delirium dalziel

7/29/2019 Delirium Dalziel

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DELIRIUM


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Delirium: Synonyms

Acute confusional state

Acute organic brain syndrome Acute brain failure

Acute toxic psychosis


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Case - Delirium79 year old lady

lives alone, manages own apartment

slightly forgetful (according to daughter) 7 months ago:

started slowing down

losing interest; insomnia

Rx Amitriptyline/Oxazepam


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PMed Hx: HTN

Meds: Hydrochlorothiazide 25 mg OD

Amitriptyline 50 mg qhs Oxazepam 15-30 mg qhs

79-year-old lady


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One week prior to hospitalization

c/o pain in right knee

O/E slightly swollen

prescribed: Naproxen 250 mg BID

79-year-old lady


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Tripped on rug, sustained a hip fracture

Brought to hospital. Spent 12 hours in ER

ORIF the following day 1st POD

climbing over bedrails

shouting all night sleeping in day

pulling out her IVs

79-year-old lady


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All Confusion is

Not DementiaAlways Consider

Delirium

Delirium


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Delirium - Is Often Missed

43% of cases unrecognized by RNs

32%-66% of cases unrecognized by

MDs


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Epidemiology in Elderly

Prevalence :

Hospitalized Medically Ill 10 - 30%

ER 10 -18%

Incidence:

In Hospital 10 - 36%

Post-operatively up to 50%

Cardiac Surgery 17 - 73%

Orthopedic 28 - 52%

D I H


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De r um In Hosp taPrognosis

Course:

Can be quite variable

Prevalence:

Typical 10-12 days

Range 1-8 weeks

Lasting > 30 days 15%

Increased LOS

Discharge to LTC

Hospital cost


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Delirium: Prognosis

40%

25%

25-33%

Recovery

Permanent Cognitive Impairment

Mortality


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Delirium: Prognosis Following recovery, annual incidence

of dementia 20%

Increased Institutionalization rate


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Delirium: Prognosis

Delirium may serve as a marker for future

cognitive decline

Patients need to be FOLLOWED for the

development of dementia.


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Delirium (DSM-IV)

A: Disturbance of consciousness(reduced clarity of

awareness of the environment) with reduced ability to focus,

sustain or shift attention

B: Change in cognition (eg. memory deficit, disorientation,language disturbance) or development of a perceptual

disturbance not due to pre-existing, established or

developing dementia

C: The disturbance develops over a short period of time(hours to days) and tends to fluctuate during the course of

the day.

D. Evidence of aetiology

l


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Delirium: CognitiveEvaluation

Interview patient and caregiver to

determine if any acute changes in

mental status or behaviour

Confusion Assessment Method

f i


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Confusion AssessmentMethod

Acute change in mental statusAND

Inattention/fluctuationPLUS

Disorganized thinkingOR

Altered level of consciousness

Sensitivity 94-100% Specificity 90-95%

Ann Intern Med. 1990; 113:941

Arch Intern Med. 1995; 155:301

C f i A


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Confusion AssessmentMethod

Most Important

1. Acute change in mental status?

2. Disorganized thinking?

3. Altered level of consciousness?4. Inattention/fluctuation?

5. Psychomotor agitation/retardation?

6. Perceptual disturbance?

7. Disorientation?

8. Sleep wake cycle altered?

9. Memory impairment? Least ImportantAnn Intern Med. 1990;113:941

D li i C i i


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Delirium: CognitiveEvaluation

MMSE:

inaccurate tool to diagnose delirium as the

patient: fluctuates

has poor attention/concentration

helpful tool to demonstrate improvement incognitive status when following patient.

C i F f


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Comparative Features ofDelirium and Dementia

Delirium Dementia

ONSET develops abruptly develops slowly

DURATION brief, hours to days chronic, months to yrs

ATTENTION impaired normal, except insevere cases

LOC fluctuating clear

SPEECH incoherent, ordered

disorganized anomic/aphasic

NOTE: Disorientation and memory impairment may be present with both


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Delirium - Core Features

Acute onset and fluctuating course

Inattention; Easily distractible

Disorganized thinking

Altered level of consciousness


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Spectrum Of Delirium

Spectrum of Psychomotor Activity :

HYPOACTIVE delirium (lethargy, excess

somnolence, sluggish)

Individuals often not recognized as they

may not cause a disturbance so theydont get ATTENTION


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Spectrum Of Delirium

HYPERACTIVE delirium

(agitated, hallucinating,inappropriateness)

MIXED - combination of

both


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Delirium: Signs Restlessness, agitation

Picking at the air/clothes...

Myoclonus (often multifocal)

Asterixis (suggests a metabolic cause)

Hallucinations (usually visual, tactile)

M j Ri k F t f th


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Major Risk Factors for theDevelopment of Delirium Dementia

Pre-existing Cognitive Decline


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Delirium (in Hospitalized Elderlypts)

Dehydration

Severe illness

Vision Impairment


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Causes of Delirium:A Checklist

D: Drugs anticholinergics, ETOH

E: Endocrine BS, Na, Ca, Mg, cortisol, etc.

M: Metabolic organ failure, hypoxia, etc.E: Epilepsy or seizures postictal status

N: Neoplasm especially SIADH, CNS

T: Trauma concussion, surgeryI: Infection any

A: Apoplexyany vascular event MI, PE, CVA

Fi di th C f


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Finding the Cause ofDelirium

I: Infections UTIs, pneumonia, encephalitis, etc.

