 10, 406-411. Cole, M. G., McCusker, J., Bellavance, G., Primeau, B. J., Bailey, R. F.,
Bonnycastle, J. J., et al. (2002). Systematic detection and multidisciplinary
care of delirium in older medical inpatients: A randomized trial. CanadianMedical Association Journal, 167(7), 753-759 Dolan MM, Hawkes WG, Zimmerman SI, et al. Delirium on Hospital
admission in aged hip fracture patients: prediction of mortality and 2-yearfunctional outcomes. J Gerontol (Med Sci) Sep 2000; 55A (9): M527-M534.
Duppils GS, Wikblad K. Acute confusional states in patients undergoing
hip surgery. A prospective observation study. Gerontology 2000; 46: 36-43.
Edelstein DM, Aharonoff GB, Karp A et al. Effect of postoperative deliriumon outcome after hip fracture. Clinical Orthopaedics & Related Research2004; 422: 195-200
Edlund A, Lundstrom M, Lundstrom G et al. Clinical profile of delirium in
patients treated for femoral neck fractures. Dement Geriatr Cogn Disord1999; 10: 325-29 Edlund A, Lundstrom M, Brannstrom B et al. Delirium before and after
operation for femoral neck fracture. J Am. Geriatr Soc 2001; 49: 1335-1340
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
64/70
Selected References: Eriksson M, Samuelsson E, Gustafson Y et al. Delirium after Coronary
Bypass Surgery evaluated by the Organaic Brain Syndrome Protocol Scandcardiovasc J 2002; 36: 250-255
Francis et al., JAMA 1990; 263: 1097-1101; Hamann J, Bickel H, Schwaibold H et al. Postoperative confusional state in
typical urologic population: incidence, risk factors, and strategies for
prevention. Urology 2005; 65 (3): 449-53. Hofste WJ, Linssen CA, Boezeman Eh et al. Delirium and cognitive
disorders after cardiac operations: relationship to pre- and intraoperativequantitative electroencephalogram. International journal of clinicalmonitoring & computing. 1997 Feb; 14 (1): 29-36.
Inouye, S. (November 2003), Delirium- Translating Research into Practice( presentation at Hamilton Conference).
Inouye, S. K. (2000). Prevention of delirium in hospitalized older patients:Risk factors and targeted intervention strategies. Annals of Medicine,32(4), 257-263.
Inouye, S., Bogardus, S., Charpentier, P., Summers, L., Acampora, D.,Holford, T., et al. (1999). A multi-component intervention to preventdelirium in hospitalized older patients. The New England Journal of
Medicine, 340(9), 669-676. Inouye SK, Viscoli CM, Horwitz RI et al. A predictive model for delirium in
hospitalised elderly medical patients based on admission characteristics.Ann Intern Med 1993; 119: 474-81
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
65/70
Selected References: Inouye SK, Charpentier PA. Precipitating factors for delirium in
hospitalized elderly persons: predictive model and interrelationship withbaseline vulnerability. JAMA 1996; 275 (11): 852-7.
Inouye SK. Dement Geriatr Cogn Disord 1999; 10: 393-400 Kamel HK, Iqbal MA, Mogallapu R et al. Time to ambulation after hip
surgery: relation to hospitalization outcomes. J Gerontol Series A-BiO SCI& MED SCI 2003; 58 (11): 1042-5
Kalisvaart KJ, deJonghe JFM, Bogaards MJ et al. Haloperidol prophylaxisfor elderly hip-surgery patietns at risk for delirium:a randomized placeboe-controlled study. J Am Geriatr Soc 2005; 53: 1658-66. Knill RL, Novick TV& Skinner BA. Idiopathic Postoperative delirium is associated with long-term cognitive impairment. Can J. Anaesthes 1991; 38: A54
Lawlor PG, Gagnon B, Mancini IL et al. Occurrence, causes and outcome ofdelirium in patients with advanced cancer. Arch Intern Med 2000; 160:786-94.
Liu et al. J Am Geriatr Soc 2000; 48: 405-412 Lowery DP, Wesnes K, Ballard CG. Subtle attentional deficits in the
absence of dementia are associated with an increased risk of post-operative delirium. Dem & Geriatr Cogn Dis 2007; 23 (6): 390-4
Lundstrom M, Edlund M, Lundstrom G et al. Reorganization of nursing andmedical care to reduce the incidence of postoperative delirium andimprove rehabiliatation outcome in elderly patients treated for femoralneck fractures. Scandinavian Journal of Caring Sciences 1999; 13 (3):193-200.
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
66/70
Selected References: Lundstrom M, Edlund A, Bucht G et al. Dementia after delirium in patients
with femoral neck fractures. J Am Geriatr Soc 2003; 51: 1002-1006 Lundstrom M, Olofsson B, Stenvall M et al. Postoperative delirium in old
patients with femoral neck fracture: a randomized intervention study.Aging-Clinical & Experimental Research, 2007; 19 (3): 178-86
Lynch EP, Lazor MA, Gellis JE et al. The impact of postoperative pain on
the development of postoperative delirium. Anest Analg 1998; 86 (4):781-5 Marcantonio ER, Goldman L, Mangione CM et al. A Clinical Prediction rule
for Delirium after elective noncardiac surgery. JAMA 1994; 271: 134-139 Marcantonio ER, Goldman L, Orav EJ et al. The association of
intraoperative factors with the development of postoperative delirium. AmJ Med 1998; 195 (5): 380-4.
Marcantonio ER, Flacker JM, Michaels M, et al. Delirium is independentlyassociated with poor functional recovery after hip fracture. J. Am. GeriatrSoc 2000; 48: 618-624
Marcantonio ER, Rudolph JL, Culley D et al., Serum biomarkers fordelirium. J. Gerontol MED SCI 2006; 61A (12): 1281-6.
