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Bree Johnston MD MPH
Professor of Medicine
Geriatrics Cross
Cover Challenges
What every Intern needs to
know before their first call
night
Supported by a grant by the Donald
W. Reynolds Foundation
Why is This Important?
• Increase of population age 65+ from 37
million in 2005 to over 70 million in
2030
• 12% of the US population in 2005 to
20% in 2030
• 2009: Older Americans account for
– 35% of all hospital stays
– 34% of all prescriptions
– 90% of all nursing home use
Retooling for an Aging America Institute of Medicine Report 2008
Learning Objectives
• By the end of this talk, you should
be able to:
– Discuss the basic approach to the
evaluation and management of falls,
delirium, and incontinence in the cross
cover setting
– Discuss the indications for restraints and
foley catheters
– Discuss the evidence base for these
approaches
– Discuss the prevalence and impact of
each of these issues
3
It is Midnight
• You have just admitted your third patients,
Mrs. Jones. She is an 85 year old woman who
has dehydration and urosepsis. She has a
history of osteoarthritis and HTN.
• The ED physician started her on
piperacillin/tazobactam, prn acetaminophen
and normal saline at 75cc/hour
• She is now on the inpatient unit. Her vital
signs are T 37.5, P90, R 16, BP 130/80, 02 sat
99% on RA.
• She has an indwelling urinary catheter in.
The nurse asks if she still needs it.
Which of the following would be an
indication for indwelling catheter
placement
(or in this case, maintenance) ?
A. Urinary incontinence
B. Patient is a fall risk
C. Delirium with inability to communicate
voiding needs
D. Urinary retention
E. All of the above
DuBeau C, CHAMP Foley Catheter Use
Only 4 indications
1. Inability to Void
2. Urinary Incontinence and:
– open sacral or perineal wound
– palliative care and patient preference
3. Urine Output Monitoring
– Always consider daily weights first
– Critical Illness—frequent/urgent
monitoring needed
– Pt unable/unwilling to collect urine
4. After general or spinal Anesthesia
– Short term only
DuBeau C, CHAMP Foley Catheter Use
Only 4 indications
1. Inability to Void
2. Urinary Incontinence and:
– open sacral or perineal wound
– palliative care and patient preference
3. Urine Output Monitoring
– Always consider daily weights first
– Critical Illness—frequent/urgent
monitoring needed
– Pt unable/unwilling to collect urine
4. After general or spinal Anesthesia
– Short term only
DuBeau C, CHAMP Foley Catheter Use
Two Basic Reasons for inability to
void:
1. Poor Pump
– Meds: anticholinergics, Ca channel
blockers, opioids
– Sacral Cord Disease, neuropathy
2. Blocked Outlet
– Prostate Disease
– Constipation / Impaction
– Less commonly:
• Supra-Sacral Spinal Cord Disease (e.g.,
MS)
• Women: scarring, large cystocele
DuBeau C, CHAMP Foley Catheter Use
http://champ.bsd.uchicago.edu/foleyCath/index.html
Why should catheter use be minimized?
• Infection Risk:
– Cause of 40% nosocomial infections
• Other morbidity
– Associated with delirium
– Urethral & meatal Injury
– Bladder & renal Stones
• Uncomfortable
• Restrictive
– Increase risk of falls and immobility
Saint S LB, Goold SD. Ann Int Med. 2002;137:125-127.
Holroyd-Leduc JM MK, Covinsky KE. J Amer Geriatr Soc.52:712-718.
Why should catheter use be minimized?
• Medicare will no longer pay for
infections associated with foley
catheters
– Average catheter associated
infection costs $600
– Urinary tract associated bacteremia
costs $2800
– Increasingly important focus of
hospital QI initiatives
Saint S et al. Annals of Int Med June 16, 2009
Now it is 3am
• You have just gotten to sleep after
admitting your 6th patient when you are
paged to the medicine floor
• The nurse asks you “May I have a
restraint order for Mrs. Jones? She is
agitated and trying to pull out her IV”.
• Her vital signs are T 37.5, P90, R 16, BP
130/80, 02 sat 99% on RA.
