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David Kappel, MD, FACS - Bioethics

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David Kappel, MD, FACSUniversity of PittsburghMedical Ethics Conference 2017Disclosure: Nothing to Disclose
DELIRIUM“Just another night in the ICU”
Acute disruption of attention and cognitionInouye, S.K., Schlesigner, M.J., & Lydon, T.J.
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A problem ??Mortality 25-33%morbidityfunctional declineresource utilizationhospital costslength of stayrate of nursing home placementCole, M.G, Primeau, F.J.Murray, Levkoff, S.E., Wetle, T.T., Beckett, L., Cleary, D.D., Schor, J.D., Lipsitz, L.A., Row, J.W., Evans, D.A.Inouye, S.K.
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CostAverage cost per day survived2 ½ times greaterHealth care system burden$38 - $152 Billion/yearLeslie, D.L., Marcantonio, E.R., Zhang, Y., Leo-Summers, L., & Inouye, S.K.
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PopulationPatients>6548% all days hospital careLeslie, D.L., & Inouye, S.K.
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PopulationMost common complication in hospitalized patients age 65 & over20% of admitted60% of certain surgeries80% of ICU patientsHarvard Women’s Health Watch
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PopulationBy 2020 – 53% all older than 65Currently 55% all operations in > 65 years oldRobinson, T.N., Raeburn, C.D., Tran, Z.V., Angles, E.M., Brenner, L.A., & Moss, M.
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ImpactLength of stayPost discharge Institutionalization6 month mortalityRobinson, T.N., Raeburn, C.D., Tran, Z.V., Angles, E.M., Brenner, L.A., & Moss, M.
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Magnitude of Problem62% risk mortalityLeslie, D.L., Zhang, Y., Holford, T.R., et. al.
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Recovery after hip fractureDelirium 41% patientspersisted @ D/C 39%Persisted at 6 months 6%Poor functional recovery at one month post-op with deliriumMarcantonio, E.R., Flacker, J.M., Michaels, M., & Resnick, N.M.
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Cardiac ICU patients20% of patientsICU days (+3)Mortality (27% vs. 3%)Pauley, Lishmanov, Schumann, Gala, van Diepen, & Katz
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Medical service patients mortality ≈ 2Xshort and long term decline in functional healthFrancis & Kapoor
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Elective surgery>70Delirium of all adverse events influenced:Length of StayInstitutional discharge30 day re-admission rateGleason, Schmitt, Kosar, Tabloski, Saczynski, Robinson, Cooper, Rogers, Jones, Marcantonio & Inouye
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“…advances in the field are hampered by insufficient recognition of the seriousnessand impactof the problem of delirium…”Leslie, D.L., & Inouye, S.K.
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Baseline physical frailty is associated with development of post-operative deliriumLeung, Tsai, & Sands
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EtiologyMetabolic disturbanceHypoxiaConstipation/dehydrationImmobilityPainSleep disruptionSensory impairmentMedical therapiesNelson
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PreventionHospital Elder Life Program (HELP)MobilizationSleep enhancementOrientationTherapeutic activitiesEnvironmental modificationRubin, Neal, Fenlon, Hassan & Inouye
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Confusion Assessment Method – CAMGeriatrics Consultation75% delirium unrecognizedInouye, van Dyck, Alessi, Balkin, Siegal & Horwitz
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Treatment?Antipsychotic – dopaminergic blockade for ? Dopamine excess & acetylcholine deficiencyHaloperidol ? Treating providersHshieh, Fong, Marcantonio & Inouye
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Risks of treatment with antipsychoticRisk of mortality in dementia33 % continued after discharge?Multiple side effects and complications including deathMuench & HamerJasiak, Middleton, Camamo, Erstad, Snyder & Huckleberry
