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CLARIFYING CONFUSION: A RESEARCH APPROACH TO DELIRIUM

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Title: CLARIFYING CONFUSION: A RESEARCH APPROACH TO DELIRIUM


1
CLARIFYING CONFUSIONA RESEARCH APPROACHTO
DELIRIUM
  • Sharon K. Inouye, M.D., M.P.H.
  • Professor of Medicine
  • Yale University School of Medicine
  • F/shared/inouye/talksslides/McMaster_Medical
    Grand Rounds.doc

2
WHAT IS DELIRIUM?(Acute Confusional State)
  • Definition
  • acute decline in attention and cognition
  • Characteristics
  • common problem
  • serious complications
  • often unrecognized
  • may be preventable

3
EPIDEMIOLOGY OF DELIRIUM
  • Prevalence (on admission) 10-40
  • Incidence (in hospital) 25-60
  • Hospital mortality 10-65
  • 2-20 x controls
  • Excess annual health
  • care expenditures gt8 billion

4
CURRENT IMPACT OF DELIRIUM
  • 35 of the U.S. population aged 65 years is
    hospitalized each year, accounting for gt 40 of
    all inpatient days
  • Assuming a delirium rate of 20
  • 7 of all persons 65 years will develop
  • delirium annually
  • Delirium will complicate hospital stay for gt 2.2
    million persons/year, involving gt 17.5 million
  • in-patient days/year
  • Estimated costs gt 8 billion/year

5
IMPACT OF DELIRIUM
  • Beyond hospital costs
  • Post-hospital costs
  • Institutionalization
  • Rehabilitation
  • Home care
  • Caregiver burden
  • Aging of U.S. population

6
RECOGNITION OF DELIRIUM
  • Previous studies 32-66 cases unrecognized by
    physicians
  • Yale-New Haven Hospital study (1988-1989)
  • 65 (15/23) unrecognized by physicians
  • 43 (10/23) unrecognized by nurses

7
DEVELOPMENT OF A DELIRIUM INSTRUMENT
  • Ref Inouye SK, et al. Ann Intern Med. 1990,
    113 941-8.

8
CONFUSION ASSESSMENT METHOD(CAM)
  • Developed to provide a quick, accurate method
    for detection of delirium
  • For non-psychiatrically trained clinicians
  • Both clinical and research settings

9
KEY FEATURES OF DELIRIUM
  • Acute onset and fluctuating course
  • Inattention
  • Disorganized thinking
  • Altered level of consciousness
  • Note disorientation and inappropriate
    behavior not useful diagnostically

10
CAM
  • ACUTE ONSET
  • Is there evidence of an acute change in
  • mental status from the patients baseline?

11
CAM
  • FLUCTUATING COURSE
  • Did this behavior fluctuate during the past
  • day, that is, tend to come and go or
  • increase and decrease in severity?

12
CAM
  • INATTENTION
  • Did the patient have difficulty focusing
    attention,
  • for example, being easily distractible, or
    having
  • difficulty keeping track of what was being said?

13
CAM
  • DISORGANIZED SPEECH
  • Was the patients speech disorganized or
    incoherent, such
  • as, rambling or irrelevant conversation,
    unclear or illogical
  • flow of ideas, or unpredictable switching from
    subject to
  • subject?

14
CAM
  • ALTERED LEVEL OF CONSCIOUSNESS
  • Overall how would you rate this patients level
    of consciousness?
  • Alert (normal)
  • Vigilant (hyperalert)
  • Lethargic (drowsy, easily aroused)
  • Stupor (difficult to arouse)
  • Coma (unarousable)

15
SIMPLIFIED DIAGNOSTIC CRITERIA
  • -- Uses 4 criteria assessed by CAM
  • (1) acute onset and fluctuating course
  • (2) inattention
  • (3) disorganized thinking
  • (4) altered level of consciousness
  • -- The diagnosis of delirium requires the
    presence of criteria
  • (1), (2) and (3) or (4)

16
VALIDATION OF CAM
  • Site I Site II
  • (n30) (n26)
  • Sensitivity 10/10 (100) 15/16 (94)
  • Specificity 19/20 (95) 9/10 (90)
  • Positive predictive
  • accuracy 10/11 (91) 15/16 (94)
  • Negative predictive
  • accuracy 19/19 (100) 9/10 (90)
  • Likelihood ratio 20.0 9.4
  • (positive test)

17
CAM SIGNIFICANCE
  • Helped to improve recognition of delirium
  • Widely used standard tool for clinical and
    research purposes nationally and internationally
  • Translated into five languages
  • Used in over 100 original published studies to
    date

18
MULTIFACTORIAL MODEL OF DISEASE IN OLDER PERSONS
19
BASELINE VULNERABILITY
  • Development and Validation of a Predictive Model
    for Delirium based on Admission
    Characteristics
  • Ref Inouye SK, et al. Ann Intern Med
    1993119474-81.

20
SPECIFIC AIMS
  • To identify risk factors for the development of
    delirium.
  • To develop and validate a predictive model for
    development of delirium based on admission
    characteristics.

21
METHODS
  • Patients 2 prospective cohorts of consecutive
    patients age 70 years on the medicine service,
    done in tandem, with 107 and 174 patients
  • Assessments Daily patient and nurse
    interviews, with CAM ratings

22
DEVELOPMENT OF THE PREDICTIVE MODEL
  • 13 variables with RR 1.5 entered into a
    stepwise multivariable model
  • 4 risk factors selected for the final predictive
    model

23
INDEPENDENT RISK FACTORS FOR DELIRIUM(N107)
24
PERFORMANCE OF THE PREDICTIVE MODEL
Development of Delirium
25
PRECIPITATING FACTORS
  • Development and Validation of a Predictive
  • Model for Delirium based on
  • Hospitalization Related Factors
  • Ref Inouye SK, et al. JAMA
    1996275852-7.

