Prevention of Delirium in Elderly Persons

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Prevention of Delirium in Elderly Persons

• Brian Hart, RN, MSc
• Clinical Nurse Specialist
• Providence Continuing Care Centre
• Southeastern Regional Geriatric Program

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Learning Objectives

• Define delirium based on its characteristics
• Become familiar with the experience of delirium
• Recognize the significance of delirium
• Identify the risk factors associated with the
  development of delirium
• Describe effective evidence based strategies for
  the prevention of delirium

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Delirium Definition

• An acute disruption of attention and cognition
  that has a tendency to fluctuate during the
  course of the day.
• Foreman et al. (2001)

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What Does Delirium Look Like? (Video Clip)
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Patient Recollection of Being Delirious (Video
Clip)
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Impact of Delirium on Staff (Video Clip)
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The Experience of Delirium

• trapped in incomprehensible experiences and
  turmoil of past, present and here and there,
  which are all regarded as real and at the same
  time as changing and unreal
• Andersson et al. (2002)

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Significance of Delirium

• 6-56 hospital incidence rate in elderly
• 14-24 of patients admitted delirious
• 25-61 of hip fracture patients
• 6 times greater mortality rates
• increased length of hospital stay
• increased intensity of nursing care
• more institutional placements
• greater hospital costs

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Delirium Risk Factors

• Predisposing Factors for Delirium (n107)
• Risk Factor Relative Risk
• Vision Impairment 3.5 (1.2, 10.7)
• Severe Illness 3.5 (1.5, 8.2)
• Cognitive Impairment 2.8 (1.2, 6.7)
• Inouye (1998)

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Delirium Risk Factors

• Precipitating Factors for Delirium (n196)
• Precipitating Factor Relative Risk
• Use of physical restraints 4.4 (2.5-7.9)
• Malnutrition 4.0 (2.2-7.4)
• gt3 new medications 2.9 (1.6-5.4)
• Use of bladder catheter 2.4 (1.2-4.7)
• Iatrogenic event 1.9 (1.1-3.2)
• Inouye (1998)

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Delirium Risk Factors

• Rate of delirium per day...
• Predisposing and Precipitating Factors
• Predisposing Precipitating Factors Group
• Factors
• Group Low Intermediate High
• Low 0 0 0
• Intermediate 0 3.2 13.6
• High 1.4 4.9 26.3
• Inouye (1998)

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Prevention of Delirium

• Inouye et al. (1999)
• n 852 medical inpatients
• controlled prospective matching strategy
• Intervention
• Standardized protocol for the management of
  cognitive impairment, sleep deprivation,
  immobility, visual/hearing impairment, and
  dehydration
• Outcome
• Incidence of delirium

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Prevention of Delirium

• Significant reduction in incidence of delirium
  (9.9 vs 15, odds ratio 0.60, P0.02)
• Significant decreased of delirium episodes (62
  vs 90)
• Significant reduction in total of days with
  delirium (105 vs 161 days)
• Costs of implementing were offset by care cost
  savings

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Prevention is the key!

• Primary prevention of delirium is probably the
  most effective treatment strategy
• Inouye et al. (1999)

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Prevention of Delirium

• Cognitive Impairment
• orientation protocol
• therapeutic activities
• Sleep Deprivation
• non-pharmacological sleep protocol
• sleep enhancement protocol
• Immobility
• early mobilization protocol
• minimal use of immobilizing equipment

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Prevention of Delirium

• Visual Impairment
• use of visual aids and adaptive equipment
• Hearing Impairment
• use of amplifying devices
• earwax disempaction
• Dehydration
• early recognition of dehydration
• volume repletion

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Summary

• Delirium is deleterious for the patient, health
  care provider and health system
• Primary prevention may be the most effective
  approach
• Prevention strategies are feasible!

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Resources

• Inouye et al. (1999). A multicomponent
  intervention to prevent delirium in hospitalized
  older patients. New England Journal of Medicine,
  340(9), 669-676.
• Inouye et al. (2000). The Hospital Elder Life
  Program A model of care to prevent cognitive and
  functional decline in older hospitalized
  patients. Journal of the American Geriatrics
  Society, 48,1697-1706.
• Hospital Elder Life Program (www.info.med.yale.edu
  /intmed/elp/index.htm)