reducing confusion - avoiding and managing perioperative delirium beth cummings, md frcpc...

Reducing Confusion - Avoiding and managing perioperative delirium

Beth Cummings, MD FRCPCBeth Cummings, MD FRCPCPerioperative Medicine RoundsPerioperative Medicine RoundsGIM Fellowship Program, McGill GIM Fellowship Program, McGill

UniversityUniversityNovember 3, 2009November 3, 2009

Learning ObjectivesLearning Objectives

1.1. Understand the impact of delirium in Understand the impact of delirium in the perioperative periodthe perioperative period

2.2. Identify modifiable and non-modifiable Identify modifiable and non-modifiable risk-factors for perioperative deliriumrisk-factors for perioperative delirium

3.3. Develop an approach to reducing the Develop an approach to reducing the incidence of perioperative deliriumincidence of perioperative delirium

4.4. Develop an approach to the Develop an approach to the management of perioperative deliriummanagement of perioperative delirium

1. The scope of the 1. The scope of the problemproblem

(or Why should we care?)(or Why should we care?)

How common is delirium?How common is delirium?

Francis & Kapoor. Journal of General Internal Medicine 5 (1990) 65-79.

How frequently now?How frequently now?

► All hospitalized patients (medical + surgical)All hospitalized patients (medical + surgical) 22-31% overall22-31% overall 14% - 56% of elderly14% - 56% of elderlyInouye SK et al. Annals of Internal Medicine 1993; 474-481. Inouye SK et al. Annals of Internal Medicine 1993; 474-481. Ganai S et al. Arch Surg 2007; 1072-1078.Ganai S et al. Arch Surg 2007; 1072-1078.

► Postoperative patientsPostoperative patients 47% overall47% overallNoimark D. Age and Ageing 2009; 1-6.Noimark D. Age and Ageing 2009; 1-6.

37-74% of geriatric patients37-74% of geriatric patientsGanai S et al. Arch Surg 2007; 1072-1078.Ganai S et al. Arch Surg 2007; 1072-1078.

10-15% of general surgery patients10-15% of general surgery patients 50% of hip fractur patients50% of hip fractur patientsFrancis & Kapoor. Journal of General Internal Medicine 1990; 5: 65-79.Francis & Kapoor. Journal of General Internal Medicine 1990; 5: 65-79.Rubino FA. Neurol Clin N Am 2004; 261-276.Rubino FA. Neurol Clin N Am 2004; 261-276.

The scope of the problemThe scope of the problem

► Postoperative delirium associated with Postoperative delirium associated with higher mortalityhigher mortality1, 2, 4, 51, 2, 4, 5

Mortality ratios 1.6 – 19.7Mortality ratios 1.6 – 19.711

► 2.0 in controls matched for age, sex, and diagnosis2.0 in controls matched for age, sex, and diagnosis 10% - 65% of patients died10% - 65% of patients died11

► In hospital, at 3 mos, at 6 mos, at 12 mos, at 2 yrsIn hospital, at 3 mos, at 6 mos, at 12 mos, at 2 yrs

1.1. Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-792.2. Rubino, FA. Neurol Clin N Am 2004; 22: 261-276.Rubino, FA. Neurol Clin N Am 2004; 22: 261-276.3.3. Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821.Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821.4.4. Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73. Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73. 5.5. Inouye SK et al. Ann Int Med 1993; 119:474-481.Inouye SK et al. Ann Int Med 1993; 119:474-481.

Increased MortalityIncreased Mortality

Increased MorbidityIncreased Morbidity

► Post-operative delirium associated Post-operative delirium associated with higher morbiditywith higher morbidity2, 3, 42, 3, 4

More falls & fracturesMore falls & fractures More disruptive behaviourMore disruptive behaviour More incontinence More incontinence Foley Foley UTI UTI More physical & chemical restraintsMore physical & chemical restraints


Poor functional recoveryPoor functional recovery

► Poor functional recoveryPoor functional recovery22

Greater need for LTC or assisted living Greater need for LTC or assisted living on discharge from hospitalon discharge from hospital1, 4, 51, 4, 5

Worse functional outcome 6 months Worse functional outcome 6 months after surgeryafter surgery33

1.1. Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-79Francis J & Kapoor WN. Journal of General Internal Medicine 1990; 5: 65-792.2. Rubino, FA. Neurol Clin N Am 2004; 22: 261-276.Rubino, FA. Neurol Clin N Am 2004; 22: 261-276.3.3. Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821.Thomas DR & Ritchie CS. JAGS 1995: 43: 811-821.4.4. Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73.Franco K, Litaker D, Locala J, Bronson D. Psychosomatics 2001; 42: 68-73.5.5. Inouye SK et al. Ann Int Med 1993; 119:474-481.Inouye SK et al. Ann Int Med 1993; 119:474-481.

