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ACP HospitalistWeekly 8-4-10

Highlights

• Updated guidelines issued on management of spontaneous intracerebral hemorrhage
• Review: Most medical futility studies draw conclusions from insufficient data

Delirium

• New guidelines on diagnosing, preventing and treating delirium
• Delirium associated with higher risk of mortality, dementia in elderly

From the College

• Hospitalists wanted for survey and program development

Cartoon caption contest

• And the winner is…

Physician editor: A. Scott Keller, FACP

Highlights

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Updated guidelines issued on management of spontaneous intracerebral hemorrhage

The American Heart Association and American Stroke Association recently issued updated guidelines on management of spontaneous intracerebral hemorrhage (ICH).

Outcomes of spontaneous cerebral hemorrhage can be improved with timely, appropriate medical treatment. The AHA and ASA issued these guidelines in part to stress to clinicians the importance of their role and to provide "an evidence-based framework" for care. New recommendations or those revised from the 2007 guidelines include the following:

• Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively.
• Patients with ICH whose international normalized ratios are elevated due to oral anticoagulants should have warfarin withheld, receive therapy to replace vitamin K-dependent factors and correct the international normalized ratio, and receive intravenous vitamin K.
• In patients presenting with a systolic blood pressure of 150 to 220 mm Hg, acute lowering of systolic blood pressure to 140 mm Hg is probably safe.
• Patients with cerebellar hemorrhage who have neurologic deterioration or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible.
• No clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate.
• Glucose should be monitored and normoglycemia is recommended.
• After documentation of cessation of bleeding, low-dose subcutaneous low-molecular weight heparin or unfractionated heparin may be considered for VTE prophylaxis in patients with lack of mobility after 1-4 days from onset of ICH.
• Patients with clinical seizures, and patients with a change in mental status who are found to have electrographic seizures on EEG, should be treated with antiepileptic drugs.
• When stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein E ε2 or ε4 alleles, and greater number of microbleeds on MRI.
• After the acute ICH, in patients without medical contraindications, blood pressure should be well controlled, especially in those whose ICH location is typical of hypertensive vasculopathy.

The complete guidelines were published online July 22 by Stroke.

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Review: Most medical futility studies draw conclusions from insufficient data

Most studies that claim to guide determinations of medical futility are based on insufficient data, and don't provide the statistical confidence needed to make clinical decisions, a review found.

Researchers searched the MEDLINE database for articles between 1980 and 2008 that reported original outcome data in critically ill or cardiac arrest patients and claimed the data could support or refute decisions to limit treatment in similar patients. Case reports were excluded from the review, as were studies of outcome after a decision to withhold or withdraw treatment. The researchers found 47 studies in which the main conclusion was that treatment in a given situation was futile, and 45 articles in which the main conclusion was that treatment could be effective. Results were published in the July 20 Journal of General Internal Medicine.

Only 13% of articles that said a given treatment was futile had explicit definitions of futility or other criteria for limiting treatment. Among studies that refuted futility claims, only 11% gave a definition of futile therapy. The original criteria for quantitative futility were fulfilled by just 28% of data; these came almost exclusively from studies of CPR for cardiac arrest. There was a great deal of statistical overlap between data that were used to support futility claims, and data used to refute such claims.

Many studies drew dissimilar conclusions based on data that were statistically similar; indeed, the data were often insufficient to provide statistical confidence for making a decision either way, the researchers noted. Most studies also lacked explicit pre-determined thresholds for futility, they said. The data were often obtained in small groups of patients, which compromised statistical confidence, they said. "Our findings imply that in most circumstances, physicians cannot confidently rely on published outcome data to make determinations of medical futility," they concluded. Indeed, the limitations "argue against a strictly empirical approach to decisions on limiting treatment in patients in very poor prognosis."

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Delirium

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New guidelines on diagnosing, preventing and treating delirium

The U.K.'s National Institute for Health and Clinical Excellence (NICE) has released new guidelines on recognizing, preventing and managing delirium, based on systematic reviews of best available evidence and cost-effectiveness, an article said.

Poorly recognized, delirium affects as many as 30% of inpatients, yet it can be prevented in about one-third of at-risk patients, the article said. When patients first present to the hospital, they should be assessed for risk factors, including age 65 years and older; cognitive impairment (past or present), dementia or both; current hip fracture; and severe illness. Patients should also be observed once admitted to the hospital for any changes in the risk factors for delirium, said the guidelines, which were published online July 28 by BMJ.

