in the Elderly Thomas Robinson, MD Surgery Grand Rounds March 10 th, 2008

Post- Operative Delirium in the Elderly Thomas Robinson, MD Surgery Grand Rounds March 10 th, 2008

What is the most common post-operative complication in elderly patients?

What is the most common post-operative complication in elderly patients? DELIRIUM Marcantonio et al. JAMA (1994) 271:134.

Diagnostic Criteria for Delirium 1. Disturbance of Consciousness 2. Change in Cognition 3. Acute Onset 4. Coexisting Physiologic Disturbance Diagnostic and Statistical Manual of Mental Disorders DSM IV - Fourth Edition (1994)

In 2004, what percent of all operations in the United States were performed on patient older than 65 years?

In 2004, what percent of all operations in the United States were performed on patient older than 65 years? 55% (Age > 65) 45% (Age < 65) GRS: A Core Curriculum in Geriatric Medicine 6 th Ed. (2006)

U.S. Population Aged 65 and Over 80 Population (Millions) 60 40 20 0 1900 1930 1960 1980 2002 2030 Calendar Year

U.S. Population Aged 65 and Over 80 25 Population (Millions) 60 40 20 15 Percent Total Population 10 20 5 0 1900 1930 1960 1980 2002 2030 0 Calendar Year

Post-Operative Delirium in the Elderly Risk Factors Natural History Outcomes Motor Subtypes

Post-Operative Delirium in the Elderly Risk Factors Natural History Outcomes Motor Subtypes Treatment

Organic Causes of Delirium DELIRIUMS (mnemonic) D E L I R I U M S S rugs (anticholinergics, polypharmacy) motional (depression) ow PO2 states (MI, PE, anemia, CVA) nfection (sepsis) etention of urine or stool ctal states (seizure, post-ictal) nder-nutrition/under-hydration etabolic (electrolytes, glucose) ubdural (acute CNS processes) ensory (impaired vision & hearing)

Etiology of Post-Operative Delirium Consecutive patients older than 50 years being admitted post-operatively to the SICU. 88% (56/64) - No underlying cause identified. 12% (8/64) - Organic cause identified. 75% - Sepsis 12% - Stroke 12% - Alcohol Withdrawal DVAMC

Age and Post-Operative Delirium 100 Incidence of Delirium (%) 80 60 40 20 0 50-59 60-69 70-79 80-89 Age by Decade (years) DVAMC

Pre-Operative Risk Factors DELIRIUM Present (n=64) Absent (n= 80) Age (years) 69±9 61±6 *p<.001 Albumin (g/dl) 3.3±0.8 3.9±0.4 *p<.001 Hematocrit (%) 38±7 44±4 *p<.001 Functional Status(Barthel Index) 91±11 99±3 *p<.001 Dementia (Mini-Cog Test) 2.8±1.6 4.6±0.7 *p<.001 Co-Morbidities (Charlson Index) 4.6±2.4 1.8±1.4 *p<.001 History of Alcohol Abuse 82% 18% *p=.009 DVAMC

Intra- and Post- Operative Risk Factors DELIRIUM Present (n=64) Absent (n= 80) INTRA-OPERATIVE Blood loss (ml) 752±1033 655±1515 p=.73 OR time (minutes) 298±137 282±105 p=.44 Intra-Op Hypotension (SBP<90) 88% 27% *p<0.001 POST-OPERATIVE Blood Transfusion (units) 3.1±3.3 1.3±2.1 *p=0.001 DVAMC

Strongest Risk Factors for the Development of Post-Operative Delirium Pre-Existing Dementia Functional Impairment Older Age More Co-Morbidities Lower Albumin Intra-Operative Hypotension DVAMC

Frailty Predicts Delirium Given a similar surgical stress, the core components of frailty are stronger predictors of developing post-operative delirium than the specific details of the operation.

Strongest Risk Factors for the Development of Post-Operative Delirium Pre-Existing Dementia Functional Impairment Older Age More Co-Morbidities Lower Albumin Intra-Operative Hypotension DVAMC

Threshold Theory of Cognitive Decline The hypothetical construct of reduced brain reserve capacity represented by changes in the brain s actual neurons or the milieu of neurotransmitters which makes an individual more vulnerable to a cognitive clinical deficit such as delirium. Satz P. Neuropsych (1993) 7:273.

Changing Cognitive Function in the Elderly 100 Dementia 80 Brain Reserve Capacity 60 40 20 0 50 60 70 80 90 100 Age (Years)

Threshold Theory of Cognitive Decline 100 Dementia 80 Brain Reserve Capacity 60 40 20 0 50 60 70 80 90 100 Age (Years)

Threshold Theory of Cognitive Decline 100 Dementia Delirium 80 Brain Reserve Capacity 60 40 20 0 50 60 70 80 90 100 Age (Years)

Post-Operative Delirium in the Elderly Risk Factors Natural History Outcomes Motor Subtypes Treatment

Incidence of Delirium Cataract Surgery 5 Medial Ward 1 Vascular Operation 4 Hip Fracture 3 DVAMC SICU 6 DHMC Trauma ICU 7 Medical ICU 2 < 5% 15% 36% 40% 44% 59% 72% 1 NEJM (1999) 340(9):669. 2 JAGS (2006) 54:479. 3 JAGS (2002) 50:850 4 Gen Hosp Psych (2002) 24:28. 5 Int Psych (2002) 14:301. 6 DVAMC 7 DHMC

