Modelli di Prevenzione

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1 14 Congresso Nazionale AIP DELIRIUM DALLA DIAGNOSI AL TRATTAMENTO Firenze, 12 aprile 2014 Modelli di Prevenzione Giorgio Annoni Cattedra e Scuola di Specializzazione in Geriatria Università degli Studi di Milano-Bicocca S.C. Clinicizzata di Geriatria Azienda Ospedaliera San Gerardo

2 Preventive Medicine The branch of medical science concerned with the prevention of disease and the promotion of physical and mental health through the study of the etiology and epidemiology of disease processes.

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4 Epidemiology Delirium approximately 40% of hospitalized elderly pts >65 yrs approximately 50% of pts post-hip fracture approximately 30% of pts in surgical intensive care units approximately 20% of pts on general medical wards approximately 15% of pts on general surgical wards

5 Delirium: diagnosis, prevention and management Implementing NICE guidance July 2010 NICE clinical guideline 103

6 Preventive Medicine ASSESS RISK INSTITUTE PREVENTIVE MEASURES

7 ASSESS RISK INSTITUTE PREVENTIVE MEASURES

8 HIGH RISK PATIENTS Demographics -Age Cognitive Impairment Medical Comorbidity Decreased Oral Intake/Dehydration Functional Impairment Sensory Impairments Number of Drugs

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10 82 vs 36 pts

11 HIGH RISK CLINICAL SITUATIONS Acute Intercurrent Illnesses/AMI/CAP Injury (Hip Fracture) Neurologic Disease (vascular) Surgery Infections Pain Drugs

12 Some drug classes that are associated with delirium Medications with psychoactive effects: 3.9-fold increased risk 2 or more meds: 4.5-fold Sedative-hypnotics: 3.0 to 11.7-fold Narcotics: 2.5 to 2.7-fold Anticholinergic drugs: 4.5 to 11.7-fold Other Misc: steroids, H2 blockers, NSAIDs Risk of delirium increases as number of meds prescribed and daily assumed

13 L esperienza della Clinica Geriatrica di UNIMIB

14 Caratteristiche di base del campione (n = 1304) n % Sesso, F ,4 Età 84,2 ±6,6 Ultranovantenni ,8 Provenienza 506 pazienti (38.8%) hanno sviluppato delirium Domicilio senza badante nel corso del ricovero ,3 Domicilio con badante ,7 RSA 125 9,0 Dipendenza funzionale (2 o più funzioni ADL perse) ,7 Deterioramento cognitivo (rilievo anamnestico ) ,6 Malnutrizione (MNA-SF <8) ,3

15 Determinanti associati allo sviluppo di delirium No delirium (n=798) Delirium (n=506) P-value Età, anni 83,4 ± 6,7 85,5 ± 6,1 < 0,001 Sesso femminile, n (%) 452 (56,6) 291 (57,5) 0,758 Living status, n (%) Domicilio senza badante 604 (75,7) 255 (50,4) Domicilio con badante 152 (19,0) 185 (36,6) < 0,001 RSA 42 (5,3) 66 (13,0) ADL precedente il ricovero (0-6) 3,8 ± 2,1 1,9 ± 2,0 < 0,001 NMS Il all ingresso delirium (0-9) interessa, 4,4 soprattutto, ± 3,2 2,0 i pazienti ± 2,4 più < 0,001 Deterioramento cognitivo, n (%) 140 (17,5) 285 (56,3) < 0,001 MMSE all ingresso (0-30) 22,3 ± 6,5 13,0 ± 7,5 < 0,001 Charlson Comorbidity Index 3,0 ± 2,4 2,9 ± 2,0 0,315 SOFA all ingresso 1,7 ± 1,6 2,6 ± 2,4 < 0,001 MNA-SF all ingresso (0-14) in atto 9,2 ± e 3,1 con CV 7,3 ± 3,2 < 0,001 Albumina all ingresso (g/dl) 3,4 ± 0,5 3,2 ± 0,6 < 0,001 PCR all ingresso (mg/dl) 6.0 ± 7,5 8,2 ± 8,8 < 0,001 Urea all ingresso (mg/dl) 66,0 ± 44,4 74,1 ± 52, Creatinina all ingresso (mg/dl) 1,3 ± 0,9 1,4 ± 0,9 0,196 Classi di farmaci al domicilio Antidepressivi 118 (14,8) 102 (20,2) 0,012 Neurolettici 50 (6,3) 120 (23,7) < 0,001 Benzodiazepine 148 (18,5) 89 (17,6) 0,662 Posizionamento CV, n (%) 270 (33,8) 309 (61,1) < 0,001 Stato infettivo, n (%) 447 (56,0 371 (73,3) < 0,001 anziani, disabili, detriorati cognitivamente, malnutriti trattati con neurolettici, con segni di flogosi/sepsi

