Everymans Psychosis: Delirium by Barbara Olesko, MS, RN, NP

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Everymans PsychosisDeliriumby Barbara Olesko,
MS, RN, NP
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Introduction

• From the Latin phrases de (away from or down)
• and lira (furrow or track in the fields)
• -- Delirium means to be off track
• Other commonly used terms confusion, acute
  confusional state, acute brain failure, acute
  dementia, acute organic syndrome, cerebral
  insufficiency, metabolic encephalopathy, organic
  brain syndrome, reversible toxic psychosis, and
  ICU psychosis

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Prevalence

• Medical patients 10-30
• Post-op surgical patients up to 51
• Hospitalized patients with cancer 15-85
• Hospitalized patients with AIDS 30-40

• Hospitalized elderly 10-40
• Terminally ill up to 80
• Ambulatory Cancer patients 20

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Delirium at SMH

• From 7/03 6/04, there was an 19.1 rate of
  delirium. This 19.1 represents 238/1246 total
  consults.
• Of the 238 consults we diagnosed as delirious,
  only 59 were accurately identified as delirious
  (24.8 accuracy rate).
• The rest of the requests were to evaluate
  dementia, depression or behavior problems.
• Conclusion Delirium is often overlooked or
  misdiagnosed as depression or psychosis, or
  misattributed to dementia.

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Clinical Features

• Disturbance in consciousness with a change in
  cognition (reduced awareness of the environment,
  attention wanders, easily distracted,
  disorientation, perceptual disturbance, language
  disturbance, memory problems)
• Disturbance in sleep-wake cycle
• Disturbance in behavior (agitation or lethargy)
• Disturbance of emotions
• Disturbance develops over a short period of time,
  with a fluctuating course over the day
• Disturbance is a direct physiological consequence
  of a medical condition

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Behavioral Observations

• Provider repeats the same question, not getting
  any answer or getting multiple answers
• Patient may perseverate on an answer to a
  previous question rather than appropriately shift
  attention.
• Language disturbance may be manifested by
  inability to name things, difficulty articulating

• Behavioral disturbance may be groping, picking at
  bed clothes, trying to get out of bed at
  inappropriate times or when its unsafe, calling
  out, screaming cursing, muttering, moaning or
  making other sounds.
• Emotional disturbance may show anxiety, fear,
  depression, irritability, anger and even euphoria

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Behavioral Observations (cont.)

• Speech may be rambling and irrelevant, pressured,
  incoherent, with unpredictable switching from one
  thing to another
• Perceptual disturbances may include
  misinterpretations, illusions, and
  auditory/visual hallucinations

• Disorientation is most often to time and place,
  rarely to person
• Behaviors may be more pronounced at night,
  possibly d/t a decrease in sensory stimuli

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Diagnostic Criteria for Delirium Due
to(indicate general medical condition)

• Disturbance of consciousness (i.e. reduced
  clarity of awareness of the environment) with
  reduced ability to focus, sustain, or shift
  attention.
• A change in cognition (such as memory deficit,
  disorientation, language disturbance) or the
  development of a perceptual disturbance that is
  not better accounted for by a preexisting,
  established or evolving dementia.
• The disturbance develops over a short period of
  time (usually hours to days) and tends to
  fluctuate during the course of the day.
• There is evidence from the history, physical
  examination, or laboratory findings that the
  disturbance is caused by the direct physiological
  consequences of a general medical condition.
  (DSM-IV, 1994)

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Diagnostic Criteria for Substance Induced Delirium

• Criteria A, B C from Delirium due to a General
  Medical Condition
• In addition, there is evidence from the history,
  physical examination or laboratory findings of
  either (1) or (2)
• (1) the symptoms in Criteria A B developed
  during Substance Intoxication
• (2) medication use is etiologically related
  to the disturbance
• Examples are intoxication from alcohol,
  amphetamines, cannabis, cocaine, hallucinogens,
  inhalants, opioids, sedatives, hypnotic
  anxiolytics, other/unknown substance

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Diagnostic Criteria for Substance Withdrawal
Delirium

• Criteria A, B C from Delirium due to a General
  Medical Condition
• Furthermore, there is evidence from the history,
  physical or laboratory findings that the symptoms
  in Criteria A and B developed during, or shortly
  after, a withdrawal syndrome.
• Examples are withdrawal from alcohol,
  sedative, hypnotic or anxiolytic or other/unknown
  substance.

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Diagnostic Criteria for Delirium Due to Multiple
Etiologies

• Criteria A, B C from Delirium due to a General
  Medical Condition
• There is evidence from the history, physical
  examination, or laboratory findings that the
  delirium has more than one etiology (e.g., more
  than one medical condition, or a general medical
  condition plus substance intoxication, medication
  side effect and/or sensory deprivation.

