Dr. Peg Gray-Vickrey [email protected]1 Acute Care: Delirium & Dementia National Conference for Nurse Practitioners October 7, 2016 Session 208 Dr. Peg Gray-Vickrey Objectives • Identify common causes and clinical presentation of dementia and delirium in the older adult. • Outline effective techniques for diagnosing dementia and delirium. • Examine evidence-based interventions for the older adult with dementia and delirium. Delirium • The term delirium is based on the Latin roots • de- away from • lira- furrow in field • ium- Latin for singular • This literally means “a going off the plowed track” “a madness”
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Acute Care: Delirium & Dementia - etouches · Acute Care: Delirium & Dementia ... on general surgical unit •40-50% recovering from hip ... monitoring and patient outcomes in a general
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• Delirium is a disturbance of the higher cortical centers that causes a reduced ability to focus, sustain, or shift attention. • Rapid and drastic decline of cognitive functioning
• Perceptual disturbances • Hallucinations
• Delusions
Prevalence
• Delirium is one of the most common syndromes that older adults develop • 30% of older adults • 1-2% in the community • 10-15% on general surgical unit
• 40-50% recovering from hip surgery • 50% CABG • 70-87% in the ICU (for older patients)
• 10-20% in general medical unit • Cardiac patients 11-46% • Orthopedic patients 12-51% • CVA 10-27%
• Up to 80% in near-death terminal cases
• 32-96% of elderly patients are discharged without complete resolution of symptoms • Common in Nursing Homes following hospital admission
Prevalence – Lack of Awareness
• Chart Reviews in most general hospitals will show that delirium is only mentioned 1-2% when published research suggests a prevalence of 30-50%
• Clinicians fail to recognize and address postoperative delirium in as many as 80% of the cases
Clark C. Preventing hospital acquired delirium. Health Leaders. 2015; April; 60-63.
Brooks P, Spillane J. Dick K, Stuart-Shor E. Developing a strategy to identify and treat older patients with postoperative delirium. AORN. 2014;99(2);256-275.
• Likely affects multiple domains of the central nervous system
• Cause is unknown
• Current Theories:
• Deficiency in the cholinergic neurotransmitter system
• Melatonin abnormalities
• Neuronal damage secondary to oxidative stress or inflammation
• Inflammation induced perivascular edema leading to hypoxia and subsequent reduced synthesis of acetylcholine
• No known genetic markers for predisposition to delirium
Pathophysiology
• Neuroimaging of the brain reveals general disruption in higher cortical function with dysfunction in the following areas, particularly on the non-dominate side:
• Prefrontal cortex
• Subcortical structures
• Thalamus
• Basal ganglia
• Frontal and temporoparietal cortex
• Fusiform cortex
• Lingual gyri
• Functional neuroimaging (SPECT) has shown up to a 40% reduction in cerebral blood flow
Fong, TG, Bogardus, ST, Daftary, A, et.al. Cerebral perfusion changes in older delirious patients using 99mTc HMPAO SPECT. J Gerontol A Biol Sci Med Sci. 2006;61(12):1294-1299.
Outcome
• Symptoms typically resolve in 10-12 days
• May last up to 2-6 months
• Duration is dependent on underlying problem and management
• 44% of cases have 2 or more etiologies
• May progress to stupor, coma, seizures or death, especially if untreated
• Persistent delirium is associated with functional impairments of ADL’s and IADL’s
Criteria for Identifying Delirium • The Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition, 2013 (DSM-5) diagnostic criteria for delirium is as follows:
• Disturbance in attention (ie, reduced ability to direct, focus, sustain, and shift attention) and awareness.
• Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) that is not better accounted for by a preexisting, established, or evolving dementia.
• The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day.
• There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause.
• Electrolytes, CBC and differential, Renal and Liver function tests, fasting blood sugar
• Thyroid function studies
• EKG
• Oxygen saturation
• Urinalysis with sediment/culture
• Urine and blood drug screens
• Thiamine and vitamin B-12 levels
• Neuroimaging
Need for Family Education
“In many ways, delirium is an accepted but often undisclosed complication of inpatient care, because patients are unaware of the risks. Clinicians don’t think they can prevent it, so they don’t talk about it like they might regarding a risk of an infection or fall.”
Clark C. Preventing hospital acquired delirium. Health Leaders. (2015); April; 60-63.
• Findings suggest that antipsychotic reduce the incidence of postoperative delirium, at least in certain surgical populations with a baseline delirium risk of 18%.
Folk M, et. al. Do antipsychotics prevent postoperative delirium? A systematic review and meta analysis. Intl
J Geriatr Psychiatry. 2015; 30:333-344.
Oncology
• Haloperidol is considered the medication of choice to treat fear and hallucinations experienced by patients with delirium.
• Electrocardiograms should be monitored for lengthening of QT interval with ongoing haloperidol administration.
• If agitation or delirium cannot be controlled with routine pharmacologic and nonpharmacologic interventions, or if the patient is actively dying, palliative sedating drugs may be ordered
Clinical Practice Guidelines for Delirium in the ICU • American Association of Critical Care Medicine revised their
Clinical Practice Guidelines (originally published in 2002) in 2013
Barr, J, Fraser, G, Puntillo, K. et. al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the Intensive Care Unit. Critical Care Medicine, 2013;41(1): 263-306.