Increased length of stayIncreased length of stay

►Longer length of stayLonger length of stay1, 2, 51, 2, 5

Length of stay Length of stay ≥ 14 days≥ 14 days44


► Retrospective Chart ReviewRetrospective Chart Review► Inclusion criteriaInclusion criteria

≥≥70 y/o 70 y/o 2-3 of visual impairment, cognitive impairment, 2-3 of visual impairment, cognitive impairment,

dehydration (BUN: Crt dehydration (BUN: Crt ≥18)≥18) Severe illness requiring “major abdominal Severe illness requiring “major abdominal

surgical procedures” – eg. open exploration for surgical procedures” – eg. open exploration for bowel perforation, obstruction, bleeding, bowel perforation, obstruction, bleeding, ischemia, infection, and cancerischemia, infection, and cancer

► Excluded “less serious diseases” eg. Excluded “less serious diseases” eg. uncomplicated hernia repair or uncomplicated hernia repair or cholecystectomycholecystectomy

Arch Surg. 2007;142(11):1072-1078

Ganai et al. – Indications for Ganai et al. – Indications for SurgerySurgery

Ganai et al. - FindingsGanai et al. - Findings

►ResultsResults Delirium 60%Delirium 60% Mortality 20%Mortality 20% Prolonged length of stay (Prolonged length of stay (≥14 days) 32%≥14 days) 32%

Table 5. Univariate Analyses of Association of Clinical Factors With Adverse Table 5. Univariate Analyses of Association of Clinical Factors With Adverse OutcomesOutcomes

Increased costs ($)Increased costs ($)

►Franco, Litaker, Locala, Bronson Franco, Litaker, Locala, Bronson (2001)(2001) Economic analysisEconomic analysis

►Preop assessment by internal medicine for Preop assessment by internal medicine for elective, inpatient, non-cardiac procedureselective, inpatient, non-cardiac procedures

►Patients Patients ≥ 50 y/o≥ 50 y/o►Expected length of stay > 2 daysExpected length of stay > 2 days

11.4% had post-op delirium11.4% had post-op delirium LOS 6.0 days vs. 4.6 days (p<0.001)LOS 6.0 days vs. 4.6 days (p<0.001)

CostsCosts

2. Recognizing delirium2. Recognizing delirium

http://www.cartoonstock.com/lowres/rni0036l.jpg

Often not diagnosedOften not diagnosed

►May be missed in up to 50% of casesMay be missed in up to 50% of casesFranco, Litaker, Locala, Bronson (2001)Franco, Litaker, Locala, Bronson (2001)

More often noted by nursing than by MDs More often noted by nursing than by MDs

DSM IV criteriaDSM IV criteria

►DeliriumDelirium Disturbance of consciousness with reduced Disturbance of consciousness with reduced

ability to focus, sustain, or shift attentionability to focus, sustain, or shift attention A change in cognition or the development A change in cognition or the development

of a perceptual disturbance that is not of a perceptual disturbance that is not accounted for by dementiaaccounted for by dementia

Develops over hours to days and fluctuatesDevelops over hours to days and fluctuates Direct physiological consequence of Direct physiological consequence of

underlying general medical condition, underlying general medical condition, substance use, substance withdrawal, substance use, substance withdrawal, medication side-effect…medication side-effect…

Clinical manifestationsClinical manifestations

►Wandering attentionWandering attention►Easily distractedEasily distracted►HyperactiveHyperactive

Especially night-time agitationEspecially night-time agitation►HypoactiveHypoactive

Daytime lethargyDaytime lethargy►ConfusionConfusion►““He’s just not himself, Doctor”He’s just not himself, Doctor”

3. Risk factors for 3. Risk factors for deliriumdelirium

A Case…A Case…

►Mrs. A.Mrs. A. 72 year-old admitted for elective right 72 year-old admitted for elective right

hemicolectomy for colon Cahemicolectomy for colon Ca PMH & BaselinePMH & Baseline

►Hypertension – well controlled on HCTZHypertension – well controlled on HCTZ►Plays golf regularly in spring & summer; cross-Plays golf regularly in spring & summer; cross-

country skiing in wintercountry skiing in winter►Retired accountant; now “does the books” for Retired accountant; now “does the books” for

a local not-for-profit organizationa local not-for-profit organization

►What’s her delirium risk?What’s her delirium risk?