Which of the following would be an
indication to use a restraint?
A. Patient is trying to pull out IV
B. Patient at risk of falling
C. Patient is trying to pull out foley catheter
D. Patient is demented or delirious and does
not understand the treatment plan
E. All of the above
F. None of the above
Restraint Use
• Last resort
• Only use if all other options exhausted,
including changing treatment plan
– Do you need an IV or a monitor?
– Would the patient do better as an outpatient?
– Can you alter the treatment plan/goals?
• Use least restrictive restraint (eg, “GeriChair” before posey or 4 point)
• Use for shortest period possible
2009 Accreditation Process Guide for Hospitals Joint
JCAHO has strict standards on
restraint use
• Standard PC.03.02.01: The hospital limits its use
of restraint for non–behavioral health purposes.
• Standard PC.03.02.03: Written policies and
procedures guide the hospital’s safe use of
restraint for non–behavioral health purposes.
• Standard PC.03.02.05: Use of restraint for non–
behavioral health purposes is initiated either by an
individual order or by an approved protocol, the
use of which is authorized by an individual order.
• Standard PC.03.02.07: The hospital monitors
patients who are restrained for non–behavioral
health purposes.
2009 Accreditation Process Guide for Hospitals Joint
Commission on Accreditation of Healthcare Organizations,
http://www.jointcommission.org..
14
Indications for Restraints
• Patient at danger of hurting self/others
AND there are no other alternatives
• Restraint must be least restrictive possible
AND used for shortest amount of time
• Creative approaches can usually eliminate
need for restraints
• (More difficult in ICU/critical care setting),
but often sedation is preferable
• Generally NOT to be used in patients who
are fall risk
– increases risk of injury due to falls
Creative approaches
• Minimize use of IVs and think about
alternatives to all lines and tubes
• Heparin lock IV and cover with dressing
• Sit up by nurse’s station during day and
provide activity kits
• Get family/friends to assist
• Treat pain and attend to patient’s comfort
• Try to keep patient occupied and active
during the day so that they can sleep at
night
So how can you reduce falls if you
can’t use restraints?
• Difficult, probably only 20% preventable
• Many of the interventions that work for
delirium reduction also work for fall reduction
• Keep patient active during day and involve PT
early if patient has an abnormal gait
• Use low beds rather than restraints or bedrails
• Scheduled toileting
• Think about reducing risk factors for injury
from falls
– Osteoporosis
– Pros and Cons of anticoagulation
– Restraint reduction reduces injuries
Inouye et al N Engl J Med 360:2390, June 4, 2009
17
Ms. Jones is “out there”
• When you go to see the patient, she is
moaning, pulling at her IV, and seems to be
hallucinating.
• You perform a physical examination, which is
fairly benign. She is crying “help me, help
me” and pulling at her IV. She can’t use a
numerical pain scale but says her pain is bad.
• You review her medications and I’s/O’s. She
has taken no prn acetaminophen and no other
prns. Her urine output has been good.
• Latest labs were normal with the exception of
a WBC of 11,000 with a slight left shift, a BUN
of 28 (with a creatinine of 1.0)
What should you do next, in addition to
repeating her labs?
A. Order ativan 0.5mg PO or IV
B. Order haloperidol 0.5mg PO or IV
C. Order restraints, to be re-evaluated in the
morning
D. Perform and Document mental status testing
E. Perform CT and LP
Delirium Diagnosis
MINI-COG (OR JUST CLOCK DRAW) OR DAYS OF
WEEK BACKWARD PLUS CAM
• Mini-cog -> normal v. abnormal
– 3 item recall plus clock draw test
– Normal:
• Unlikely to have delirium OR dementia
– Abnormal:
• Is it delirium OR is it dementia OR is it both
(may be hard to know for sure)
• It the patient demonstrates inattention during
the test, suspect delirium
• OR
– Consider days of week or months of year backward
to look for inattention
Inouye Engl J Med 354:1157, March 16, 2006
Delirium: Diagnosis CAM
1. Acute Onset &
Fluctuating Course
AND
2. Inattention
plus either
3. Disorganized
Thinking
4. Altered LOC
DELIRIUM
Inouye SK et al. Ann Intern Med 1990;113:941-948.
