b.e.a.t. delirium - wordpress.com...• add this to the incidence yields an overall occurrence of...
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B.E.A.T.Delirium
AmyE.SeitzCooley,MS,RN,ACNS-BC
ClinicalNurseSpecialist
YorkCollegeofPennsylvaniaDNPStudent
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SITUATION
“Theveryfirstrequirementinahospitalisthatitshoulddothesick
noharm!” FlorenceNightingale:NotesonNursing
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Deliriumwasfirstdescribedmorethan2500yearsago…
Itremainspoorlyunderstoodandisfrequentlyunrecognized!
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Nurses…
• Arekeytodetectingandreportingdelirium
symptomssincetheyspendtimewith
patients...yetmanytimestheconditiongoes
unrecognizedandthereforeispoorly
managed! Bakeretal.,2015
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Storytime…Haveyouexperienced?
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BACKGROUND
“Whydoesthishappentopatientsthat
comeinwithaUTI?” YorkHospitalTower3RN
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AACNHartford-sponsoredFacultyDevelopment
Delirium:Background• Diagnosisofdeliriumishighlyclinicalanddependent
uponclinician'slevelofexpertise,systematicscreening&carefulclinicalobservations
• Progressiontostuporand/orcoma,seizures,anddeathispossible.
• Deliriumisacardinalsignofageropsychiatricemergencyandmustbepromptlyidentifiedandaddressedwithbiopsychosocialandenvironmentalinterventions.
• Earlyrecognitionofdeliriumfollowedbyrapidmanagementofunderlyingmedicalandenvironmentalfactorsdecreasestheseverityandcanleadtoimprovedoutcomes.
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Delirium…
• Isanacutedeclineofcognitivefunctioning Inouyeetal,2014
• Itiscommon,serious,costly,under-recognized
andoftenfatal Inouyeetal,2014
• Itaffectsasmanyas50%ofhospitalizedadults
65yearsandolder Leslieetal.,2014
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DeliriumOutcomes…
• Oneofthemostpreventableadverseeventsforolder
patients Inouye,2006
• Longerhospitalstays
• Morehospitalacquiredcomplications--falls
• Morelikelytobeadmittedtolongtermcare
• Increasedincidenceofdementia
• Increasedmortality NationalInstituteforHealthandCareExcellence(NICE),2010
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DeliriumCosts…
• Estimatedtodeliriumrangefrom$16,303to
$64,421perpatientwiththenationalburdenon
healthcarerangingfrom$38to$152billionyearly
Leslieetal.,2008
• Morethan$182billionperyearin18European
countriescombined OECD,2014;WHO,2012
Thecosttopatients…immeasurable…
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Delirium:Definition
Atransientandnonspecificorganicmentalsyndromecharacterizedby:
§ Acuteonset(hourstodays),tendingtofluctuateoverthe24hourperiod
§ Reducedabilitytofocus,sustainorshiftattention§ Disturbedlevelofconsciousness,suchasreduced
clarityofawareness§ Changeincognitionsuchasmemoryloss,
disorientationand/orlanguagedisturbance§ Perceptualdisturbancenotaccountedforbypre-
existing,establishedorevolvingdementia
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Delirium…• Prevalenceofdelirium(onadmission)ingeneralmedical
and“oldage”medicalunitsis18-35%
• Addthistotheincidenceyieldsanoveralloccurrenceof29-64%inthesetypesofunits
Inouye,etal.,2014
• Siddiqietal.(2006)reportedoccurrencerateperadmissionof11-42%
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DeliriumCauses…
• Usuallymultifactorial;thismodelhasbeen