Natural History of Delirium Incidence Duration (days) Time to Onset (days) 44% 4.0±5.1 2.4±1.9 DVAMC

Cumulative Incidence of Post-Operative Delirium 100 80 Cumulative Incidence (%) 60 40 20 0 1 2 3 4 5 6 7 Post-Operative Day DVAMC

The Biphasic Distribution of Post-Operative Delirium DELIRIUM Organic Identifiable Cause No Identifiable Cause Initial Presentation of Delirium (Post-Operative Days) 5.6±3.5 1.9±0.9 *p=0.02 DVAMC

The Biphasic Distribution of Post-Operative Delirium Number of Subjects 30 25 20 15 10 5 0 No identifiable cause of delirium Delirium due to an organic cause 1 2 3 4 5 6 7 8 9 10 11 12 Post-Operative Day DVAMC

Post-Operative Delirium in the Elderly Risk Factors Natural History Outcomes Motor Subtypes Treatment

Outcomes and Delirium DELIRIUM Present (n=64) Absent (n= 80) Length of ICU Stay (days) 9.7±8.0 4.6±2.1 *p<0.001 Length of Hospital Stay (days) 16.3±10.9 7.9±3.9 *p<0.001 Cost of Hospitalization ($ in 1,000s) 50.1±33.6 31.6±14.1 *p<0.001 Post-Discharge Institutionalization 33% 1% *p<0.001 DVAMC

Mortality and Delirium DELIRIUM Present (n=64) Absent (n= 80) Hospital Mortality 5% 0% p=0.086 30 Day Mortality 9% 1% *p=0.045 Six Month Mortality 20% 3% a *p=0.001 a n=78 two patients lost to 6 month follow up DVAMC

Post-Operative Delirium in the Elderly Risk Factors Natural History Outcomes Motor Subtypes Treatment

Motor Subtypes of Delirium A spectrum of psychomotor behavior is found in delirium. Delirium Motor Subtypes Hypoactive Hyperactive Mixed Type Meagher et al. J of Neuropsych and Clin Neurosc (2000) 12(1):51.

Motor Subtypes of Delirium Hypoactive Pure lethargy, somnolence Hyperactive Pure agitation Mixed Type Fluctuation between lethargy and agitation Meagher et al. J of Neuropsych and Clin Neurosc (2000) 12(1):51.

Incidence - Motor Subtypes of Delirium Post-Op SICU Trauma ICU Medical ICU Hypoactive Hyperactive Mixed Type 66% 1% 33% DVAMC

Incidence - Motor Subtypes of Delirium Post-Op SICU Trauma ICU Medical ICU Hypoactive 66% 46% Hyperactive 1% 15% Mixed Type 33% 39% DHMC

Incidence - Motor Subtypes of Delirium Post-Op SICU Trauma ICU Medical ICU Hypoactive 66% 46% 44% Hyperactive 1% 15% 2% Mixed Type 33% 39% 55% Peterson et al. JAGS (2006) 54:479.

Adverse Events - Motor Subtypes of Delirium 23% (17/74) incidence of adverse events 21 events occurred in 17 subjects Adverse Events 52% (11/21) Pulled tube/line 29% (6/21) Sacral decubitus ulcer 20% (2/21) Falls 5% (1/21) Extubation DVAMC

Adverse Events - Motor Subtypes of Delirium MOTOR SUBTYPE Hypoactive (n=8) Mixed (n=11) Pulled line/tube 25% 82% p=0.024 Sacral Decubitus Ulcer 75% 0 *p=0.001 DVAMC

Outcomes - Motor Subtypes of Delirium MOTOR SUBTYPE No Delirium Mixed Hypoactive n=98 n=23 n=50 Age (years) 60±6 65±9* 71±9* *p=0.001 6 Month Mortality 3% 9%* 32%* *p=0.041 DVAMC

Post-Operative Delirium in the Elderly Risk Factors Natural History Outcomes Motor Subtypes Treatment

Pharmacologic Treatment - ICU Haldoperidol 2 mg q20 min (while agitation persists) OR Degree of Agitation Mild Moderate Severe Initial Dose Haldoperidol PO, IM or IV 0.25-2mg 2-4mg 4-8mg Jacobi et al. Crit Care Med (2002) 30(1):119.

Pharmacologic Treatment - ICU Maintenance Dose: 50% of total loading dose is the maintenance dose divided every 6-8 hours daily Continue maintenance dose for 24-48 hours before tapering Taper: Taper maintenance dose by 20-30% daily until off.

Pharmacologic Treatment - ICU Haldoperidol Administration Control Maintain Taper Moderate Agitation 2:00AM 2mg IV 2:30AM 2mg IV 3:00AM 2mg IV 3:30AM Agitation controlled Order 1mg TID IV or PO x 24 hrs. Keep daily dose for 24 48 hrs. 0.5mg PO BID for 24 hrs. then DC

Pharmacologic Treatment - Ward General Recommendation: Haldoperidol 1-2 mg q2-4 hrs PRN May be administered PO/IM/IV For Elderly Patients: Haldoperidol 0.25-0.5mg q4hrs PRN Practice Guideline for Treatment of Patients with Delirium (1999) American Psychiatric Association

Post-Operative Delirium in the Elderly Dementia is the strongest risk factor for delirium. Delirium resulting from an organic cause occurs later in the post-op course compared to geriatric delirium. Outcomes are worse in subjects who develop delirium. Delirium presents in three distinct motor subtypes. Hypoactive delirium has the worst prognosis.