A different case…A different case…

►Mrs. K.Mrs. K. 72 year-old admitted for elective right 72 year-old admitted for elective right


►CRF due to DM2 – creatinine 198, on insulin CRF due to DM2 – creatinine 198, on insulin 4x/d4x/d

►Lives by herself but has help from her children Lives by herself but has help from her children to pay billsto pay bills


What we know…What we know…

►Millar (1981)Millar (1981) Consecutive series of 100 patients, Consecutive series of 100 patients, ≥65 ≥65

y/oy/o 48 bed general surgical unit (3 surgeons)48 bed general surgical unit (3 surgeons) ““psychiatrically assessed before and in psychiatrically assessed before and in

the first week after elective surgery”the first week after elective surgery”►Standardized interviewStandardized interview►Cognitive testCognitive test►Nurses recorded “any psychiatric abnormality Nurses recorded “any psychiatric abnormality

in the ‘cardex’”in the ‘cardex’”

Millar’s findingsMillar’s findings

►Post-operative psychiatric illnessPost-operative psychiatric illness Age over 80Age over 80 Major operationsMajor operations Biliary tract or malignant diseaseBiliary tract or malignant disease Prescription of at least 5 drugsPrescription of at least 5 drugs

Millar’s findings cont’dMillar’s findings cont’d

► Post-operative intellectual impairmentPost-operative intellectual impairment Abnormal electrolytes/ureaAbnormal electrolytes/urea Cardiovascular problemsCardiovascular problems Respiratory diseaseRespiratory disease Wound infectionWound infection Morphine or diamorphine analgesiaMorphine or diamorphine analgesia IV infusionsIV infusions Foley cathetersFoley catheters

** … mental status changes were an early ** … mental status changes were an early sign of complications **sign of complications **

► Independent risk factors for the Independent risk factors for the development of deliriumdevelopment of delirium Vision impairment Vision impairment ARR 3.51 (1.15 - 10.72)ARR 3.51 (1.15 - 10.72) Severe illness Severe illness ARR 3.49 (1.48 - ARR 3.49 (1.48 -

8.23)8.23)►APACHE II > 16 or nurse rating of severeAPACHE II > 16 or nurse rating of severe

Cognitive impairmentCognitive impairment ARR 2.82 (1.19 - ARR 2.82 (1.19 - 6.65)6.65)►MMSE <24MMSE <24

High BUN:CrtHigh BUN:Crt ARR 2.02 (0.89 - 4.60)ARR 2.02 (0.89 - 4.60)►Ratio Ratio ≥18≥18

Inouye et al. - ValidationInouye et al. - Validation

Delirium RiskDelirium Risk►Low risk patients = 0 pointsLow risk patients = 0 points

RR 1.0RR 1.0► Intermediate risk patients = 1-2 pointsIntermediate risk patients = 1-2 points

RR 2.5 in development cohortRR 2.5 in development cohort RR 4.7 in validation cohortRR 4.7 in validation cohort

►High risk patients = 3-4 pointsHigh risk patients = 3-4 points RR 9.2 in development cohortRR 9.2 in development cohort RR 9.5 in validation cohortRR 9.5 in validation cohort

Inouye et al. - OutcomesInouye et al. - Outcomes

Death or nursing home placementDeath or nursing home placement►Low risk (0 points)Low risk (0 points)

9% development cohort / 3% validation 9% development cohort / 3% validation cohortcohort

► Intermediate risk (1-2 points)Intermediate risk (1-2 points) 16% development cohort / 14% validation 16% development cohort / 14% validation

cohortcohort►High risk (3-4 points)High risk (3-4 points)

42% development cohort / 26% validation 42% development cohort / 26% validation cohortcohort