Milisen K, Foreman MD, Abraham IL et al. A nurse-led interdisciplinaryintervention program for delirium in hip-fracture patients. JAGS 2001; 49(5): 523-32
Millar K, Asbury AJ & Murray GD. Pre-existing cognitive impairment as afactor influencing outcome after cardiac surgery. Br. J Anaesth 2001; 86(1): 63-7
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
67/70
Milstein A, Pollack A, Kleinman G et al. Confusion or delirium followingcataract surgery: an incidence study of one-year duration. InternationalPsychogeriatrics 2002; 14 (3): 301-6.
Morrison RS, Magaziner J, Gilbert M et al. Relationship between pain andopioid analgesics on the development of delirium following hip fracture. JGerontol Seres A- Bio & Med Sci 2003; 58 (1): 76-81 23.
New Zealand Guidelines Group (1998). Guidelines for the Support andManagement of People with Dementia.
Olofsson SM, Weitzner MA, Valentine AD et al. A retrospective study ofthe psychiatric management and outcome of delirium in the cancerpatient. Supportive care in cancer 1996 Sep; 4 (5) : 351-7.
Ozbolt LB, Paniagua MA, KaiserRM. Atypical antipsychotics for thetreatmetn of delirious elders. J Am Med Dir Assoc 2008; 9: 18-28)
Registered Nurses Association of Ontario (RNAO)(2003). Nursing BestPractice Guideline: Screening for Delirium, Dementia and Depression inOlder Adults.
Registered Nurses Association of Ontario (RNAO)(2004). Nursing Best
Practice Guideline: Caregiving Strategies for Older Adults with Delirium,Dementia and Depression
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
68/70
Selected References:
Rolfson DB, McElhaney JE, Rockwood K et al. Incidence and Risk factorsfor delirium and other adverse outcomes in older adults aftercoronaryartery bypass surgery. Can J Cardiol 1999; 15 (7): 771-776
Rodgers A, Walker N, Schug S et al. Reduction of postoperative mortality
and morbidity with epidural or spinal anaesthesia: results from overview ofrandomised trials. BMJ 2000; 321: 1-12. Rudolph JL, Jones RN, Levkoff SE et al. Derivation and validation of a
prospective prediction rule for delirium after cardiac surgery. Circulation2009; 119: 229-36.
Rudolph, J.L., Babikian, V.L., Birjinuiuk, V. et al. Atherosclerosis isassociated with delirium after coronary artery bypass graft surgery. J. Am.
Geriatr. Soc. 2005; 53: 462-466. Rudolph JL, Jones RN, Grande LJ et al. Impaired executive function is
associated with delirium after coronary bypass graft surgery. J Am GeriatrSoc 2006; 54 (6): 937-41.
Schneider F, Bohner H, Habel U et al. Risk factors for postoperativedelirium in vascular surgery. Gen Hosp Psychiatry 2002; 24: 28-34.
Seymour DG, Vaz FG. A prospective study of elderly general surgicalpatients: II. Post operative complications. Age and Ageing 1989; 18: 316-26
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
69/70
Selected References:
Stromberg L, Lindgren U, Nordin C et al. The Appearance anddisappearance of cognitive impairments in elderly patients duringtreatment for hip fracture. Scand J Caring Sci 1997; 11: 167-175.
Summers WK, Reich TC. Delirium after cataract surgery. Review and two
cases. AM J Psychiatry 1979; 136: 306-9. Tabet N, Howard R. Non-pharmacological interventions in the prevention
of delirium. Age & Ageing 2009 Jul; 38 (4): 374-9 Tardiff BE, Newman MMF, Saunders AM, et al. Preliminary report of a
genetic basis for cognitive decline after cardiac operations. Ann ThoracSurg 1997; 64: 715-20
Tuma R, DeAngelis LM. Altered mental status in patients with cancer.Arch Neurol 2000; 57: 1727-31.
Van der mast RC & Roest FHJ. Delirium after cardiac surgery: a criticalreview. J Psychosom Res 1996; 41 (1): 13-30.
Van der Mast R. Pathophysiology of delirium. J Geriatr Psychiaty Neurol1998;11:138-45
Vaurio LE, Sands LP, Wang Y et al. Postoperative delirium: the importanceof pain and pain management. Anesth & Analg 2006; 102 (4): 1267-73.
Selected References:
-
8/4/2019 Oct 6 - Postop Delirium in the Older Person (Brymer)
70/70
Selected References:
Veliz-Reissmuller G, Aguero Torres H, van der Linden J et al. Pre-operativemild cognitive dysfunction predicts risk for post-operative delirium afterelective cardiac surgery. Aging-Clinical & Experimental Research, 2007; 19(3): 172-7
Wacker P, Nunes PV, Cabrita H et al. Post-operative delirium is associatedwith poor cognitive outcome and dementia. Dementia & GeriatricCognitive Disorders 2006; 21 (4): 221-7
Williams-Russo P, Urquhart BL, Sharrock NE et al. Postoperative delirium,predictors and prognosis in elderly orthopedic pateitns; J Am Geriatr Soc1992; 40 : 759-67
Williams-Russo P, Sharrock NE, Mattis S et al. Cognitive effects after
epidural vs. general anesthesia in older adults. JAMA 1995; 274: 44-50 Yamagata K, Onizawa K, Yusa H et al. Risk factors for postoperative
delirium in patients undergoing head and neck cancer surgery.International Journal of Oral & Maxillofacial Surgery. 34 (1): 33-6, 2005Jan