wellvalidatedandwidelyacceptedInouyeetal.,2015
• Dependoncomplexitiesofrelationshipswith
predisposingfactorsinvulnerablepatients
withprecipitatingfactors Inouyeetal.,2015
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DeliriumRiskFactorsPredisposing
• Baselinecognitiveimpairment;
dementia
• Underlyingillnessorco-morbidity
• Functionalimpairment
• Advancedage
• Chronicrenalinsufficiency
• Dehydration
• Malnutrition
• Sensoryimpairment—visionorhearing
• Malesex
Precipitating• Medication
• Immobilization
• Indwellingcatheters
• Restraints
• Dehydration
• Malnutrition
• Illnesses—infection,electrolyte
imbalances
• Hospitalization—environmental
• Psychosocialfactors
• Alcohol
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PredictiveModel
Inouyeetal,2014
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Delirium:Medication-RelatedPrecipitatingFactors
§ Anticholinergics§ Opiates§ Benzodiazepines§ Corticosteriods§ Alcoholwithdrawal§ Sedative-hypnoticdrugwithdrawal§ Anynewlyprescribedmedication§ Overthecounter(OTC)“homeremedies,”especiallythosewith
anticholinergiceffects(NSAIDS,nasalsprays,coldandflumeds)§ Additionof3newlyprescribedmedications
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UnrecognizedbyNurses• Continuestobeattributedtonormalageingprocess—
lackofunderstandingdifferencesbetweendelirium,
dementia,anddeliriumsuperimposedondementia
(DSD)
• Fluctuatingnatureofdelirium
• Impactofdeliriumeducationonrecognition
• Communicationbarriers
• Inadequateuseofdeliriumassessmenttools
Husseinetal.,2014
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ASSESSMENT
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DeliriumSigns
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Delirium:ClinicalPresentationClinicalsubtype
MixedHypoactiveHyperactive
§ Increasedpsychomotoractivity,suchasrapidspeech,irritability,andrestlessness
§ Lethargy§ Slowedspeech• Decreased
alertness§ Apathy
§ Shiftbetweenhyperactiveandhypoactivestates
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RECOMMENDATIONS
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HereiswheretheB.E.A.T.ComesintoPlay…
• B=EstablishthePatient’sBaseline
• E=Evaluatecurrentcognitionandscreen
• A=Assessfordeliriumriskfactors
• T=Treattherisk!!
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• Earlyidentification&modificationofpredisposingfactors
• Earlyrecognition&
treatmentofcognitiveimpairment
• Rapididentification&
treatmentofacuteillness
• Assessment&appropriatemanagementofpain
• Maintenanceofnormalsleep-
wakecycle• Avoidanceofdeliriogenic
medications&polypharmacy
• Assuranceofadequatehydration&nutrition
PreventionofDeliriuminOlderAdults
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• Enhancementofsensorystatusbyuseofsensoryaids&appropriatelevelsoflight&sound
• Enhancementofcognitive
reserve• Provisionforfamily
presence
• Avoidanceofurinarycatheterization
• Avoidanceofphysical
restraintuse• Assessment&management
ofdrugandalcoholwithdrawal
PreventionofDeliriuminOlderAdults
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Delirium:History
• Whendidthechangeinmentalstatusbegin?• Doestheconditionchangeovera24-hourperiod?• Isthereachangeintheperson’ssleeppatterns?• Whatspecificthoughtproblemshavebeennoticed?• Isthereahistoryofmentalillnessorsimilarthought
disturbance?• Hastherebeenasuddendeclineinphysicalfunctionora
newonsetoffalls?• Queryfamilyorcollateralsourcefrompriorsettingas
to‘whatisnormal’forthispatient.
