On June 10th, the pre-conference workshop kicked-off the 2018 annual meeting after a full day meeting of the Board of Directors.
A panel of experts covered epidemiology, phenotypes, pathophysiology, outcomes, monitoring, and management of delirium. An afternoon interactive vignette session facilitated application of skills learned from the morning with bedside simulations. The day concluded by discussing opportunities to enhance delirium survivorship and hearing first hand from a delirium survivor.
Delirium: Back to basics
After a welcome from pre-conference planning committee members Leanne Boehm, PhD, RN, ACNS-BC, Vanja Douglas, MD and Stacey Williams, CPNP; Dr. Pratik Pandharipande provided a brief history of delirium and a charge to be superheroes on behalf of our patients.
Pratik Pandaripande, MD, MSCI
Dr. Pandharipande highlighted that while Hippocrates first described delirium in 500 BC there are now at least 16 characterizations and it is essential to come together under one term to make an impact by using the tools we have to change outcomes. Dr. Pandharipande asserted that this conference is not just about getting together or our professional careers, it is for our patients. We need to support them with the goal of survivorship, so that patients might return to the quality of life they expected prior to hospitalization.
Vanja C. Douglas, MD and Stacey Williams, CPNP
Neurologist Dr. Vanja Douglas presented an overview of delirium epidemiology and phenotypes so that attendees were equipped with knowledge to differentiate between delirium and other medical conditions, the subtypes of delirium, prevalence, and causes. He urged the audience to particularly keep an eye out for hypoactive delirium as this subtype is harder to catch and often leads to worse outcomes. Dr. Douglas noted that delirium results from a combination of risk factors and specific insults. For example a young patient with no risk factors would likely develop delirium from a serious insult such as encephalitis, or an individual with a strong risk factor such as mild dementia could develop it with a lesser insult such as a UTI. He concluded by sharing the AWOL delirium risk prediction model (Age, World backward, Orientation, iLlness severity).
Jose Maldonado, MD, FAPM, FACFE
ADS President Jose Maldonado MD, FAPM, FACFE spoke about Delirium pathophysiology. He presented a Systems Integration Failure Hypothesis [SIFH] (Maldonado, Int J Geriatr Psych 2017). He highlighted the association between frailty and higher incidence of delirium as well as age, cognitive impairment, and dopamine administration.
Timothy Girard, MD, MSCI spoke about delirium outcomes, specifically mortality and long-term cognition. He highlighted that patients with delirium during a hospital stay have a higher rate of mortality during the hospitalization which remains elevated years after the delirium has resolved. He also presented data that delirium has a negative impact on long term cognitive functioning. When measuring the number of days patients were in the ICU and cognitive performance a year later, cognitive outcomes worsened as the number of days increased, even when controlling for severity of illness. He concluded by stating that we do know there is an association between short term and long term worsening cognition, but we need to learn more about whether there is truly an independent association with mortality and a causal pathway versus an independent insult.
Stacey Williams, CPNP and Leanne Boehm, PhD, RN, ACNS-BC
Stacey Williams CPNP and Leanne Boehm, PhD, RN, ACNS-BC addressed delirium monitoring. Ms. Williams focused on pediatric monitoring and highlighted tools such as the Preschool Confusion Assessment Method for the ICU (psCAM-ICU) for children less than five years of age and the Cornell Assessment of Pediatric Delirium (CAPD). She also highlighted obstacles for pediatric delirium diagnosis. Dr. Boehm featured five adult delirium screening tools including the Delirium Triage Screen (DTS), the Brief Confusion Assessment Method (bCAM), the 3D Confusion Assessment Method (3D-CAM), the 4AT- Rapid Clinical Test for Delirium and the Nursing Delirium Screening Scale (NuDESC). She highlighted the considerations of age, time for assessment, training requirements, and assessment type including whether it is objective versus subjective.
Alasdair MacLullich, MRCP, PhD
Alasdair MacLullich, MRCP, Phd presented on the relationship between cognition and delirium, including a review of the DSM-5 delirium criteria. He raised a concern about the diversity of cognitive tests of attention for delirium assessment. The Months Backwards was noted as a simple, brief, convenient and low burden test. For arousal assessment he highlighted the DELAPP software test. Dr. MacLullich stated the importance of monitoring for recovery. He concluded by encouraging the assessment for altered arousal first, and if the patients can engage, utilizing a cognitive test of attention. He asserted that diagnosis requires DSM-5 criteria as well as clinical judgement and that arousal and cognitive tests can help with monitoring.
my patient has delirium- now what?