Non-modifiable risk factorsNon-modifiable risk factors

►Risks inherent to the patientRisks inherent to the patient Neurological diseaseNeurological disease

Myasthenia gravis, Parkinson’s, previous CVAMyasthenia gravis, Parkinson’s, previous CVA

Psychiatric diseasePsychiatric diseaseDepression, BAD, anxiety, psychosisDepression, BAD, anxiety, psychosis

Mild cognitive impairment or dementiaMild cognitive impairment or dementia Severe chronic systemic illnessSevere chronic systemic illness

Chronic renal failure, chronic liver diseaseChronic renal failure, chronic liver disease

HTN, DM, MI, CVA, A-fib, PAD, CHF, ASA HTN, DM, MI, CVA, A-fib, PAD, CHF, ASA ≥3≥3

Potentially modifiable risk Potentially modifiable risk factorsfactors

► AnaesthesiaAnaesthesia General anaesthesia increases risk for 24-48hrsGeneral anaesthesia increases risk for 24-48hrsRubino FA. Neurol Clin N Am 2004; 261-276Rubino FA. Neurol Clin N Am 2004; 261-276

► Presence of delirium preoperativelyPresence of delirium preoperatively► Pre-operativePre-operative

HypoalbuminemiaHypoalbuminemia Abnormal sodium, potassium, glucoseAbnormal sodium, potassium, glucose HypermagnesemiaHypermagnesemia High BUN: CrtHigh BUN: Crt LeukocytosisLeukocytosis

PrecipitantsPrecipitants

►Systemic diseaseSystemic disease Infection, organ failureInfection, organ failure

►Toxins and drugsToxins and drugs Withdrawal of EtOH, benzos, sedativesWithdrawal of EtOH, benzos, sedatives

►Primary cerebral diseasePrimary cerebral disease Acute CVA, seizureAcute CVA, seizure

►Psychophysiologic statesPsychophysiologic states Anxiety, sensory deprivation, Anxiety, sensory deprivation,

overstimulation, unfamiliar environmentoverstimulation, unfamiliar environment

Iatrogenic causesIatrogenic causes

►DehydrationDehydration►DisorientationDisorientation►DrugsDrugs► ImmobilizationImmobilization► Sleep deprivationSleep deprivation

Dr Sharon Marr’s approachDr Sharon Marr’s approach

►DD rugsrugs►EE lectrolyte abnormalitieslectrolyte abnormalities►LL ack of drugs (eg. Benzo withdrawal)ack of drugs (eg. Benzo withdrawal)► II nfectionnfection►RR educed sensory inputeduced sensory input► II ntracranial process (CVA, seizure, ntracranial process (CVA, seizure,

bleed)bleed)►UU rinary retention / fecal impactionrinary retention / fecal impaction►MM yocardial (MI, CHF)yocardial (MI, CHF)

Approach to preventionApproach to prevention

►Minimize potential precipitants in Minimize potential precipitants in patients at high risk of deliriumpatients at high risk of delirium Use lower dose narcoticsUse lower dose narcotics Avoid benzodiazepinesAvoid benzodiazepines Avoid anticholinergics (including Gravol)Avoid anticholinergics (including Gravol) Enable normal sleep-wake patternsEnable normal sleep-wake patterns Promote early mobilizationPromote early mobilization Allow access to HAllow access to H22O unless O unless

contraindicatedcontraindicated

Can we prevent delirium?Can we prevent delirium?

► Inouye et al. (1999)Inouye et al. (1999) Controlled clinical trial – general medical serviceControlled clinical trial – general medical service Patients matched for age, sex, baseline delirium riskPatients matched for age, sex, baseline delirium risk Interventions aimed at addressing 6 risk factorsInterventions aimed at addressing 6 risk factors

Cognitive impairment (orientation, therapeutic activities)Cognitive impairment (orientation, therapeutic activities)

Sleep deprivation (warm drink, quiet ward, less done Sleep deprivation (warm drink, quiet ward, less done overnight)overnight)

Immobility (early mobilization)Immobility (early mobilization)

Visual impairment (visual aids)Visual impairment (visual aids)

Hearing impairment (amplifiers, communication techniques)Hearing impairment (amplifiers, communication techniques)

Dehydration (encouraged po fluids)Dehydration (encouraged po fluids)