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Delirium:ChangeinMentalStatus
§ Anabnormalmentalstatusexamthatisachangefrombaselineforthe
personisthehallmarkofdelirium
§ Abnormalitiesmayincludeinattention,fluctuationsinlevelof
consciousness,newshorttermmemoryimpairment,alteredspeech
patterns,disorganizedspeechand(possibly)delusionsor
hallucinations
§ Mentalstatusscreeningtestsarehelpfulinidentifyingcognitive
deficitsandshouldbeperformedroutinelyinolderpatients:on
admissionandatleastdailyduringstay
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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment
DeliriumAssessment:DirectObservation
§ Routineandperiodicobservationoftheolder
adult’slevelof:
§ Alertness(alert,hyper-alertorhypo-alert)
§ Generalbehavior
§ Mood&affect
§ Speechdisturbance/verbalizations
§ Motorbehavior
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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment
Delirium:PhysicalExam
Examineforsignsof:§ Hypoxia§ Volumedepletion/overload§ Cardiovascularinjury§ Metabolicencephalopathy§ Alcoholwithdrawal§ Hypo-orhyperthermia§ Newonsetincontinence§ Urinaryretentionorfecalimpaction
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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment
Delirium:DiagnosticTests
Choicebasedonhistoryandphysicalfindings
Baselinelaboratorystudies:
• Urinalysis
• BasicorComprehensiveMetabolicPanel
• Bloodwork:CBC,Thyroidfunctiontest
Furtherdiagnostictesting(basedonexam):
• HeadCT
• EKG
• ChestX-Ray
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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment
Delirium:DiagnosticTestscont'd
• Whendifficultto
differentiatedelirium
fromacutepsychotic
state
Electroencephalography
Theelectroencephalogramreveals:
Diffuseslowinginmostcasesofdelirium
Fastac:vityincasesofdeliriumrelatedtodrugwithdrawal
Normalpa=ernsinpa:entswithacutefunc:onalpsychosis
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Delirium:EnvironmentalPredisposingFactors
• Transferswithinthehospitalorunit
• Absenceofaclockorwatch
• Absenceofreadingglasses,hearingaid
• Absenceoffamilymembers
• Useofphysicalrestraints
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DifferentiatingDeliriumfromDementia&Depression
• Chroniccognitiveimpairmentseenindementiatypically:
– Occursgraduallyovertime
– Persistsgreaterthanonemonth
– Isirreversible
• Mostolderadultswithdementiaarealertandabletomaintain
attentionintheearlystagesofdementia
• Depressionmayalsopresentacutelywithdeficitsinabilitytosustain
attention.
• Depressionmaypresentsimilartohypo-orhyper-activedelirium;
therefore,itisimportanttoscreenfordepressioninolderadultswho
presentwithamixedpicture.
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Delirium:DifferentialDiagnosis
• Withrecentchangeincognition,anolderpersonshouldbe
presumeddeliriousuntilprovenotherwise
• Suddencognitiveand/orfunctionaldeteriorationina
patientwithdementiasuggestsdeliriumsuperimposedon
dementia
• Apathy,slowedspeechandmooddisturbancemaybe
indicativeofhypoactivedeliriumratherthandepression
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Delirium:DifferentialDiagnosis• Functionalpsychosis
– Acutefunctionalpsychosiscanresembledelirium
– Onsetatanearlierage
– Mostolderpatientswithfunctionalpsychosishaveahistoryofpsychiatric
illness
– Hallucinationstendtobeauditory
– Delusionsaremoreelaboratethanthoseassociatedwithdelirium
– DementiawithLewyBodiesincludesfluctuatingcognitionandvisual
hallucinations
– Consultationwithapsychiatristoraneurologistmaybenecessaryindifficult
cases
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Delirium:GeneralManagement
• Multi-componentinterventionsaremosteffective
• Promptrecognition&treatmentofunderlyingcause
• Creationofamaximumsupportiveenvironment
• Immediatemedicaltreatmentasnecessary
• Discontinuationorreduceddosesofmedicationsthoughttobe
deliriogenic
• Useofenvironmentalinterventionssuchasadeliriumroom
Ensure
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Delirium:GeneralManagement-Nutrition&Hydration
§ Accurate 24 hour I & O
§ Avoidance of depletion-dehydration syndrome
§ Enteral tube feeding or hyperalimentation as necessary
§ Address any excess output issues such as polyuria or diarrhea
§ Toilet patient on a schedule
Ensure
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Delirium:GeneralManagement
• Pulmonarycaretoensureadequateoxygenation,avoidatelectasisand
pneumonia
• Bowelandbladderprotocolstopreventortreatconstipation,diarrhea,
andurinaryincontinence
• Vigilenceforfallriskandpatientsafety
• Usecognitivestimulation
• Avoidcomplicationsofimmobility—mobilize,mobilize,mobilize!!
