Whats New in the Patient Safety World
October 2015
Predicting Delirium
Weve done several
articles on delirium every year since 2008 (see the full list at the end of
todays column). The Pennsylvania Patient Safety Authority has noted a 7-fold increase
in patient safety events related to delirium reported to the Pennsylvania
Patient Safety Reporting System (PA-PSRS) over a 10-year period from 2005 to
2014 (Feil
2015). The author, Michelle Feil,
attributes this increase largely to increased awareness and better recognition
of delirium rather than to a true increase in the incidence and prevalence of
delirium.
Though the PA-PSRS
data are limited in some respects to the data input by the reporters, Feil was able to determine both predisposing factors and
likely precipitating factors in many cases. Male gender and age 65 or older
were noted as predisposing factors in 57% and 54.3% of reports, respectively.
Pre-existing cognitive dysfunction (14.3%), depression (10.8%), and serious
illness (11.7%) were other frequent predisposing factors but were likely
underreported compared to age and sex, which were required entries in their own
fields in the reports. The most common precipitating factors mentioned were intercurrent illness or other physiologic cause (45.7%),
specific medications (29.4%), environmental factors (22.9%), and surgery or
procedure requiring sedation (10.8%).
Almost all areas of care
were represented in the PA-PSRS data. General care areas accounted for about
50% of reports, ICUs 11.7% and psychiatry or chemical dependency services
12.3%. The delirium-related patient safety events ran the gamut of incident
types, with 35% being falls. Sometimes delirium delayed recognition of other
serious condition (eg. sepsis).
Feil goes on to describe strategies to prevent
delirium, such as the HELP program and guidelines from several specialty
societies on management of delirium as weve described in several previous
columns. Multimodal non-pharmacologic approaches remain the mainstay in
management of delirium. Pharmacologic management remains controversial. A
recent meta-analysis (Kishi
2015) suggests that second
generation antipsychotics have a benefit for the treatment of delirium with
regard to efficacy and safety compared with haloperidol. However, the numbers
are small and even those authors acknowledge that larger studies are needed.
It is well
recognized that the occurrence of delirium has prognostic significance for
patients. It is associated with increased morbidity and mortality, longer
lengths of hospital stay, increased likelihood of institutionalization, and
higher healthcare costs. But does the subtype of delirium have any predictive
value? Hypoactive delirium is the subtype most often overlooked yet it is just
as important to recognize this subtype. A new study in terminally ill cancer
patients found that such patients with hypoactive or mixed delirium were more
likely to have shorter survival periods (Kim
2015).
A recent review of
risk stratification models for predicting delirium actually found a need for
better predictive tools (Newman
2015). The authors found only 10 cohort
studies of validated tools for predicting delirium. Quality of the studies was
moderate to good but there was substantial heterogeneity and only one study was
replicated. The most common risk factors identified were pre-existing cognitive
impairment, medical comorbidity, elevated BUN, and impaired ADLs (activities
of daily living).
While we agree with
the Newman study that the tools for predicting delirium may not yet be perfect,
we still strongly recommend consideration of risk factors for delirium in any
patient scheduled to undergo surgery. In fact, we think it is one of the three
most important considerations in the pre-operative evaluation (the other two
being assessing risk for obstructive sleep apnea and frailty). Particularly in
patients identified as having risk factors for delirium it makes sense to avoid
those potential precipitating factors that can be avoided and to screen these
patients more frequently for delirium.
Some of our prior
columns on delirium assessment and management:
·
October
21, 2008 Preventing
Delirium
·
October
14, 2008 Managing
Delirium
·
February
10, 2009 Sedation
in the ICU: The Dexmedetomidine Study
·
March
31, 2009 Screening
Patients for Risk of Delirium
·
June 23,
2009 More
on Delirium in the ICU
·
January
26, 2010 Preventing
Postoperative Delirium
·
August
31, 2010 Postoperative
Delirium
·
September
2011 Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery
· December 2010 The ABCDE Bundle
·
February
28, 2012 AACN
Practice Alert on Delirium in Critical Care
·
April 3, 2012 New
Risk for Postoperative Delirium: Obstructive Sleep Apnea
·
August
7, 2012 Cognition,
Post-Op Delirium, and Post-Op Outcomes
·
September
2013 Disappointing
Results in Delirium
·
October
29, 2013 PAD:
The Pain, Agitation, and Delirium Care Bundle
·
February
2014 New
Studies on Delirium
·
March
25, 2014 Melatonin
and Delirium
·
May 2014
New
Delirium Severity Score
·
August
2014 A
New Rapid Screen for Delirium in the Elderly
·
August
2014 Delirium
in Pediatrics
·
November
2014 The
3D-CAM for Delirium
·
December
2014 American
Geriatrics Society Guideline on Postoperative Delirium in Older Adults
·
June 16,
2015 Updates
on Delirium
References:
Feil M. Delirium: Patient Safety Event Reporting and Strategies to Improve Diagnosis, Prevention, and Treatment. Pa Patient Saf Advis 2015; 12(3): 85-95
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2015/Sep;12%283%29/Pages/85.aspx
Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry 2015; Published online first September 4, 2015
http://jnnp.bmj.com/content/early/2015/09/04/jnnp-2015-311049.abstract
Kim S-Y, Kim S-W, Kim J-M, et al. Differential Associations Between Delirium and Mortality According to Delirium Subtype and Age: A Prospective Cohort Study. Psychosomatic Medicine 2015; Post Author Corrections: September 18, 2015
Newman MW, O'Dwyer LC, Rosenthal L. Predicting delirium: a review of risk-stratification models. Gen Hosp Psych 2015; 37(5): 408-413
http://www.sciencedirect.com/science/article/pii/S0163834315001279
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