Recommended interventions to prevent delirium include:

• Ensure those at risk of delirium are cared for by people familiar to the person. Don't change staff excessively during the person's stay.
• Avoid moving patients within and between units or rooms unless absolutely necessary.
• Within 24 hours of admission, assess people at risk for the following clinical factors that might precipitate delirium:
• cognitive impairment, disorientation or both;
• dehydration, constipation or both;
• hypoxia;
• immobility or limited mobility;
• infection;
• multiple medications;
• pain;
• poor nutrition;
• sensory impairment; and
• sleep disturbance.

At-risk, admitted patients should also be assessed daily for behavioral changes or fluctuations. The changes may be reported by the patient, a relative or caregiver, and may affect cognitive function (poor concentration, slow responses, confusion); perception (for example, visual or auditory hallucinations); physical function (reduced mobility or movement, restlessness, agitation, sleep disturbance, appetite changes); and social behavior (lack of cooperation, withdrawal, alternations in mood or attitude).

If delirium indicators are present, the patient should be clinically assessed based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, or the short confusion assessment method (CAM), the guidelines said. For those diagnosed with delirium, identify and manage the possible underlying cause(s); reorient the person (for example, explain where the person is, who they are and what your role is); and provide reassurance. Consider involving family and friends to help with reassurance. If a person with delirium is distressed or considered a risk to self or others, use verbal and non-verbal de-escalation techniques. If needed, consider short-term haloperidol or olanzapine at the lowest appropriate dose and titrate slowly.

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Delirium associated with higher risk of mortality, dementia in elderly

Delirium in elderly patients is associated with an increased risk of death, dementia and institutionalization, independent of any comorbidities, a new meta-analysis found.

Researchers used several databases to find observational studies of elderly patients with delirium that were published between January 1981 and April 2010. The studies contained data on mortality, institutionalization and/or dementia after a minimum of three months of follow-up. Of 2,939 references in the original search, 51 germane articles were found. Primary analyses included only studies that controlled for age, sex, comorbid illness or illness severity, and baseline dementia. Results were published in the July 28 Journal of the American Medical Association.

In the primary analysis, which used adjusted hazard ratios (HRs), delirium was associated with a higher risk of death compared to controls after an average follow-up of 22.7 months (38.0% risk for patients with delirium vs. 27.5% for control patients in 7 studies; HR, 1.95; 95% CI, 1.51 to 2.52). Patients with delirium also had a higher risk of institutionalization after an average of 14.6 months of follow-up (33.4% risk for patients with delirium vs. 10.7% risk for control patients in 7 studies; odds ratio [OR], 2.41; 95% CI, 1.77 to 3.29), and of dementia after 4.1 years of follow-up (62.5% risk for patients with delirium and 8.1% risk for control patients in 2 studies; OR, 12.52; 95% CI, 1.86 to 84.21). These risks existed independently from age, sex, comorbid illness, illness severity or presence of dementia at baseline.

The results indicate that older people who experience delirium should be considered a vulnerable population, the authors wrote. Past research indicates delirium can be prevented in some cases, but management doesn't improve mortality or the need for institutionalization once delirium is present, they noted. "Identifying patients at high risk for delirium and implementing strategies aimed at preventing delirium may help to avert some of the delirium-associated poor outcomes these patients experience," they wrote. The findings also suggest delirium is not just a marker for underlying disease, as this factor (along with age, sex and baseline dementia) was controlled.

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From the College

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Hospitalists wanted for survey and program development

ACP would like to work with practicing hospitalists to develop innovative programs, products and services to better meet the needs of physicians working in inpatient settings. If you are currently a practicing hospitalist, and would like to be involved in this important College activity, please click here to take a survey.

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Cartoon caption contest

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And the winner is …

ACP HospitalistWeekly has tallied the voting from its latest cartoon contest, where readers are invited to match wits against their peers to provide the most original and amusing caption.

 

 

 

 

 

 

 

 

 

"I told you you'd like our new patient-centered medical home."

This issue's winning cartoon caption was submitted by Russell A. Kaphan, ACP Member. Readers cast 98 ballots online to choose the winning entry. Thanks to all who voted!

The winning entry captured 52% of the votes.

The runners-up were:
"The beer is nice and all, but I still feel sick …I really think I need a shot."
"I've found this product to be the best for producing a urine sample quickly."

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