• Minimizeskinbreakdown
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Delirium:ManagingtheEnvironment
§ Presenceoffamilymembers
§ Inclusionoffamiliaritemsfromhome
§ Useofglasses&hearingaids
§ Avoidanceofphysicalrestraints
§ Deliriumroomforhighriskpatients
§ Night-lightandminimizationofnoise
§ Interruptsleeponlywhenabsolutelynecessary
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Delirium:MaximizingCognition
• Re-orientatingstrategies– Inclusionoforientingfactsin
normalconversation– Discussionofcurrentevents– Discussionofspecificinterests– Structuredreminiscence– Wordgames– Cognitivestimulation
• Findoutwhatthepersonlikestodotooccupytime!
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Delirium: MedicationManagement
Usemedicationswhen:
§ behaviorsassociatedwithpsychoticthinkingandperceptual
disturbances(e.g.,hallucinations)poseasafetyriskorare
distressingtotheindividual.
§ deliriuminterfereswithneededmedicaltherapiesandbehavioral
interventionsfail
DoNotusemedicationsasasubstitutefordetection,correction,or
eliminationofunderlyingcausesofdelirium
Uselowdosesofmedicationsovertheshortestpossibletimeperiod
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AACNHartford-sponsoredFacultyDevelopment
Delirium:MedicationManagement
§ Firstlinetherapy:Lowdoseshigh-potencyneuroleptics(e.g.,haloperidol)§ Associatedwithextrapyramidalsymptoms(EPS)
§ Newerantipsychotics(e.g.,olanzapineandrisperidon)havealowerincidenceofEPSandmaybebettertoleratedinolderpatients
§ NeurolepticMalignantSyndrome,amoreserioussideeffectofantipsychotictherapy,canoccurwithhigh-potencyaswellaswithnovelanti-psychotics
§ Benzodiazepines(e.g.,lorazepam)arerecommendedwithalcoholwithdrawalorwithdrawalfrombenzodiazepines.§ Innon-alcoholwithdrawal,benzodiazepinespotentially
worsendeliriumandshouldbeusedwithcaution
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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment
DeliriumManagement:Aftercare§ Helpthepatientandfamilyunderstandthebizarreand
bewilderingexperience§ Psychiatriccaretofacilitateresolutionthrough:
§ Sensitiveretrospectiveexplorationoftheexperience§ Increasingpatient’sunderstandingandacceptance§ Encouragingpatientstoreportriskofdeliriumfor
subsequenthospitalizations§ Comprehensivedischargeplanning
§ Homecarereferral§ Physicalandoccupationaltherapy§ Psychiatricnursinghomecareservices
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eSlide-P3562-AACNHartford-sponsoredFacultyDevelopment
Delirium:Conclusion• Historicallyseenas:Abenignandexpectedcondition
relatedtohospitalization• Currentlyseenas:Aserioushealthproblemwith
significantnegativeconsequences• NursesandNAsarefrontlineinearlyidentificationof
patientsmostatriskfordeliriumandearlydetectionofsymptoms
• Routineandsystematicassessmentforconfusioniskey
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Resources
• Activityboxes…
• Portal…
• Whenwouldyouliketohavevolunteer
servicesleadactivities??
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B=BaselineChange?E=EvaluateCurrentCognitionandScreenA=AssessforDeliriumRiskT=TreattheRiskusingNonpharmacologicalInterventions