Delirium and cognitive impairment in the peri- operative period - - PowerPoint PPT Presentation

▶
delirium and cognitive impairment in the peri operative
SMART_READER_LITE
LIVE PREVIEW

Delirium and cognitive impairment in the peri- operative period - - PowerPoint PPT Presentation

Dec 31, 2023 144 likes •602 views

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

slide-1
SLIDE 1

Delirium and cognitive impairment in the peri-

  • perative period

Richard Sztramko Assistant Professor, McMaster University Divisions of Geriatrics and General Internal Medicine

slide-2
SLIDE 2

Disclosures

  • Chief Medical Officer - Reliq Health Technologies
  • Director - Virtual Ward Medicine Corp
  • Director - Apollo Healthcare Technologies
slide-3
SLIDE 3

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

slide-4
SLIDE 4

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
slide-5
SLIDE 5

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

slide-6
SLIDE 6

Pathophysiology

  • Inflammation
  • Stress and related hormonal imbalances
  • Neurotransmitter abnormalities
slide-7
SLIDE 7

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
slide-8
SLIDE 8

Risk Factors

  • Age
  • Dementia
  • Previous delirium
  • Medical comorbidities
  • Polypharmacy
  • Frailty
slide-9
SLIDE 9

Incidence of delirium

slide-10
SLIDE 10

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
slide-11
SLIDE 11

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
slide-12
SLIDE 12

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

slide-13
SLIDE 13

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

slide-14
SLIDE 14

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

slide-15
SLIDE 15

Diagnosis at the bedside

vity 95%, Specificity 95% - works in demented/non-demented pat

slide-16
SLIDE 16

Diagnosis at the bedside

Marcantonio et al. 2014. Annal Int Med.

slide-17
SLIDE 17

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
slide-18
SLIDE 18

Prevention

  • Prototypic - Hospital Elder Life Program - Delirium

Prevention Trial - Inouye et al. NEJM 2004

  • Hydration/Nutrition
  • Sleep
  • Cognitive stimulation
  • Mobility
  • Vision/Hearing
slide-19
SLIDE 19

Prevention

slide-20
SLIDE 20

Prevention

  • Figures
slide-21
SLIDE 21

Prevention

Incident Delirium

slide-22
SLIDE 22

Prevention

Incident Falls

slide-23
SLIDE 23

Prevention

Pre-printed orders (PPOs) Rockwood

slide-24
SLIDE 24

Prevention

Pre-printed orders (PPOs) Rockwood

slide-25
SLIDE 25

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

slide-26
SLIDE 26

Prevention

RR 0.64 Delirium RR 0.40 Severe Delirium

slide-27
SLIDE 27

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

slide-28
SLIDE 28

Pharmacologic Prevention

slide-29
SLIDE 29

Prevention

  • Antipsychotics
  • Theory to prevent or quiet down altered

neurotransmission before it gets started

slide-30
SLIDE 30

Prevention

slide-31
SLIDE 31

Prevention

slide-32
SLIDE 32

Prevention

slide-33
SLIDE 33

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
slide-34
SLIDE 34

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

slide-35
SLIDE 35

Prevention

slide-36
SLIDE 36

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

slide-37
SLIDE 37

Prevention

  • Cholinesterase Inhibitors
  • Gabapentin
slide-38
SLIDE 38

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

slide-39
SLIDE 39

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!
slide-40
SLIDE 40

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
  • f quetipine and loxapine
slide-41
SLIDE 41

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

slide-42
SLIDE 42

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

slide-43
SLIDE 43

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
slide-44
SLIDE 44

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

slide-45
SLIDE 45

Thank you!

  • Questions and Discussion