Impact of delirium on patients
following Hip fracture surgery

Dr Chrys Pulle MBBS FRACP
Geriatrician
The Prince Charles H...
Background
Hip fractures predicts morbidity and
mortality
• 7-10% Inpatient 30 day mortality
• 12-37% 1 yr mortality
• 50%...
Delirium
• Disturbance of
consciousness with
reduced ability to focus,
sustain or shift attention
• Perceptual disturbance...
What?: linear causality
Risk Factors
Vulnerability

Hypertension
Vulnerability

Atherosclerosis

Pathology
Myocardial Infa...
Does linear causality work for delirium?

Vulnerability

Dementia

Triggers

Triggers

Syndrome

Delirium
GERIATRIC SYNDROMES

Incontinence

Confusion

Iatrogenesis

Falls

Homeostenosis
MULTIFACTORIAL MODEL OF DELIRIUM
IN OLDER PERSONS

Ref: Inouye SK et al. JAMA 1996; 275:852-857
Why do patients present with
delirium?
 When complex systems fail, they fail
with their highest-order functions first
 O...
So the characteristics of delirium are:
 Under recognised
 Poorly understood
 Common
 Serious
 Preventable
 Manageab...
The Confusion Assessment Method (CAM)
Diagnostic Algorithm
Feature 1: Acute Onset and Fluctuating Course
Feature 2: Inatte...
Flacker JM. J Gerontol Biol Sci 1999;54:B239-46
Delirium: Presentation
Subtypes
– Agitated 30%
• Better recognized
• More attention to treatment
• Associated with improve...
Delirium Subtypes
•
•
•
•
•
•

AGITATED
Psychosis
Visual Hallucinations
Delusions
Hypervigilance
Language
disorganization
...
DELIRIUM OUTCOMES
Post Hip Fracture Delirium
Table 1: Risk Factors for Delirium Post Acute Hip Fracture

Pre-existent Diagnosis of
Dementia
...
Geriatrician/ MDT Management of
Delirium
Post Op Mx of Hypotension,
Oxygenation, Fluid & Electrolyte
Balance

Early mobili...
Hierarchy of Delirium Management
Track
cognition and
mobility
Rehabilitation:

Reorientation:

Optimisation:

Correction:
...
1.Post Op
Hypotension
Guidelines
• Routine
Monitoring of
Hypotension
• Anaemia
• Urine Output
• Oxygenation

ORTHOPAEDIC P...
2. Medical Post-operative
Complications
• Pneumonia
• UTI
• Ischaemic Heart
Disease
• DVT/ PE
• CVA

•
•
•
•
•
•
•

FBE
EL...
Routine Surveillance
3. Pain Management
4. Bowel & Bladder Management
5. Medication Review
6. Nutritional Review
7. Withdr...
Environmental
•
•
•
•
•
•
•

Sensory inputs
Restraint avoidance
Close Observation
Diurnal variation
Doll Therapy
Family in...
Agitated Delirium
•
•
•
•

Delirium Screened and Investigated
Low Dose Antipsychotics
Benzodiazepines for withdrawal state...
Chrys Pulle - Prince Charles Hospital -  Impact of delirium on patients following Hip Fracture surgery
Chrys Pulle - Prince Charles Hospital -  Impact of delirium on patients following Hip Fracture surgery
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Chrys Pulle - Prince Charles Hospital - Impact of delirium on patients following Hip Fracture surgery

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Chrys Pulle, Geriatrician Hip Fracture Unit, The Prince Charles Hospital Brisbane delivered this presentation at the 2nd Annual Hip Fracture Management Conference 2013. This conference is the only regional event to discuss practical innovations and improvement processes for the management of Hip Fractures in the hospital setting.

Find out more at http://www.healthcareconferences.com.au/hipfracture2013

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Chrys Pulle - Prince Charles Hospital - Impact of delirium on patients following Hip Fracture surgery

