Delirium Teaching Rounds “ Itching for a Fight!”
description
Transcript of Delirium Teaching Rounds “ Itching for a Fight!”
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Delirium Teaching Rounds “Itching for a Fight!”
November 4, 2011
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Objectives
• Identify risk factors and key presenting features of delirium
• Appreciate the role of different professions in recognition and management
• Identify medications that contribute to the development of delirium
Duke GEC
www.interprofessionalgeriatrics.duke.edu
A BIG Problem
• Hospitalized patients over 65: – 10-40% Prevalence– 25-60% Incidence
• ICU: 70-87%• ER: 10-30%• Post-operative: 15-53%• Post-acute care: 60%• End-of-life: 83%
Levkoff 1992; Naughton, 2005; Siddiqi 2006; Deiner 2009.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Costs of Delirium• In-hospital complications1,3
– UTI, falls, incontinence, LOS– Death
• Persistent delirium– Discharge and 6 mos.2 1/3• Long term mortality (22.7mo)4 HR=1.95• Institutionalization (14.6 mo)4 OR=2.41
– Long term loss of function• Incident dementia (4.1 yrs)4
OR=12.52• Excess of $2500 per hospitalization
1-O’Keeffe 1997; 2-McCusker 2003; 3-Siddiqi 2006; 4-Witlox 2010
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Clinical Features of Delirium
• Acute or subacute onset• Fluctuating intensity of symptoms • Inattention • Disorganized thinking• Altered level of consciousness
– Hypoactive v. Hyperactive• Sleep disturbance• Emotional and behavioral problems
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Common Risk Factors for DeliriumPredisposing• Advanced age• Preexisting dementia• History of stroke• Parkinson disease• Multiple comorbid conditions• Impaired vision• Impaired hearing• Functional impairment• Male sex• History of alcohol abuse
Precipitating• New acute medical problem• Exacerbation of chronic medical problem• Surgery/anesthesia• New psychoactive medication• Acute stroke• Pain• Environmental change• Urine retention/fecal impaction• Electrolyte disturbances• Dehydration• Sepsis
Marcantonio, 2011.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Itching for a Fight!
• Mr. S is an 81 year old retired Baptist minister admitted for an exploratory laparotomy…..
• Gather in a group with students representing all professions
• Read the case and discuss the questions• Designate a spokesperson• Have fun!
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Common Risk Factors for DeliriumPredisposing• Advanced age• Preexisting dementia• History of stroke• Parkinson disease• Multiple comorbid conditions• Impaired vision• Impaired hearing• Functional impairment• Male sex• History of alcohol abuse
Precipitating• New acute medical problem• Exacerbation of chronic medical problem• Surgery/anesthesia• New psychoactive medication• Acute stroke• Pain• Environmental change• Urine retention/fecal impaction• Electrolyte disturbances• Dehydration• Sepsis
Marcantonio, 2011.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Anticholinergic Exposure in Geriatric Patients
Smaller reserve of neurotransmitters + Increased blood brain barrier
permeability
= ↑ Sensitivity to adverse effects of anticholinergic medications
Fundamentals of Geriatric Pharmacotherapy 2010
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Adverse Effects of Anticholinergics Central
• Confusion• Memory Impairment• Cognitive Dysfunction• Drowsiness• DizzinessContributing to:• Delirium• Unsteady gait• Increased falls risk
Peripheral• Urinary retention• Constipation• Dry mouth• Dry eyes• Worsening of glaucoma• Impaired sweating• Tachycardia
Pharmacotherapy 2005; 25 (11):1592–1601
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Anticholinergic Risk Score (ARS)
• Ranks medications for anticholinergic potential on a 3-point scale:• 0= no or low risk• 3 = high anticholinergic potential
• To calculate the patient’s ARS score: identify anticholinergic medications and add the total points for each medication.
• Anticholinergic effects are cumulative!
Arch Intern Med 2008; 168: 508-513
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Game time:
Anticholinergic Medications!
The Game
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Anticholinergic risk scale3 points
Amitriptyline HydroxyzineAtropine products Imipramine
Benztropine MeclizineCarisoprodol Oxybutynin
Chlorpheniramine PerphenazineChlorpromazine Promethazine
Cyproheptadine Thioridazine
Dicyclomine TizanidineDiphenhydramine Trifluoperazine
Fluphenazine Hyoscyamine
Arch Intern Med 2008; 168: 508-513
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Anticholinergic Risk Scale
2 pointsAmantadine Loperamide
Baclofen LoratadineCetirizine Nortriptyline
Cimetidine OlanzapineClozapine Prochlorperazine
Cyclobenzaprine Pseudoephedrine
Desipramine Tolterodine
Arch Intern Med 2008; 168: 508-513
Duke GEC
www.interprofessionalgeriatrics.duke.edu
1 pointCarbidopa-levodopa Pramipexole
Entacapone QuetiapineHaloperidol Ranitidine
Methocarbamol Risperidone Metoclopramide Selegiline
Mirtazapine Trazodone
Paroxetine Ziprasidone
Anticholinergic Risk Scale
Arch Intern Med 2008; 168: 508-513
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Anticholinergic Activity
0/+ (No or minimal)Celecoxib Fentanyl
Hydrocodone PropoxypheneDuloxetine AmoxicillinCephalexin Levofloxacin
Digoxin FurosemideDonepezil Phenytoin
Topiramate Diphenoxylate
JAGS 2008; 56 (7): 1333-1341
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Non-PharmacologicManagement of Pruritus
• Wearing sheer clothing• Avoiding hot baths, alcohol, spicy foods• Maintain proper humidity of rooms• Avoid contact with wool or animal fur• Prevent dry skin (moisturize and apply emollients)• Apply cold wet dressings• Keep fingernails short
“Happiness is having a scratch for every itch.”–Ogden Nash
Reich, 2011; Patel, 2010.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
PharmacologicManagement of Pruritus
Medication/ClassMedication/Class DrawbacksDrawbacksTopical Agents
Menthol Short-acting, may be irritating to skin
Anesthetics (lidocaine) May cause allergic contact dermatitis
Antihistamines Limited efficacy and contact allergies
Capsaicin Burning sensation when initiating
Corticosteroids May only be effective if inflammation involved
Systemic Agents
Antihistamines Sedation, delirium, etc.
Opioid Receptor Antagonists (naloxone) Reverse opioid effects (pain management)
Antidepressants May only be useful in psychiatric conditions
Reich, 2011; Patel, 2010.
Duke GEC
www.interprofessionalgeriatrics.duke.edu
Summary
• Maintain a high level of suspicion– Watch out for precipitating medications
• Discuss with other members of the team– Involve pharmacists
• Consider non-pharmacologic strategies for treating common problems (e.g. pruritis)
• Inform/educate patients and families
Duke GEC
www.interprofessionalgeriatrics.duke.edu
A better way….
PsychosocialPsychosocial
PharmacologicPharmacologic
PhysiologicPhysiologic
EnvironmentalEnvironmental
Medicine
Nursing
PT/OT
Pharmacy
Social work
Nutrition
PA’s
Patients and
Caregivers
Administrators
NP’s