Inouye (1999) - ResultsInouye (1999) - Results

►Decreased rate of deliriumDecreased rate of delirium 9.9% vs. 15%, p=0.02 (42 vs. 64 cases)9.9% vs. 15%, p=0.02 (42 vs. 64 cases)

►Fewer total number of days of deliriumFewer total number of days of delirium 105 vs. 161 days, p=0.02105 vs. 161 days, p=0.02

►Fewer total number of episodes of Fewer total number of episodes of deliriumdelirium 62 vs. 90 episodes, p=0.0362 vs. 90 episodes, p=0.03

►Average cost $6341 per case of delirium Average cost $6341 per case of delirium preventedprevented

Holroyd-Leduc, CMAJ Holroyd-Leduc, CMAJ 2009.2009.

Table 2. Examples of Table 2. Examples of strategies that targeted strategies that targeted

risk factors in risk factors in multicomponent multicomponent

intervention for the intervention for the prevention of deliriumprevention of delirium

4. Managing delirium4. Managing delirium

http://www.acphospitalist.org/weekly/archives/2008/04/30/cartoon.jpg

Approach to managementApproach to management

► Identify precipitant and reverse/treat itIdentify precipitant and reverse/treat it Infection Infection

CBC, U/A, UCx, +/- CXR, +/- wound Cx, +/- blood CxCBC, U/A, UCx, +/- CXR, +/- wound Cx, +/- blood Cx Hypoxemia, hypercarbic resp failure, Hypoxemia, hypercarbic resp failure,

hypoglycemia hypoglycemia ABG, O2 sat, CBGMABG, O2 sat, CBGM

Dehydration, electrolyte disturbance Dehydration, electrolyte disturbance SMA-10 (Na, Ca, Crt, BUN), volume statusSMA-10 (Na, Ca, Crt, BUN), volume status

PainPainPoorly controlled pain Poorly controlled pain oror side-effects from side-effects from

medicationsmedications

Consider the less commonConsider the less common

►Consider other causes of delirium not Consider other causes of delirium not directly related to the ORdirectly related to the OR EtOH/benzo withdrawalEtOH/benzo withdrawal Acute CVA or seizureAcute CVA or seizure

►Good history and exam – Most patients do not Good history and exam – Most patients do not need CT head or EEGneed CT head or EEG

Intracranial bleedIntracranial bleed►Any patient on full-dose anticoagulation or Any patient on full-dose anticoagulation or

with hx of head trauma due to fall from bedwith hx of head trauma due to fall from bed

Avoid making things worse…Avoid making things worse…

► Judicious use of medicationsJudicious use of medications Reduce doses of narcoticsReduce doses of narcotics Eliminate benzos and anticholinergicsEliminate benzos and anticholinergics Consider Imovane (zopiclone) if qhs sleep Consider Imovane (zopiclone) if qhs sleep

medication is still neededmedication is still needed►Non benzodiazepineNon benzodiazepine►May still worsen confusion or agitationMay still worsen confusion or agitation►Start with 3.75 mg po qhs prnStart with 3.75 mg po qhs prn

RxRx

► Treat with antipsychotics – Haldol Treat with antipsychotics – Haldol (haloperidol)(haloperidol) Risperdal, Zyprexa, Seroquel, Clozaril Risperdal, Zyprexa, Seroquel, Clozaril 1.6x 1.6x

death rate in dementia, not approved for deliriumdeath rate in dementia, not approved for delirium Unlikely to cause EPS in short termUnlikely to cause EPS in short term Can start with low doses (0.5 mg) but can Can start with low doses (0.5 mg) but can

increase doses as neededincrease doses as needed Can Rx po or IMCan Rx po or IM Avoid IV (arrhythmia and sudden cardiac death)Avoid IV (arrhythmia and sudden cardiac death) Watch for NMSWatch for NMS

Fever, muscle rigidity, AMS, high CKFever, muscle rigidity, AMS, high CKFrancis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.O’Keefe ST. Age and Ageing 1999; 28-S2: 5-8.O’Keefe ST. Age and Ageing 1999; 28-S2: 5-8.

Other RxOther Rx

►Use benzodiazepines only for Use benzodiazepines only for EtOH/sedative withdrawalEtOH/sedative withdrawal Otherwise, may worsen confusion & Otherwise, may worsen confusion &

agitationagitation

Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.O’Keefe ST. Age and Ageing 1999; 28-S2: 5-8.O’Keefe ST. Age and Ageing 1999; 28-S2: 5-8.

