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)

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)

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

Delirium Risk Factors

Predisposing Factors for Delirium (n=107)

Risk Factor
Vision Impairment Severe Illness Cognitive Impairment

Relative Risk
3.5 (1.2, 10.7) 3.5 (1.5, 8.2) 2.8 (1.2, 6.7)

Inouye (1998)

Delirium Risk Factors

Precipitating Factors for Delirium (n=196)

Precipitating Factor
Use of physical restraints Malnutrition >3 new medications Use of bladder catheter Iatrogenic event

Relative Risk
4.4 (2.5-7.9) 4.0 2.9 2.4 1.9 (2.2-7.4) (1.6-5.4) (1.2-4.7) (1.1-3.2)

Inouye (1998)

Delirium Risk Factors

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

Inouye (1998)

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 Incidence of delirium

Outcome

Prevention of Delirium
Significant reduction in incidence of delirium (9.9% vs 15%, odds ratio= 0.60, P=0.02) 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

Prevention is the key!

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

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

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

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!

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, 48,16971706.

Hospital Elder Life Program (www.info.med.yale.edu/intmed/elp/index.htm)