Your patient
• She remembers 0/3 objects, and just draws
squiggles on her clock
• Cannot attend to days of week backwards,
going back and forth between seeming sleepy
and agitated
• Based on CAM, you note:
– Onset is acute
– Patient has inattention
– She has both disorganized thinking and altered
level of consciousness
• You make diagnosis of DELIRIUM
Why is Delirium important?
Delirium is Common:
• Prevalence
– 14-24% geriatric patients on admission
• Incidence
– 6-56% general hospital populations
• ICU
– 70-87% geriatric ICU pts
• Post Op
– 15-53% geriatric patients
Inouye, N Engl J Med 354:1157, March 16, 2006
Why is Delirium important?
• Delirium is associated with increased
mortality
– 22-76% in hospital mortality
– 35-40 % 1 year mortality
• Delirium is associated with increased length
of stay and costs of care
– Delirium accounts for 49% of geriatric inpatient
hospital days
– $2,500/pt, + post hospital care
– 6.9 billion medicare dollars/year
• Life threatening dx in 10-30% of delirium
presenting to ED
Inouye, N Engl J Med 354:1157, March 16, 2006
Cole MG, Aust J Hosp Pharm 2001;31:35-40.
Diagnosis Problems
• Hypoactive most common
– Mistaken for depression/withdrawn appearance
– May be associated with higher mortality rates in
patients with dementia
– RNs may not report because patients are well
behaved
• Temporal variability
– Requires multiple time points to assess throughout
day
– RNs and Family may aid in the diagnosis
Yang FM et al. Psychosomatics. 2009
Distinguishing Delirium from Dementia
Feature
Delirium
Dementia
Teaching Points
Onset
Sudden
Insidious
Need to know the
patient’s baseline
Attention &
Consciousness
Disordered
Normal
Except in advanced
dementia
Fluctuates
Gradual
decline
Helpful to check
multiple times over
course of day
Hallucinations
Usually
Visual
Usually
absent
Requires attention
to mental status
evaluation
Involuntary
Movements
Tremor,
picking,
asterixis
Usually
absent
Attentive
Observation
Required
Course
Follow up Ms. Jones
Her examination, with the exception of her
delirium, is normal. Her labs are normal,
including a renal panel, calcium, CBC. Her
ECG is normal. She is moaning and saying
“help me, help me”.
You note that as an outpatient, she was on MS
contin 30 BID for chronic OA and neuropathic
pain.
What should you do next?
A. Order CT scan of head
B. Begin around the clock pain medications
C.
Order restraints
Management (4 steps)
1. Minimize the Risk Factors (Iatrogenic)
2. Search for Medical Etiologies, underlying
cause
3. Support the patient/safety concerns
4. Treat Symptoms
Risk Factors for Delirium
• Physical restraints, immobilization, foley
catheter
• Malnutrition
• > or = to 3 medicine classes added or
withdrawing chronic medications
• Sleep deprivation
• Psychoactive Medications
• Failure to control pain
• Urinary Retention (post foley, opiates,
anticholinergics)
Inouye, N Engl J Med 354:1157, March 16, 2006
Delirium and Pain
• Untreated pain is a risk factor for delirium
– Pain often overlooked in demented/delirious
patients
• Low dose around the clock pain medications
for patients in pain (e.g. post op) such as
acetaminophen, weak opioid, or stronger
opioid for worse pain/tolerant patients
appears to REDUCE delirium
• OVERTREATMENT of pain can contribute to
delirium too
• Demerol increased delirium risk – avoid it
Vaurio, Linnea E Anesth Analg 2006 102: 1267-1273
Fong HK et al. Anesth Analg. 2006
31
Medications commonly
contribute to Delirium
• 40% of delirium thought to be
related to medications
• Common Offending Agents
– Anticholinergics
• Combinations of meds with
anticholinergic properties additive
• H2 blockers
• Diphenhydramine
– Psychoactive medications
