Delirium vs. TBI in the Elderly - Duke University

Delirium vs. TBI in the Elderly - Duke University

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Attention Orientation Memory of recent events Difficulty speaking Rambling, nonsense speech Visual hallucinations Withdrawn behavior Restlessness/agitation Disturbed sleep patterns Extreme emotions Case Study 92 yo male s/p fall down carport stairs +LOC (?LOC prior to fall d/t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.

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