The Chicken or the Egg: Delirium and TBI in the Elderly Brecken Hentz MS CCC-SLP Lindsay Dutko MA CCC-SLP Chicken or Egg? Fall Deliriu m TBI Hospita
l Traumatic Brain Injury in the Elderly A blow or jolt to the head or a penetrating head injury that disrupts normal function of the brain TBI can occur in absence of positive Head CT Unintentional Falls are #1 cause (51%) with MVC next (9%) Older age is associated with higher mortality after severe TBI Recovery after TBI is more limited for older than younger survivors Less capacity for compensation Reduced cognitive reserves Differences in the Aging Brain Older adults who experience an apparently trivial event in which there has been a minor trauma to the head.often present with more insidious and delayed symptom onset of undiagnosed TBI
Unique pathophysiology of the older brain Slowly expanding SDH late onset TBI May be easily confused with delirium Flanagan, et al., 2006 TBI vs. Delirium TBI Delirium Onset immediately following accident USUALLY except in the elderly when a SDH is slowly expanding
Attention Orientation Awareness Memory Judgment Reasoning Problem Solving Executive Functioning Initiation/Impulsivity Behavior (agitation) -Onset is generally not until after pt arrives at hospital; can occur as early as in the ED or even prior to hospitalization, though -
Attention Orientation Memory of recent events Difficulty speaking Rambling, nonsense speech Visual hallucinations Withdrawn behavior Restlessness/agitation Disturbed sleep patterns Extreme emotions Case Study 92 yo male s/p fall down carport stairs +LOC (?LOC prior to fall d/t dehydration from stomach virus); GCS 13 in ED Brain CT: L parieto-occipital SDH; L subarachnoid
hemorrhange; L anterior temporal lobe cerebral contusion PMH: DM II, HTN, h/o multiple TIAs, chronic dysphagia secondary to esophageal strictures last dilated 7/2012, GERD, recently diagnosed follicular lymphoma, hearing loss NPO for several days prior to placement of NG tube with eventual placement of PEG tube secondary to very high aspiration risk and poor secretion management D/cd to SNF after a 9-day hospitalization with re-admission for AMS suspected for metabolic changes after 17 days D/cd back to SNF Mental Status on First Admission Baseline: Mostly independent but does not drive Primary caregiver for wife with dementia Supportive family
In ED: Nonverbal Not following commands Minimal eye opening Throughout hospitalization Gradual improvement (Rancho Level 3 5) across hospitalization but with significant variability in LOA/MS throughout each day No agitation Mental status on d/c was still confused, but appropriate with deficits in recall, processing, and attention. Mental Status on 2nd Admission Per family report, at SNF improved to at least a Rancho
Level 6 Increased impairments from prior hospitalization Poor orientation Limited auditory comprehension Poor topic maintenance Tangential Impaired safety awareness/insight (attempting to get out of bed) Extremely agitated (grabbed granddaughter and clinicians wrists
Calmer with no one present in the room No changes in head CT (wanted to ensure no evolution of previous findings) Discussion What are this patients risk factors for delirium? Common Risk Factors for Delirium Predisposing
Advanced age Preexisting dementia History of stroke Parkinsons disease Multiple cormorbid conditions Impaired vision Impaired hearing Males History of alcohol abuse Precipitating
Acute medical problem Exacerbation of chronic medical problem Surgery/anesthesia New phsychoactive medication Acute stroke Pain Environmental change Urine retention/ fecal impaction Electrolyte disturbances Dehydration Sepsis Discussion Does this patient have delirium? If so, on which admission (s)?
Criteria for Delirium Disturbance of consciousness with attentional impairment Change in cognition or development of a perceptual disturbance not attributable to dementia Disturbance develops over a short time and fluctuates during the course of the day Disturbance is caused by a general medical condition Discussion What could have been done to prevent this patients delirium? Now that he has delirium, what can we do to manage it?
Prevention/Management TBI Limit stimulation (no tv, radio, limit visitors) Calm environment (lights low, door closed) Brief periods of appropriate stimulation with majority of the day/ night for rest
Bring personal items from home Have a routine Minimize restraint use Both Frequent orientation Allow movement as physically able and safe Appropriately address
vision/hearing impairments Call PVR 6812020 Engage pt in appropriate cognitive stimulation Allow for uninterrupted sleep at night Hydration Delirium Lights on during the
day (allow for TV and radio per pts preference) Frequent engagement by visitors/staff Therapeutic activities (i.e. word searches, newspapers, conversations, etc) Strategies Orientation: Verbal re-orientation Written re-orientation
Safety Awareness: Active bedside attendant Verbal cues Written cues More Strategies Attention/Receptive Language Eliminate distractions Close the door Turn off the TV, radio, etc
Limit # of people in the room when having conversations For delirium, even though you want family present and familiar background noise to keep pt oriented and awake, when you are communicating with pt, environment needs to be quiet Sit directly across from the pt Sit pt upright and comfortably Provide multimodal communication as able i.e. Use gestures, pictures, and written key words to supplement verbal information More Strategies Expressive Language Simplify language; ask 1 question at a time i.e. say Do you hurt? instead of Are you ready for more pain medicine?
i.e. say You fell and hit your head. You are at Duke Hospital instead of You fell and sustained a brain hemorrhage, so your family brought you into Duke Hospital. If not verbal or minimally verbal attempt to elicit nonverbal yes/no responses Verify responses with opposite question i.e. Ask both Are you hot? and Are you cold? i.e. Ask both Are you in pain? and Are you comfortable? Provide tangible choices i.e. show the pt both orange juice and apple juice Provide written choices In Conclusion
Delirium can co-occur with other cognitive and communication impairments, like TBI. Management of delirium in these patients may have to be modified to best fit the patient.
A common fallacy is to assume artificial selection is the same as natural selection. Artificial selection, though, comes from goals, purposes and plans of people; it's a form of intelligent design. One form of this fallacy is "computer evolution" -...
Prompts for Standard. 1. At the end of chapter one, Gatsby can be seen reaching toward a "single green light" (21). In chapter five, Daisy is compared to the green light, and Nick explains that Gatsby's "enchanted objects had diminished...
(d) (i) A power-driven vessel of less that 12 metres in length may in lieu of the lights prescribed in paragraph (a) of this Rule exhibit an all-round white light and sidelights; (ii) a power-driven vessel of less than 7...
Passes through aligned pits of neighbouring tracheids Pit membrane consists of 1o wall only Tissue Systems Vessel members (advanced): Stack end to end to form a vessel (long) Perforation plate at ea. end of a member permits easy water flow...
hPL) Prepares mammary glands for milk production. Synergistic with growth hormone at other tissues. Ensures adequate glucose and protein is available for the fetus. Placental. Prolactin. Helps convert mammary glands to active status
The Health Benefits of Drinking Tea… Fact or Fiction? By: Payton Seelinger What is tea? History of Tea Discovered in 1st millennium B.C. Brought to America by Peter Stuyvesant Chinese Emperor Shen Nung Variety of Tea Black Tea Green Tea...
Recognizing rituals and ritual like activities Big R Little r Ritualized behavior Similarities between rituals and routines The may have a similar appearance Involve more than one family member, Involve overt behavior, Repetition of form and content, There is continuity...
Ready to download the document? Go ahead and hit continue!