• Benzos, sleepers
– Multiple medications
• Directed medical workup
– Good history and physical exam
– CBC, chemistries, LFT’s, glucose, calcium,
CXR, U/A, ECG
– Basic infectious workup
– Consider oxygenation and CO2 retention
– Hydration
– Consider ETOH/drug withdrawal
– Consider urinary retention/fecal impaction
• LP and CT generally low yield
– <5% of cases
– Consider with head trauma, focal neurologic
findings, fever, no other cause, younger
patients
• EEG generally low yield
– Consider in patients at high risk of
seizures/status
Pharmacologic Management
• No FDA approved pharmacologic treatment
• Good data is limited – most recommendations
based on expert opinion, observation, and case
reports
• Probably best to use support with family (ideal)
or sitter (second choice) when possible
• Would use medications prior to physical
restraints in most situations
• Only two indications for medications:
– severe agitation interfering with care
– danger to self or others
ANTIPSYCHOTIC USE IN DELIRIUM
• May decrease course and severity
• All have black box warnings; all
potentially increase mortality
• Need to check QTc before and after
giving
• Discuss risk with family or patients
(often not possible) prior to giving
• In ICU setting (intubated patients),
preferable to use sedatives like propofol
or dexdemetomidine
Breitbart W. Am J Psychiatry. 1996; 153: 231-7)
ANTIPSYCHOTIC USE IN DELIRIUM
• First choice is usually low dose haloperidol
0.5 – 1 mg PO HS or BID and prn
– Do not use in Parkinson’s Disease
– Do not use in Dementia with Lewy Bodies
– If uncertain, get neuro/geri/psych consult
• Atypicals can also be used
– Lower risk of extrapyramidal SEs, more expensive,
higher risk of CVA
– Risperidone: 0.5 mg PO BID and prn
– Olanzapine: 2.5-5.0 mg PO BID and prn
– Quetiapine: 25 mg po BID and prn
• Only use benzodiazepines for ETOH,
benzo withdrawal
Breitbart W. Am J Psychiatry. 1996; 153: 231-7)
Lonergan E Cochrane Database of Systematic Reviews 2007
Pharmacologic Management
• Treatment algorithm using haloperidol for
“out of control” patients:
– Load 0.5 – 1.0 mg PO or IM q 30 minutes until
manageable
– Maximum dose for naïve patients, 5 mg in a 24
hour period
• Studies show equal adverse effects to atypicals if
<3.5 mg/d
– After 24 hrs, use ½ of loading dose in divided
doses.
– Taper beginning day 2 or 3 over several days.
• If IV haloperidol, need telemetry
monitoring.
• For complex cases, consult psych,
Delirium Can be Prevented
• Targeting common delirium risk factors
can reduce delirium incidence by 1/3
Inouye SK, et al. NEJM. 1999;340:669-676.
38
Visual
Hearing Impairment
Impairment
Dehydration
Glasses,
Visual Aids,
Early recognitio
& po repletion
Cognitive
Impairment
Orientation/
Activities
Hearing devices,
Remove earwax
Sleep Deprivation
Non-drug sleep
enhancement
Immobility
Early
Mobilization
Results

Delirium was reduced by 1/3 by instituting preventive
measures

USUAL CARE = 15% ; PREVENTION GROUP = 10%

ARR= 5.1%, NNT = 20 to prevent one episode of
delirium
Summary
• Your patients will be helped enormously if
you can:
– Avoid unnecessary foley catheters and
restraints
– Try to reduce the incidence of delirium by
preventing common risk factors
– Recognize delirium
– Appropriately manage and treat delirium
– Keep your patient active during day and
sleeping as much as possible (without
sleepers) at night
41
Resources and References
• Vanderbilt U. Medical Center
– www.icudelirium.org
• SHM: geriatrics tool box
– http://www.hospitalmedicine.org/geriresource/toolb
ox/mini_cog.htm
• University of Chicago CHAMP resource
– http://champ.bsd.uchicago.edu/
• NICHE Program and Resources
– http://wiki.nicheprogram.org/wiki/Main_Page