Delirium

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Delirium

• Suh, Guk-Hee
• Department of Psychiatry
• Hallym University College of Medicine

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Introduction

• Delirium is particularly common and problematic
  in elderly
• Increased mortality and longer hospital stay
• A phenomenon of Sudden clouding of
  consciousness
• Unable to cooperate with instructions
• Mostly unrecognised
• Common and morbid condition among hospitalized
  elderly
• Iatrogenic complications from medications and
  physical restraints

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Delirium ?

• Definition of delirium
• Acute onset
• fluctuating course removal of cause
• impaired cognitive functioning ? recovered
• Acute brain failure
• Reversible state
• Need immediate intervention
• c.f. chronic brain failure dementia

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• ??? ??? ?? ?? delirium
• Alcohol-induced persisting dementia
• Alcohol-induced persisting amnestic disorder
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• Traumatic ICH- ???? ?? ??
• Alcohol withdrawal delirium ?? ?? ?? ??
• Alcohol intoxication delirium ?? ?? ??? ?? 0,
  
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• CT / MRI
• Thiamine folate
• Emergency OP, if necessary

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Epidemiology of delirium

• elderly inpatient, medical 10-16 (Levkoff et al
  1992)
• 1 year mortality, geriatric inpatient delirium
  25
• drug-induced delirium in a intermediate care
  facility
• 6 in random sample (Rovener et al 1986)
• Eastern Baltimore Mental Health Survey (Folstein
  et al 1991)
• 0.4 of those aged 18 years and over
• 1.1 of those aged 55 years and over
• 13.6 of those aged 85 years and over

Modern practice of rapid discharge from hospital
following medical and surgical procedure is
likely to increase the incidence of delirium in
the community.
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DSM-IV criteria of delirium
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Hard disk CPU
REM
Operating System
Brainstem reticular formation, midline raphe
nucleus, locus coeruleus
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Etiology of delirium
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Assessment history

• Rate of change in the patients behaviour, the
  nature and severity of the change, and the
  prominence or otherwise of fluctuation in mental
  status
• Typically sudden onset, developing hours or days,
  often begins at night
• fluctuate in intensity
• lucid intervals occur during the day
• nocturnal worsening
• prodromal sx daytime restlessness, anxiety,
  fearfulness, hypersensitive to light or sound

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Assessment precipitating factor

• Recent illness
• Use of prescription or illicit drugs and alcohol
• Anticholinergic activity - reversible
• Exposure to environmental toxins
• Head trauma
• Pre-existing conditions such as epilepsy

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Assessment Predisposing factors

• advanced age and young age (child)
• preexisting brain damage (e.g. CVA, tumor)
• history of prior delirium
• alcohol dependence
• diabetes mellitus
• cancer
• sensory impairment (e.g. Blindness, Deafness)
• malnutrition

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Clinical examination

• General behavioral observation
• Appearance, alertness, mood
• Signs of rambling attention, distractibility, and
  agitation alternating with drowsiness
• Specific tests of attentional function
• Digit span test repeat strings of digits of
  increasing length
• Letter cancellation
• Motor sequencing test Luria three-stage command
  test
• General physical examination signs of systemic
  illness

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Two variants of delirium

• Hyperactive-hyperalert / loud delirium
• Agitated, restless, hallucination
• Hypoactive-hypoalert / quiet delirium
• Lethargic, withdrawn and often hypersomnolent
• Easily overlooked, misinterpreted as lack of
  motivation or depression
• Underlying cause is more like to be more severe,
  more difficult to treat, and associated with a
  poorer prognosis than in those with hyperactive
  delirium
• A proportion of patients may alternatively
  exhibit features of both subtypes leading to
  further confusion about the nature and evolution
  of the illness.

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Investigations
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Differential Diagnosis of Delirium
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Differential Diagnosis of Delirium
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Prognosis of delirium
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• Increased short-term mortality
• Severity of the underlying physical illness
• If successfully controlled, effect on mortality
  is marginal. (Francis et al 1990
  Francis Kapoor 1992 Pompei et al 1994)
• Increased short-term morbidity (Francis Kapoor
  1992)
• Longer hospital stay
• Higher rates of discharge to nursing-homes
• Long-term outcome of delirium is less clear.
  (Levkoff et al 1992)
• Traditionally regarded as a reversible one with
  benign outcome
• Poor long-term outcome in terms of persistent or
  recurrent symptoms

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Prevention of delirium
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• More careful prescribing of drugs
• Minimize the use of those with known deliriogenic
  potential such as anticholinergic agents (e.g.
  tricyclic antidepressants), tranquillizers and
  hypnotics with long half-lives, and narcotic
  analgesics
• Medical or Surgery unit
• pre-, peri-, and post-operative oxygenation and
  hydration
• Minimize sensory impairment
• Provide stable, familiar and orienting
  environment

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Treatment of delirium
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Acute change in behavior

• Medical emergency confusion in this case
• Cause
• Stroke
• Heart attack
• Dehydration
• Pulmonary embolus
• Pneumonia
• Side effects of medication

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• amitryptiline (Elavil) 50mg ?? ?
• ??? Carisoprodol 350mg prn ?sumatriptan inj.

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?? ??

• Poor cooperation
• V/S PR 100, B/P 180/70
• Mouth smell
• Auscultation rale and wheezing
• Chest PA right lower lobe pneumonia

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