Additional managementAdditional management

►Family members / sitters at bedsideFamily members / sitters at bedside►Eyeglasses / hearing aidsEyeglasses / hearing aids►Provide calendars / clocksProvide calendars / clocks►Avoid multiple room switchesAvoid multiple room switches

Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.Francis & Kapoor. Journal of General Internal Medicine 1990; 5:65-79.Rubino FA. Neurol Clin N Am 2004; 22: 261-276.Rubino FA. Neurol Clin N Am 2004; 22: 261-276.

Caution with physical Caution with physical restraintsrestraints

►Bedrails and restraints often usedBedrails and restraints often used No evidence of efficacyNo evidence of efficacy Vest restraints can cause death from Vest restraints can cause death from

strangulation and contribute to strangulation and contribute to pneumonia & decubitus ulcerspneumonia & decubitus ulcers

Falls more likely to result in injuryFalls more likely to result in injury55% of falls result in injury (vs. 29%)55% of falls result in injury (vs. 29%)Injuries were more severe (p<0.0001)Injuries were more severe (p<0.0001)

Francis & Kapoor. Journal of General Internal Medicine 1990; 65-79Francis & Kapoor. Journal of General Internal Medicine 1990; 65-79Tan KM et al. Irish Journal of Medical Science 2005; 174(3): 28-31Tan KM et al. Irish Journal of Medical Science 2005; 174(3): 28-31Rubino FA. Neurol Clin N Am 2004; 22: 261-276Rubino FA. Neurol Clin N Am 2004; 22: 261-276

Back to our casesBack to our cases

►Mrs. A.Mrs. A. 72 year-old admitted for elective right 72 year-old admitted for elective right


►Hypertension – well controlled on HCTZHypertension – well controlled on HCTZ►Plays golf regularly in spring & summer; cross-Plays golf regularly in spring & summer; cross-

country skiing in wintercountry skiing in winter►Retired accountant; now “does the books” for Retired accountant; now “does the books” for

a local not-for-profit organizationa local not-for-profit organization


Mrs. A.’s riskMrs. A.’s risk

►Using Inouye et al.’s risk factor model, Using Inouye et al.’s risk factor model, 0 of vision impairment, severe illness, 0 of vision impairment, severe illness, cognitive impairment, High BUN:Crtcognitive impairment, High BUN:Crt

►Using other known risk factors, has Using other known risk factors, has good functional capacity and good good functional capacity and good cognitive function at baseline. Only cognitive function at baseline. Only has well-controlled hypertension.has well-controlled hypertension.

►LOW delirium risk. No specific LOW delirium risk. No specific intervention neededintervention needed

A different case…A different case…

►Mrs. K.Mrs. K. 72 year-old admitted for elective right 72 year-old admitted for elective right


►CRF due to DM2 – creatinine 198, on insulin CRF due to DM2 – creatinine 198, on insulin 4x/d4x/d

►Lives by herself but has help from her children Lives by herself but has help from her children to pay billsto pay bills


Mrs. K.’s riskMrs. K.’s risk

►Using Inouye et al.’s risk factor model, 2 Using Inouye et al.’s risk factor model, 2 of vision impairment, severe illness, of vision impairment, severe illness, cognitive impairment, High BUN:Crtcognitive impairment, High BUN:Crt

► INTERMEDIATE delirium riskINTERMEDIATE delirium risk►Will need to use caution with Rx of Will need to use caution with Rx of

analgesia, anticholinergics, sedativesanalgesia, anticholinergics, sedatives►Should be assessed daily for Should be assessed daily for

development of delirium so development of delirium so investigation/management is not investigation/management is not delayed.delayed.

Take Home MessagesTake Home Messages

►Delirium occurs in 10-15% of general Delirium occurs in 10-15% of general surgery patients & is associated with surgery patients & is associated with increased mortality, morbidity, length of increased mortality, morbidity, length of stay, and costsstay, and costs

►Delirium may be preventable in Delirium may be preventable in intermediate/high risk patientsintermediate/high risk patients

►Management of delirium involves identifying Management of delirium involves identifying and treating the precipitant, judicious use of and treating the precipitant, judicious use of medications, improving the patient medications, improving the patient environment, and haloperidol when neededenvironment, and haloperidol when needed

Thank you.Thank you.