Heidi Engel, PT, DT presented Non-pharmacologic Techniques to Prevent and Manage Delirium highlighting the need for human connection and family collaboration. She stressed the importance of communication, regular toileting, and early mobility in the ICU, specifically walking.
Molly Gangopadhyay, MD spoke about Pharmacologic Delirium Management. She addressed which factors to consider when choosing agents as well as the treatment of pain and withdrawal. The pharmacological approaches she highlighted included Antipsychotics/Dopamine antagonists (most commonly used and studied for delirium treatment and prevention), Melatonin/Melatonin Agonists, Alpha 2 Agonists (Dexmedetomidine, Clonidine, Guanfacine), Valproic Acid, Gabapentin, Acetylcholinesterase Inhibitors, and NMDA-receptor blocking agents. She concluded by stating the need for delirium prevention and non-pharmacologic approaches first.
J. Matthew Aldrich, MD spoke about Implementing the "ABCDEF" Bundle to Reduce ICU Delirium. He highlighted the need to target the lightest sedation level possible, as well as reducing deep sedation and continuous sedation due to negative outcomes. He asserted the need for education about delirium assessment and awareness across disciplines in the ICU.
Delirium Screening in the icu, on the floor and in special populations
John Devlin, PharmD, FCCM, FCCP
ADS President Elect John Devlin, PharmD, FCCM, FCCP taught the audience how to assess patients in the ICU with the Intensive Care Delirium Screening Checklist (ICDSC). The ICDSC has 8 components, with the first 4 requiring focused bedside patient assessment and 5-8 necessitating observation across the course of the entire shift. The assessment elements include: 1. Altered level of consciousness, 2. Inattention, 3. Disorientation, 4. Hallucinations/delusion/psychosis, 5. Psychomotor agitation or retardation, 6. Inappropriate speech or mood, 7. Sleep-wake disturbance and 8. Symptom Fluctuation.
Karin Neufeld, MD, MPH presented how to assess patients on the floor with the Nursing Delirium Screening Scale (NuDESC). The NuDESC is designed to be scored every shift with the domains of disorientation, inappropriate behavior, inappropriate communication, illusions/hallucinations, and Psychomotor retardation.
Molly Gangopadhyay, MD provided education and video demonstrations on how to assess pediatric patients with the Preschool Confusion Assessment Method for the ICU (psCAM-ICU) for children less than five years of age and the Cornell Assessment of Pediatric Delirium (CAPD), building upon the overview that was provided in the morning session.
point of care delirium tools- simulation sessions
Learners participated in delirium assessment simulations and practiced administration of the tools: 4AT- Rapid Clinical Test for Delirium, the Pediatric Confusion Assessment Method for the Intensive Care Unit (pCAM-ICU), and the Confusion Assessment Method for the ICU (CAM-ICU).
taking it a step further...
James Rudolph, MD, SM facilitated a delirium case study discussion with input from the disciplines of nursing, physical therapy, and surgery.
Babar Khan, MD, MS presented the Critical Care Recovery Center (CCRC) which was established by the Indiana University Center for Aging Research, the Regenstrief Institute, and Eskenazi Health, and received the 2017 THRIVE Innovation Award from the Society of Critical Care Medicine. He highlighted the cognitive, physical, and psychological disabilities experienced by many ICU survivors. The center seeks to maximize the quality of life of acute critical illness survivors. He provided resources for ICU Survivor support groups online through Facebook and in person with THRIVE.
O. Joseph Bienvenu, MD, PhD
O. Joseph Bienvenu, MD, PhD informed the audience about ICU diaries which are a low cost intervention written for sedated and ventilated patients by relatives and clinicians (especially nurses) without medical jargon to fill in memory gaps and provide an understanding of what happened while patients were critically ill. The patient can read these entries afterwards and is more able to understand what has happened and also record what they recall.
The pre-conference concluded with the perspective of Scott Pinner, MD, a physician who personally experienced delirium. He shared specific examples of his story with vulnerability and encouragement of ways to improve patient care. He asserted that delirium is treated by everyone who walks in the room.