  1. 1. Impact of delirium on patients following Hip fracture surgery Dr Chrys Pulle MBBS FRACP Geriatrician The Prince Charles Hospital Brisbane
  2. 2. Background Hip fractures predicts morbidity and mortality • 7-10% Inpatient 30 day mortality • 12-37% 1 yr mortality • 50% reduced functional performance
  3. 3. Delirium • Disturbance of consciousness with reduced ability to focus, sustain or shift attention • Perceptual disturbance not accounted for by a pre-existing, established or evolving dementia • Develops over a short period of time and fluctuates during the course of a day • Needs acute investigation
  4. 4. What?: linear causality Risk Factors Vulnerability Hypertension Vulnerability Atherosclerosis Pathology Myocardial Infarction Disease Chest Pain Symptom Complex
  5. 5. Does linear causality work for delirium? Vulnerability Dementia Triggers Triggers Syndrome Delirium
  6. 6. GERIATRIC SYNDROMES Incontinence Confusion Iatrogenesis Falls Homeostenosis
  7. 7. MULTIFACTORIAL MODEL OF DELIRIUM IN OLDER PERSONS Ref: Inouye SK et al. JAMA 1996; 275:852-857
  8. 8. Why do patients present with delirium?  When complex systems fail, they fail with their highest-order functions first  Older people who are frail can be conceived of a complex system that are close to failure
  9. 9. So the characteristics of delirium are:  Under recognised  Poorly understood  Common  Serious  Preventable  Manageable
  10. 10. The Confusion Assessment Method (CAM) Diagnostic Algorithm Feature 1: Acute Onset and Fluctuating Course Feature 2: Inattention Feature 3: Disorganised thinking Feature 4: Altered Level of consciousness The diagnosis of delirium by CAM requires the presence of Features 1 and 2 and either 3 or 4.
  11. 11. Flacker JM. J Gerontol Biol Sci 1999;54:B239-46
  12. 12. Delirium: Presentation Subtypes – Agitated 30% • Better recognized • More attention to treatment • Associated with improved outcome – Hypoactive 25% • Little recognized • Depression is primary differential • Associated with poor outcomes – Mixed 45%
  13. 13. Delirium Subtypes • • • • • • AGITATED Psychosis Visual Hallucinations Delusions Hypervigilance Language disorganization Mood Lability • • • • HYPOACTIVE Lethargy Apathy Easily dismissed as transient or insignificant Elderly Pts
  14. 14. DELIRIUM OUTCOMES
  15. 15. Post Hip Fracture Delirium Table 1: Risk Factors for Delirium Post Acute Hip Fracture Pre-existent Diagnosis of Dementia Delirium present on Admission Low BMI (<20) Age Fall indoors Resident of aged care facility Longer time to Surgery (>48hrs) Hypoxia Anaemia on admission Post-op transfusion Higher ASA Grade Multiple Medications
  16. 16. Geriatrician/ MDT Management of Delirium Post Op Mx of Hypotension, Oxygenation, Fluid & Electrolyte Balance Early mobilisation & rehabilitation Prevention & Treatment of Medical Post-op Complications Adequate Nutritional Intake Adequate Pain Mx Appropriate Environmental Stimuli Regular Bowel/Bladder Mx Treatment of Agitated / Hypomanic Delirium Medication review Family Consultation
  17. 17. Hierarchy of Delirium Management Track cognition and mobility Rehabilitation: Reorientation: Optimisation: Correction: Socialisation, Early mobilisation Environment, orientation, dignity, diversion activity Nutrition, hydration, comfort, toileting, sensory correction Treat the underlying causes
  18. 18. 1.Post Op Hypotension Guidelines • Routine Monitoring of Hypotension • Anaemia • Urine Output • Oxygenation ORTHOPAEDIC POST-OPERATIVE (48 hours) HYPOTENSION GUIDELINE PURPOSE: To provide guidance for early management of hypotension in post-operative orthopaedic patients. -x* Post-operative Hypotension is when the MANUAL Systolic BP scores a MEWS score of two (2) or greater. This needs to be reported to RMO (even if Total MEWS < 4). * Any score greater than zero warrants increased surveillance of the patient. This warrants increased frequency of observations. Notify the Team Leader. Clinical Assessment Nurse on Ward RMO (to review and assess the patient on the ward) The patient’s clinical presentation determines the order of assessment & treatment of the hypotensive episode Systolic BP MEWS score of 2 or greater Administer fluid bolus if prescribed. Notify RMO for review Assess volume status clinically (check urine output, JVP, mucous membranes, skin turgor and auscultate chest), order fluid bolus if indicated (consult Registrar if uncertain) Repeat bolus if indicated IV Access Ensure IV access patent If no IV access insert IVC (draw bloods if required) Oxygenation Review Oxygen Saturations, Respiratory Rate and Sedation Level Assess oxygen requirements and prescribe oxygen as appropriate Urine Output Check recent Hb (if no post surgery Hb send immediately) Check urine output is greater than 30 mls /hr. * If not voided in last 4 hours encourage to void, consider bladder scan. Observe for signs and/or symptoms of acute urinary retention. Consider signs and symptoms of anaemia. If Hb is < 100 contact RMO for patient review If urine output < 30 mls /hr consider fluid bolus. If not voided in last 4 hours assess requirement for IDC to monitor hourly urine output. Consider signs and symptoms of anaemia. Check all Hb results Draw Hb test if required If Hb 70 - 100 call Registrar to consider transfusion If Hb < 70 prescribe 1U PRBC & organise Registrar review. Consider transfusion reaction. Check for signs of bleeding Check Drains / Leg Girth / Wound / Dressings Recheck regularly with observations Look for signs of further blood loss (possibly occult) Consider Cardiac causes Check Heart Rate & Rhythm Do 12 Lead ECG Review 12 Lead ECG Liaise with Registrar considering Chest X-Ray and Bloods Temperature Check Patient Temperature report if abnormal Look for signs of sepsis Liaise with Registrar regarding septic screen Documentation Document assessment, escalation, plan and timeframe for reporting in the Medical Record If patient is under Acute Pain Service (APS): contact APS Registrar if patient remains hypotensive. -xIf no improvement of hypotension despite treatment contact Registrar / Consultant who can organise either further treatment or an ICU / Anaesthetic consult · · If patient meets MET criteria: Call MET immediately Contact Anaesthetic Registrar if within 24hrs post-op and anaesthetic concerns
  19. 19. 2. Medical Post-operative Complications • Pneumonia • UTI • Ischaemic Heart Disease • DVT/ PE • CVA • • • • • • • FBE ELFTs ABG CXR MSU CT Head CTPA /
  20. 20. Routine Surveillance 3. Pain Management 4. Bowel & Bladder Management 5. Medication Review 6. Nutritional Review 7. Withdrawal state
  21. 21. Environmental • • • • • • • Sensory inputs Restraint avoidance Close Observation Diurnal variation Doll Therapy Family input & education Reorientation & reassurance
  22. 22. Agitated Delirium • • • • Delirium Screened and Investigated Low Dose Antipsychotics Benzodiazepines for withdrawal states Daily review of continual need

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