26
SPECIFIC AIMS
  • To identify potential precipitating factors for
    delirium
  • To develop a predictive model for delirium based
    on precipitating factors, then to validate this
    model in an independent sample
  • To study the inter-relationship of baseline and
    precipitating factors for delirium

27
METHODS
  • Two prospective cohort studies, in tandem
  • Development Cohort 11/6/89 6/22/90
  • Validation Cohort 7/9/90 7/31/91
  • Eligibility Consecutive patients admitted to
    the medicine
  • service at Yale-New Haven Hospital
  • Exclusion Delirium on admission
  • Inability to be interviewed (e.g. intubation,
    coma)
  • Discharge in lt 48 hours
  • Daily patient and nurse interviews

28
DEVELOPMENT OF THE PREDICTIVE MODEL
  • 11 variables entered into stepwise multivariable
    model
  • 5 independent factors selected for final model

29
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32
IDENTIFICATION OF RISK FACTORSSIGNIFICANCE
  • Helped determine which risk factors to address
  • Identified patients at high risk for deliriumto
    target for future preventive efforts
  • Provided groundwork needed for clinical programs
    and intervention trials

33
MULTIFACTORIAL ETIOLOGY OF COMMON GERIATRICS
SYNDROMES
  • Falls
  • Dizziness
  • Incontinence
  • Pressure ulcers
  • Malnutrition
  • Functional decline

34
THE YALE DELIRIUM PREVENTION TRIAL
  • Inouye SK. N Engl J Med. 1999340669-76.

35
RISK FACTORS FOR DELIRIUM
  • Cognitive Impairment
  • Sleep Deprivation
  • Immobilization
  • Vision impairment
  • Hearing Impairment
  • Dehydration

36
YALE DELIRIUM PREVENTION PROGRAM
  • Designed to counteract iatrogenic influences
    leading to delirium in the hospital
  • Multicomponent intervention strategy targeted at
    6 delirium risk factors
  • Risk Factor Intervention
  • Cognitive Impairment.. Reality
    orientation
  • Therapeutic activities protocol
  • Sleep Deprivation..Nonpharmacologica
    l sleep protocol
  • Sleep enhancement protocol
  • Immobilization.. Early
    mobilization protocol
  • Minimizing immobilizing equipment
  • Vision Impairment. Vision aids
  • Adaptive equipment
  • Hearing Impairment. Amplifying
    devices
  • Adaptive equipment and techniques
  • Dehydration Early recognition
    and volume repletion

37
RATIONALE FOR MULTICOMPONENT APPROACH
  • Multifactorial etiology
  • Targeted risk factor approach
  • Most effective approach
  • Most clinically relevant approach

38
YALE DELIRIUM PREVENTION TRIAL METHODS
  • Design controlled clinical trial with
    individual matching from
  • 3/25/95 3/28/98
  • Subjects patients 70 years old without
    evidence of delirium, but at moderate to high
    risk for developing delirium. Sample size
    852 (426 intervention, 426 controls)
  • Units one intervention and 2 control (usual
    care) units
  • Procedures baseline, daily, and 1 mo, 6 mo, 12
    mo follow-up interviews by trained clinical
    research staff, blinded to study hypotheses and
    interventional nature

39
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40
YALE DELIRIUM PREVENTION TRIAL RESULTS
41
DELIRIUM PREVENTION TRIALSIGNIFICANCE
  • Practical, real-world intervention strategy
    targeted towards evidence-based risk factors
  • Significant reduction in risk of delirium and
    total delirium days, without significant effect
    on delirium severity or recurrence
  • Primary prevention of delirium likely to be most
    effective treatment strategy
  • Targeted, multicomponent strategy works

42
DELIRIUMHEALTH POLICY IMPLICATIONS
  • Delirium serves as a marker for quality of
    hospital care for the elderly
  • Often iatrogenic
  • Linked to processes of care
  • Common, bad outcomes
  • Delirium serves as a window for identifying
    quality improving changes.
  • Inouye SK. Am J Med. 1999106565-73

43
PATHWAYS LEADING TO DELIRIUM
  • Iatrogenesis
  • Failure to recognize delirium
  • Attitudes towards care of the elderly
  • Rapid pace and technologic focus
  • of health care
  • Reduction in skilled nursing staff

44
RECOMMENDED INTERVENTIONS TO REDUCE DELIRIUM
  • LOCAL
  • Cognitive assessment of all older patients
  • Monitoring mental status as a vital sign
  • Strategies to change practice patterns leading to
    delirium
  • Clinical guidelines/pathways for care of
    high-risk geriatric patients and delirium
  • Enhanced geriatric nursing and physician
    expertise at bedside
  • Case management to enhance coordination of care
  • NATIONAL
  • Provider education and continuing education
    requirements
  • Improved quality monitoring systems delirium as
    sentinel event
  • Create environments that facilitate high-quality
    geriatric care

45
CONCLUSIONS
  • Delirium is a common, serious problem for
    hospitalized older patients.
  • Recognition may be improved by use of simplified
    diagnostic criteria.
  • The etiology of delirium is multifactorial,
    involving vulnerability and precipitating
    factors.
  • Many cases may be preventable through a targeted
    risk factor approach.
  • Delirium serves as a quality marker for hospital
    care.
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