Questions?Questions?

ReferencesReferencesFrancis J & Kapoor WN. Delirium in Hospitalized Elderly. Journal of General Internal Medicine 1990; 5: 65-79.Francis J & Kapoor WN. Delirium in Hospitalized Elderly. Journal of General Internal Medicine 1990; 5: 65-79.

Franco K, Litaker D, Locala J, Bronson D. The Cost of Delirium in the Surgical Patient. Psychosomatics 2001; 42: 68-73.Franco K, Litaker D, Locala J, Bronson D. The Cost of Delirium in the Surgical Patient. Psychosomatics 2001; 42: 68-73.

Ganai S, Lee KF, Merrill A, Lee MH, Bellantonio S, Brennan M, Lindenauer, P. Adverse Outcomes of Geriatric Patients Undergoing Ganai S, Lee KF, Merrill A, Lee MH, Bellantonio S, Brennan M, Lindenauer, P. Adverse Outcomes of Geriatric Patients Undergoing Abdominal Surgery Who Are at High Risk for Delirium. Archives of Surgery 2007; 142(11): 1072-1078.Abdominal Surgery Who Are at High Risk for Delirium. Archives of Surgery 2007; 142(11): 1072-1078.

Inouye SK, Viscoli CM, Horwitz, RI, Hurst LD, Tinetti ME. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Inouye SK, Viscoli CM, Horwitz, RI, Hurst LD, Tinetti ME. A Predictive Model for Delirium in Hospitalized Elderly Medical Patients Baed on Admission Characteristics. Annals of Internal Medicine 1993; 119: 474-481.Baed on Admission Characteristics. Annals of Internal Medicine 1993; 119: 474-481.

Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. NEJM 1999; 340(9): 669-676.Inouye SK, Bogardus ST, Charpentier PA, Leo-Summers L, Acampora D, Holford TR, Cooney LM. NEJM 1999; 340(9): 669-676.

Laine C & Williams SV (Eds). In the clinic: Preoperative Evaluation. Annals of Internal Medicine 2009; ITC1: 1-16.Laine C & Williams SV (Eds). In the clinic: Preoperative Evaluation. Annals of Internal Medicine 2009; ITC1: 1-16.

Litaker D, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for post-operative delirium. General Hospital Litaker D, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for post-operative delirium. General Hospital Psychiatry 2001; 23: 84-89.Psychiatry 2001; 23: 84-89.

Millar HR. Psychiatric Morbidity in Elderly Surgical Patients. British Journal of Psychiatry 1981; 138: 17-20.Millar HR. Psychiatric Morbidity in Elderly Surgical Patients. British Journal of Psychiatry 1981; 138: 17-20.

Noimark D. Predicting the onset of delirium in the post-operative patient. Age and Ageing 2009; 1-6.Noimark D. Predicting the onset of delirium in the post-operative patient. Age and Ageing 2009; 1-6.

O’Keeffe ST. Delirium in the elderly. Age and Ageing 1999; 28-S2: 5-8.O’Keeffe ST. Delirium in the elderly. Age and Ageing 1999; 28-S2: 5-8.

Rubino FA. Perioperative management of patients with neurologic disease. Neurologic Clinics of North America 2004; 22: 261-276.Rubino FA. Perioperative management of patients with neurologic disease. Neurologic Clinics of North America 2004; 22: 261-276.

Tan KM, Austin B, Shaughnassy M, Higgins C, McDonald M, Mulkerrin EC, O’Keefe ST. Irish Journal of Medical Science 2005; 174(3): Tan KM, Austin B, Shaughnassy M, Higgins C, McDonald M, Mulkerrin EC, O’Keefe ST. Irish Journal of Medical Science 2005; 174(3): 28-31.28-31.

Thomas DR & Ritchie CS. Preoperative Assessment of Older Adults. Journal of the American Geriatrics Society 1995; 43(7): 811-Thomas DR & Ritchie CS. Preoperative Assessment of Older Adults. Journal of the American Geriatrics Society 1995; 43(7): 811-821.821.

reducing confusion - avoiding and managing perioperative delirium beth cummings, md frcpc...

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