16 Comparsa di delirium: regressione logistica tra le variabili indipendenti significativamente correlate all analisi univariata B (SE) OR 95% CI P-value Età 0,02 (0,01) 1,02 1,00 1,04 0,043 Deterioramento cognitivo 1,11 (0,15) 3,02 2,26 4,05 < 0,001 ADL precedente al ricovero -0,22 (0,04) 0,81 0,75 0,86 < 0,001 MNA precedente al ricovero -0,08 (0,02) 0,93 0,89 0,97 0,001 Neurolettici 0,76 (0,20) 2,13 1,44 3,16 < 0,001 Model χ 2 = 6,71 ; df = 8 ; P = 0.57 Le variabili Antidepressivi e Benzodiazepina non sono risultate significative. MNA-SF: Mini Nutritional Assessment Short Form; ADL: Katz Activity of Dailiy Living.

17 Ortogeriatria UNIMIB: rischio cumulativo di Delirium durante la degenza di 362 anziani 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% durante l'intero ricovero All ingresso in reparto Pre-operatorio Post-operatorio

18 Farmacoterapia domiciliare e delirium al momento del ricovero Non delirium Delirium p N (%) N (%) >4 farmaci assunti a domicilio 175 (12,7) 37 (17,5) 0,215 Antipertensivi 223 (11,7) 45 (16,8) 0,240 Benzodiazepine 76 (13,9) 19 (20,0) 0,155 Neurolettici 18 (12,7) 14 (43,8) 0,000 Antidepressivi 52 (15,1) 11 (17,5) 0,631 Anticomiziali 13 (15,3) 3 (18,8) 0,711 Antiaggreganti 139 (13,5) 30 (17,8) 0,261 Statine 50 (16,3) 6 (10,7) 0,284 Inibitori di pompa protonica 115 (13,6) 26 (18,4) 0,212 Steroidi 15 (15,7) 2 (11,8) 0,665

19 Ortogeriatria UNIMIB: rischio cumulativo di Delirium durante la degenza di 362 anziani 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% durante l'intero ricovero All ingresso in reparto Pre-operatorio Post-operatorio

20 Multivariate logistic regression analysis of the potential predictors of postoperative delirium among 362 orthogeriatric patients RISK FACTORS Adjusted OR (95% C.I.) p-value Age 1.02 ( ).481 Male gender 2.30 ( ).036 Functional status, Katz s Activities of Daily Living Independent or slightly dependent (ADL=5-6) Reference Moderately dependent (ADL=3-4) 4.22 ( ).001 Severely dependent (ADL=0-2) 8.31 ( ) <.001 Charlson Comorbidity Index 0.95 ( ).463 Pre-existing dementia 3.25 ( ).001 Preoperative haemoglobin levels 1.04 ( ).398 Transfusion of 2 or more blood units 2.96 ( ).001 Time from admission to surgery 2 days 0.88 ( ).647

21 Blood transfusion of more than 1,000 ml led to the greatest risk of developing delirium on the first postoperative day M. Behrends et al JAGS 61: , 2013

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23 HIGH RISK ENVIRONMENT Unfamiliar Environment Indwelling Bladder Catheter Immobility Sleep deprivation Sensory deprivation/aids Light and/or noisy Isolation

24 Keys to Effective Prevention Find and treat the underlying disease(s) and contributing factors Comprehensive Geriatric Assessment Including neurological and mental status exams Choose lab tests and imaging studies based on the above Review medication list

25 ASSESS RISK INSTITUTE PREVENTIVE MEASURES

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36 Ann Pharmacother 2013;47:

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38 A melatonin receptor agonist, REMELTEON was approved by the US Food and Drug Administration in 2005 for treatment of insomnia in adults, characterized as difficulty in falling asleep. Ramelteon activates 2 of the 3 melatonin receptors, melatonin receptors 1 and 2, and causes numerousphysiologic processes, similar to the effects of melatonin. To our knowledge, no published studies have demonstrated whether ramelteon in humans is more or less safe or effective than melatonin.

39 J Am Geriatr Soc 59:S282 S288, 2011.

40 In sintesi..

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