W: Withdrawal alcohol, benzodiazepines, sedative-hypnotics

A: Acute electrolyte disturbance, dehydration, acidosis /

alkalosis, hepatic/renal metabolic failure

T: Toxins, drugs opiates, salycilates,indomethacin, dilantinC: CNS pathology stroke, TIA, tumors, seizures, hemorrhage, infection

H: Hypoxia anemia, pulmonary/cardiac failure, hypotension

D: Deficiencies Thiamine (with alcohol abuse), B12

E: Endocrine thyroid, hypo/hyperglycemia, adrenal dysfunction,

hyperparathyroid

A: Acute vascular shock, hypertensive encephalopathy

T: Trauma head injury, post-operative, hypo/hyperthermia

H: Heavy Metals lead, mercury, manganese poisoning

M di i A i d i h


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Any drug can potentially cause

confusion

Take a careful history of any new drug

STARTED or any old drug STOPPEDrecently

Medications Associated with

Delirium

d d h


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Medications Associated withDelirium

Sedatives - hypnotics; Benzodiazepines - toxicity or withdrawal

Narcotics - especially Demerol

Anticholinergics

Antihistamines eg. Gravol Tricyclic antidepressants eg. Amitriptyline

Antiparkinsonian agents

Cardiac eg. Digitalis

Miscellaneous H2 blockers Lithium

Steroids Anticonvulsants

Metoclopramide NSAIDs eg. Indocid

D ith A ti h li i


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Drugs with AnticholinergicActivity

Tricyclic Antidepressants

eg. Amitriptyline, Doxepin, Imipramine

Dimenhydrinate (Gravol)

Ditropan

Cogentin

Anti-Parkinsonian Drugs

eg. Artane/Kemedrin

Medications Associated with


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Medications Associated withDelirium

Herbal/over the counter drugs

Cimetidine

Cough/Cold Remedies

Gravol

Sleeping medications eg. Nytol...

Miscellaneous Causes of


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Miscellaneous Causes ofDelirium

Pain

Fecal Impaction

Urinary Retention

Alcohol Intoxication or withdrawal


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Delirium: Evaluation

It is a clinical diagnosis

It requires a COMPREHENSIVE

ASSESSMENT


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Delirium: Etiology

Good Physical Exam

Assess Hydration Status

? New localizing Neurological findings

? CHF/Pneumonia

Rectal Exam to R/O Impaction

? Distended Bladder

? Infected Ulcer

Delirium: Search for


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Delirium: Search forUnderlying Etiology

Review medication list Measurement of serum levels of

medications eg. Digoxin/phenytoin...

Metabolic work up CBC

lytes/BUN/creat/glucose

Ca, albumin liver function tests

R/O infection eg. CXR; urine C&S

O2saturation/ABGs to R/O pCO2 Delirium: Search for


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ECG to R/O silent MI

CXR to R/O pneumonia as physical exam

often difficult/inaccurate

CNS work-up (if indicated): ie. CT Head

Delirium: Search for


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Positive urine cultures

Common in the elderly

Should only be used as the cause for

a delirium when patient has new

urinary symptoms.


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Prevention of Delirium Multi component intervention strategy

targeted to 6 delirium risk factors

Ref: Inouye SK, NEJM. 1999;340:669-676


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Delirium: Management

Address immediate safety

Investigate cause(s)

Identify and remove or treat underlying

cause(s)

Medications (eg. Benzodiazepines /Neuroleptics) to be used only if necessary

Nonpharmacological


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NonpharmacologicalManagement

Provide general supportive measures:

Avoid restraints

Encourage familiar faces for reassurance eg.family members

Fluids, nutrition

Low stimulation - avoid excessive noise Provide orientation (calendar, clock)

Correct sensory impairment eg. vision, hearing

Delirium: Pharmacological


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Delirium: PharmacologicalManagement

Principles

1. Use a SINGLE medication rather than two,to decrease the potential for side effects/druginteractions.

2. Start with a low dose.

3. Choose a drug with low anticholinergic activity.

4. Try to stop the medication as soon as possible,

focusing on correcting the underlying cause for thedelirium.

5. Continue to use Non-Pharmacologicalinterventions.


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Delirium: Pharmacological


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Delirium: PharmacologicalManagement

Atypical Antipsychotics (Risperidone, Olanzepine,

quetiapine)

No controlled studies at present of their use indelirium (just case reports)

MAY TRY:

low dose Risperidone starting at .25 mg BID

Olanzapine - 2.5 mg/d as starting dose

Quetiapine - 12.5 mg/d starting dose


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Suggested Readings

1. Cole MG, McCusker J, Dendukuri N, Han L. Symptoms of

delirium among elderly medical inpatients with or without

dementia. J Neuropsychiatry Clin Neurosci 2002;

14(2):167-75.

2. Francis J. Martin D, Kkapoor WN. A prospective study of

delirium in hospitalized elderly. JAMA 1990;263(8):1097-

101.

3. Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V,Cassel CK. Delirium in hospitalized older persons:

Outcomes and predictors. J Am Geriatr Soc 1994; 2(8):809-15.


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Suggested Readings

4. Inouye SK. The dilemma of delirium: Clinical and research

controversies regarding diagnosis and evaluation of delirium

in hospitalized elderly medical patients. AM J Med 1994;

97(3):278-88.

5. Inouye, SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP,

Horwitz RI. Clarifying confusion: The confusion assessment

method. A new method for detection of delirium. Ann Intern

Med 1990; 113(12):941-8.

6. Inouye SK, A Multicomponent Intervention to PreventionDelirium in Hospitalized Older Patients. NEJM.

1999;340:669-676

delirium dalziel

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