Delirium and cognitive impairment in the peri- operative period Richard Sztramko Assistant Professor, McMaster University Divisions of Geriatrics and General Internal Medicine
Disclosures • Chief Medical Officer - Reliq Health Technologies • Director - Virtual Ward Medicine Corp • Director - Apollo Healthcare Technologies
Objectives Demonstrate an understanding of the morbidity and mortality associated with acute delirium Describe key bedside tests to diagnose delirium Integrate evidence-based and evidence-informed management principles of peri-operative delirium into clinical practice Describe principles for dealing with cognitively impaired individuals in the peri-operative period
What is delirium? • Acute confusional state characterized by: • Fluctuation • Inattention • Depressed level of consciousness • Disorganized thinking • Perceptual disturbances - hallucinations/illusions • Emotional dysregulation - anxiety/paranoia/depression/apathy
What is delirium? • Not better explained by pre-existing cognitive impairment - dementa/ABI etc • Usually explained by a general medical condition, medication, status post-op • Delirium = ATN of the brain - weak brain/weak insult - strong brain/strong insult
Pathophysiology • Inflammation • Stress and related hormonal imbalances • Neurotransmitter abnormalities
Clinical Causes DIMSUS • Drugs - OTC, intoxication, withdrawal • Infection - systemic • Metabolic - liver, kidneys, 02/c02, lytes, tsh, glucose, acidosis • Structural - blood, tumor, pus, vascular insults***, inflammation, • Urinary Retention • Fecal Impaction/Constipation • Pain, sleep debt, change in environment, restraints
Risk Factors • Age • Dementia • Previous delirium • Medical comorbidities • Polypharmacy • Frailty
Incidence of delirium
Morbidity/Mortality • $164 billion in health care costs in US annually • Increased risk of: • Falls • Functional Decline • Dementia (30% of delirium cases display cog. imp. @ 6 months) • Prolonged hospital stay • Institutionalization • Estimated 30-40% of delirium cases are preventable
Delirium Prediction • Poor cognitive performance before surgery • Low hemoglobin levels • Low albumin levels • Cerebrovascular disease • Increased CRP • Prior delirium • No one validated score, but many multi-variate regressions studies to identify RF’s • Hard to operationalize aside from picking out RFs at baseline
Diagnosis at the bedside • Inattention: • Not following commands/conversation • Serial 7’s/WORLD backwards/months/days backwards • Digit Span - normal 6 forward, 4 backwards • Somnolent/tired/withdrawn • A person should be able to have a reasonable conversation with you - even if they are tired/in pain, if they can’t there’s something wrong
Diagnosis at the bedside • Inattention: • Mini-Mental State Examination • MoCA • Not created for the purpose of screening for delirium • If a sudden drop in performance, than it supports a diagnosis • Ensure that if the patient is delirious, a score isn’t permanently reflected in their medical record
Diagnosis at the bedside • Confusion Assessment Method (CAM) 1.Acute onset and Fluctuant 2.Inattention 3.Altered level of consciousness 4.Disorganized thought • 1 AND 2 plus 3 OR 4 • Long form is very onerous - 8 pages, 3D Cam is more pragmatic
Diagnosis at the bedside vity 95%, Specificity 95% - works in demented/non-demented pat
Diagnosis at the bedside Marcantonio et al. 2014. Annal Int Med.
Prevention • Modifiable Variables for Intervention: • Orientation protocols • Cognitive stimulation • Facilitating sleep • Early mobilization/minimizing restraints • Visual/hearing aids • Monitoring for offending medications • Managing pain • Bowel and bladder management
Prevention • Prototypic - H ospital E lder L ife P rogram - Delirium Prevention Trial - Inouye et al. NEJM 2004 • Hydration/Nutrition • Sleep • Cognitive stimulation • Mobility • Vision/Hearing
Prevention
Prevention • Figures
Prevention Incident Delirium
Prevention Incident Falls
Prevention Pre-printed orders (PPOs) Rockwood
Prevention Pre-printed orders (PPOs) Rockwood
Prevention • Preoperative Geriatrics Consultation • 10 specific modules of recommendations • No more than 5 recommendations at one time • No more than 3 recommendations subsequently • Focused on many of the non-pharmacological strategies already discussed
Prevention RR 0.64 Delirium RR 0.40 Severe Delirium
Non-pharmacologic Prevention • Non-pharmacologic strategies are extremely effective (pooled 0.45 OR, or RR 0.60 in a very high quality RCT) • Standardized protocols are the common theme, not necessarily the practitioners - but experience helps
Pharmacologic Prevention
Prevention • Antipsychotics • Theory to prevent or quiet down altered neurotransmission before it gets started
Prevention
Prevention
Prevention
Prevention (OFF LABEL) • Antipsychotics • No guidelines to suggest prophylaxis with antipsychotics • No predictive model practically used to identify high risk people and treat accordingly • Fairly robust signal to noise ratio, but generally reserved for treatment, not for prevention • Perhaps in the future
Prevention • Antipsychotics • No impact on length of stay • No impact on severity of delirium • No differences in adverse events • One study suggests risk of 18% is the risk level below which treatment may not be beneficial
Prevention
Prevention (OFF LABEL) • Melatonin • Mixed evidence • Much lower rate of side effects/well tolerated • No guidelines to suggest its use at this time • Explaining risks/benefits to patients and let them decide
Prevention • Cholinesterase Inhibitors • Gabapentin
Treatment • Step 1 - find and treat an underlying cause or causes (DIMSUS) • Step 2 - regulate sleep • Step 3 - regulate agitation • Step 4 - modify all other variables outlined in non-pharmacologic prevention
Treatment • Step 1 - find and treat an underlying cause or causes (DIMSUS) - you all know what do do • Don’t forget the PVR or AXR!
Treatment (OFF LABEL) • Step 2 - sleep regulation • Mild - Melatonin 3 mg po qhs - regular, increased to 6 mg • Moderate - night time quetiapine 12.5 mg - 25 mg - regular, loxapine 5 mg-10 mg SC ohs • Severe - sundowning - 1700 and 2100 doses of quetipine and loxapine
Treatment (OFF LABEL) • Step 3 - regulate agitation • Haldol 0.5 mg IM/IV q30 minutes • If more than 3 mg is required, consider alternative diagnosis and call psych • Risperidone 0.125 mg po bid, titrate up to 0.5 mg po bid
Treatment • Step 4 - modify all other factors • HELP to see if available, volunteers or pastoral care if no HELP program • dc restraints, foley catheters if possible, sometimes it’s not • Up to chair tid for meals if non-mobile or decreased exercise tolerance • Orthostatic vitals • Regular laxatives • OT - glasses/hearing aids/gait aids at bedside • PT - involvement for mobility • Counsel family on reorientation strategies and value of having them at the bedside
Cognitively Impaired • Highest risk for delirium • Call family/caregivers and ask about their baseline cognition/function • Place a high priority on non-pharmacologic strategies - family to take shifts, call family in the middle of the night • Discuss strategies with nurses
Cognitively Impaired • Parkinson’s Disease 38% rate of neuroleptic sensitivity • Dementia with Lewy Bodies 50% rate of neuroleptic sensitivity • Avoid Haldol, Risperidone, Loxapine - call a Geriatric Psychiatrist or Geriatrician for these patients as reactions can be permanent
Thank you! • Questions and Discussion
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