• There in no FDA approve medication or treatment for frontotemporal dementia.
• Treatment is often based on medications that reduce agitation, irritability and/or depression.
• FTD inevitably gets worse over time and the speed of decline differs from person to person.
• Individuals with FTD often have muscle weakness and coordination problems, leading to immobility and causing problems with swallowing, chewing, and controlling bladder and/or bowels.
Presentation of Vascular Dementia • Symptoms vary depending on severity of the blood vessel
damage and the portion of brain that has impaired blood flow
• Memory loss may or may not be a significant symptom depending on the specific brain areas where blood flow is reduced.
• Post-stroke dementia (sudden onset)
• Widespread small vessel disease
• Common early signs include impaired planning and judgment; uncontrolled laughing and crying; declining ability to pay attention; impaired function in social situations; and difficulty finding the right words.
Presentation of Vascular Dementia • Trouble concentrating
• Inability to organize thoughts
• Difficulty deciding what to do
• Restlessness
• Aphasia
• Incontinence
• Depression
Treatment
• The FDA has not approved any drugs specifically to treat symptoms of vascular dementia
• Controlling risk factors that may increase the likelihood of further damage to the brain's blood vessels is the most important treatment strategy.
• It is possible to delay the onset and progression of AD and related disorders by six or more years. • Preventative strategies • Early diagnosis • Early treatment
• Preventative therapy delays the onset of AD by 3.5 years!
• Early detection and treatment of AD delays progression by at least 2.8 years!
Diagnostic Evaluation
• Definitive diagnosis of Alzheimer’s Disease is only possible during a brain biopsy or during an autopsy (when plaques and tangles can be seen)
• A comprehensive workup is accurate in diagnosis 90% of the time
Diagnostic Evaluation
• Detailed patient history
• Family insights on how behavior and personality have changed
• Physical examination and thorough neurological examination
• Laboratory tests
• Computerized tomography or magnetic resonance imaging test
What treatments are available? • One of the biggest stumbling blocks in developing effective
drug therapy for Alzheimer's disease has been the lack of a comprehensive hypothesis that explains the mechanism behind all of the histopathological changes seen in patients suffering from Alzheimer's disease.
FDA Approved Medications
• Cholinesterase Inhibitors
• donepezil (Aricept)
• Used for all stages of Alzheimer’s Disease
• rivastigmine (Exelon)
• Approved for mild to moderate stages of Alzheimer’s Disease
• galantamine (Razadyne)
• Approved for mild to moderate stages of Alzheimer’s Disease
Clinical Expectations from Cholinesterase Inhibitor Therapy • Primary Benefits • Maintain current level of daily functioning
• “No change” means therapy is helping
• Maintain current level of cognition
• Decrease emergence of behavioral and psychological disturbances
• Secondary Benefits • Decrease caregiver burden and distress
• Maintain high level of intellectually stimulating activities • Reading
• Board games
• Playing a musical instrument
• Playing puzzle games
• Going to museums
References • Acee, A. Type 2 diabetes and vascular dementia: Assessment and clinical strategies of care.
MedSurg Nursing. 2012; 21(6): 349-353.
• The American Psychiatric Association Practice Guideline on the Use of Antipsychotics to Treat Agitation or Psychosis in Patients with Dementia. (2016). American Psychiatric Association Arlington, VA
• Andrews L, Silva S, Kaplan S, Zimbro K. Delirium monitoring and patient outcomes in a general intensive care unit. AJCC. 2015;24(1):48-56.
• Barr, J, Fraser, G, Puntillo, K. et. al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the Intensive Care Unit. Critical Care Medicine, 2013;41(1): 263-306.
• Bathula M, Gonzales J. The pharmacologic treatment of intensive care unit delirium: A systematic review. Annals of Pharmacotherapy. 2013;47(9):1168-1174.
• Bond SM. Delirium at home: Strategies for home health clinicians. Home Healthcare Nurse. 2009;27(1):24-34.
• Brooks P, Spillane J. Dick K, Stuart-Shor E. Developing a strategy to identify and treat older patients with postoperative delirium. AORN. 2014;99(2);256-275.
• Burock J. Delirium in the Elderly. Medicine and Health. 2012;95(7):214-215.
• Clark C. Preventing hospital acquired delirium. Health Leaders. 2015; April; 60-63.
• Dasgupta M, Brymer C. Prognosis of delirium in hospitalized elderly: Worse than we thought. Int J Geriatr Psychiatry. 2014;29:497-505.
• Derby S. Assessment and management of delirium in the older adult with cancer. Clinical Journal of Oncology Nursing. 2011;15(3):247-250.
References • DeSimone EM, Viereck L. Alzheimer’s disease: Increasing numbers, but no cure. U.S. Pharmacist.
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• Fong, TG, Bogardus, ST, Daftary, A, et.al. Cerebral perfusion changes in older delirious patients using 99mTc HMPAO SPECT. J Gerontol A Biol Sci Med Sci. 2006;61(12):1294-1299.
• Folk M, et. al. Do antipsychotics prevent postoperative delirium? A systematic review and meta analysis. Intl J Geriatr Psychiatry. 2015; 30:333-344.
• Gagliardi JP. Differentiating among depression, delirium, and dementia in elderly patients. Virtual Mentor. 2008;10(6):383-388.
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