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Diffusion tensor injury MRI? Structural disconnect interhemispheric and fronto – thalamic – cerebellum networksCerebellumHippocampusThalamusBasal forebrainCavallair, Dai, Guttmann, Meier, Ngo, Hshieh, Callahan, Fong, Schmitt, Dickerson, Press, Marcantonio, Jones, Inouye & Alsop
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Inouye, SK, Schlesinger, MJ & Lydon, TJ. (1999). Delirium: A symptom of how hospital care is failing older persons and a window to improve quality of hospital care.The American Journal of Medicine. 106:565-573.Cole, MG, Primeau, FJ. (1993). Prognosis of delirium in elderly hospital patients.Can Med Assoc J. 149:41-46.Murray, AM, Levkoff, SE, Wetle, TT, Beckett, L, Cleary, PD, Schor, JD, Lipsitz, LA, Rowe, JW, Evans, DA. (1993). Acute delirium and functional decline in the hospitalized elderly patient.J Gerontol. 48(5):181-186.Inouye, SK. (1992). A predictive model for delirium in hospitalized elderly medical patients based on admission characteristics.Ann Intern Med. 119:474-481.Leslie, DL,Marcantonio, ER, Zhang, Y, Leo-Summers, L & Inouye, SK. (2008). One-year health care costs associated with delirium in the elderly.Arch Intern Med. 168(1):27-32.Leslie, DL & Inouye, SK. (2011). The importance of delirium: Economic and societal costs.J. Am Geriatr Soc. 59(2):S241-S243.Harvard Health Publications.When patients suddenly become confused.http://www.health.Harvard.edu/staying-healthy/when-patients-suddenly-become-confused. Retrieved on February 25, 2016.Robinson, TN, Raeburn, CD, Tran, ZV, Angles, EM, Brenner, LA & Moss, M. (2009). Postoperative delirium in the elderly.Annals of Surgery. 249(1):173-178.Leslie, DL, Zhang, Y,Holford, TR,Bogardus, ST, Leo-Summers, LS & Inouye, SK. (2005). Premature death associated with delirium at 1-year follow-up.Arch Intern Med. 165(14):1657-1662.Marcantonio, ER,Flacker, JM, Michaels, M, & Resnick, NM. (2000). Delirium is independently associated with poor functional recovery after hip fracture.JAGS. 48:618-624.Pauley, E,Lishmanov, A. Schumann, S, Gala, GJ, vanDiepen, S & Katz, JN. (2015). Delirium is a robust predictor of morbidity and mortality among critically ill patients treated in the cardiac intensive care unity.American Heart Journal. 170:79-86.Francis, J, Kapoor, WN. (1992). Prognosis after hospital discharge of older medical patients with delirium.J AmGeriatrSoc.40:601-606.
Gleason, LJ, Schmitt, EM,Kosar, CM,Tabloski, P,Saczynski, JS, Robinson, T, Cooper, Z., Rogers Jr, SO, Jones, RN,Marcantonio, ER, & Inouye, SK. (2015). Effect of delirium and other major complications on outcomes after elective surgery in older adults.JAMA. E1-E7.Leung, JM, Tsai, TL, Sands, LP. Brief report: preoperative frailty in older surgical patients is associated with early postoperative delirium.AnesthAnalg, 112:1199-1201Nelson, JM. (2010). Recognizing, preventing, and managing delirium in hospital patients.American Nurse Today. 5(11): 43-45.Rubin, FH, Neal, K,Fenlon, K, Hassan, S & Inouye, SK. (2011). Sustainability and scalability of the Hospital Elder Life Program (HELP) at a community hospital.J AmGeriatrSoc. 59:359-365.Inouye, SK, VanDyck, CH,Alessi, CA,Balkin, S,Siegal, AP & Horwitz, RI. (1990). Clarifying confusion: the confusion assessment method. A new method for detection of delirium.Ann Intern Med. 113(12):941-948.Hshieh, TT, Fong, TG,Marcantonio, ER, & Inouye, SK. (2008). Cholinergic deficiency hypothesis in delirium: a synthesis of current evidence.JGerontolABiolSciMed Sci. 63A:M764-772.Muench, J & Hamer AM. (2010). Adverse effects of antipsychotic medications.Am Fam Physician. 81:617-622.Jasiak, KD, Middleton, EA,Camamo, JM,Erstad, BL, Snyder, LS & Huckleberry, YC. (2013). Evaluation of discontinuation of atypical antipsychotics prescribed for ICU delirium.Journal of Pharmacy Practice. 26:253-256.Cavallair, M, Dai, W, Guttmann, CR, Meier, DS, Ngo, LH,Hshieh, TT, Callahan, AE, Fong, TG, Schmitt, E, Dickerson, BC, Press, DZ,Marcantonio, ER, Jones, RN, Inouye, SK & Alsop, DC. (2016). Neural substrates of vulnerability to postsurgical delirium as revealed bypresurgicaldiffusion MRI.Brain. 139:1282-1294.

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David Kappel, MD, FACS - Bioethics