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Pathophysiology

• Most affected areas of the brain are the
  prefrontal cortex, right cerebral hemisphere
  (esp. parietal) and subcortical nuclei (esp. the
  right side of the thalamus and caudate)
• Neurotransmitters involved in the pathophysiology
  of delirium include acetylcholine, dopamine and
  gamma-aminobutyric acid, which operate in the
  cortical and subcortical nervous system pathways.

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Subtypes of Delirium

• Hyperactive Characterized by hallucinations,
  delusions, agitation and disorientation (typical
  of alcohol withdrawal and anticholinergic induced
  delirium)
• Hypoactive characterized by confusion and
  sedation, rarely with perceptual disturbances
  (typical of hepatic or metabolic
  encephalopathies, acute intoxication from
  sedatives or hypoxia)
• Mixed alternating features of each

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Risk Factors

• D drug use, added drug, changed dose, substance
  intoxication, polypharmacy, opioids Dehydration
• E electrolyte and physiologic abnormalities,
  anemia, thiamine deficiency in a non-alcoholic,
  low serum albumin
• L lack of drug (withdrawal)
• I infection (esp. UTI, URI)
• R reduced/changed sensory input (blindness,
  deafness, darkness, changed surroundings,
  undiagnosed pain, recent surgery, cataracts)
• I intracranial problems (stroke, bleeding,
  meningitis, postictal)
• U urinary retention, fecal impaction, renal
  insufficiency, indwelling foley catheter
• M myocardial problems (MI, hypoperfusion,
  arrhythmia, heart failure)
• Almost any acute illness affecting any organ
  system or exacerbation of any chronic illness may
  precipitate delirium.

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Other Risk Factors or Vulnerabilities

• Meningitis
• Ictal and post-ictal states
• Drug intoxication
• UTI
• Hypoxic encephalopathy
• Metabolic problems
• Pulmonary embolism
• Pneumonia
• CHF
• Hypothermia

• Cancer
• Withdrawal from alcohol or drugs
• Anesthesia/Post-op
• Sleep deprivation
• Prescribed medications
• CVA
• Baseline cognitive impairment
• Fever
• MI

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Causes of Delirium

• Inouye, W., et.al. (1990) Albert, M. et.al.
  (1992) - 47 are multifactorial, 17 are due to
  medications, 12 are due to fluid and electrolyte
  abnormalities, 10 are due to hypoxia and/or
  hypotension
• Trzpacz, P., et.al. (1987) Miller, J., et.al.
  (1997) Schwartz, T. et.al. (2002) - 40 are due
  to fluid and electrolyte abnormalities, 40 from
  infection, 30 drug toxicity, 26 metabolic
  disorders, 24 sensory/environment problems, 14
  low perfusion
• Brietbart, W., et.al. (1997, 2002) found the
  causes of delirium varied among patients, but
  multiple etiologies were more common than single.
  The most common causes included opioid
  analgesics, corticosteroids, systemic infections,
  hypoxia, CNS spread of cancer, dehydration and
  other medications.

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Some Therapeutic Drugs Associated with
DeliriumMass. General Handbook of General
Hospital Psychiatry, 2nd ed., 1987
ACTH baclofen Acyclovir barbiturates
benztropine methyldopa Alprazolam
bromocriptine captopril cephalosporins
metronidazole Amantadine chloramphenicol
chloroquine prednisone pentazocine Aminogl
ycosides cimetidine clonidine
cyclosporine phenytoin tacrolimus Aminophyll
ine cytorabine digitalis
diisopropamide propranolol Amitriptyline
disulfuram ephedrine ergotamine
ranitidine rifampin Amphetamine
ethambutol fluorouracil gentamycin
scopolamine Amphoteracin B indomethacin
isoniazid levodopa tamoxifen Atropine
lithium lorazepam demerol
methotrexate vancomycin and many, many more
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Elderly at increased risk

• Some variables are cognitive impairment, medical
  co-morbidities, depression and alcoholism
• Risk factors include reduced serum albumin,
  multiple severe or unstable medical problems,
  dementia, polypharmacy, metabolic disturbance,
  decreased social interactions, advanced age gt 80
  yrs., infection, fractures, visual impairment,
  fever or hypothermia and psychoactive drug use

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Delirium in the Elderly (cont.)

• Poor prognosis with increased LOS and increased
  in-hospital mortality
• Delirium during hospitalization is associated
  with post-discharge functional decline in ADLs,
  persistent or progressive cognitive impairment
  (tested at 6 12 mos), and loss of independent
  community living compared with prior hospital
  functioning

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Comparison of the Clinical Features of Delirium
and Dementia
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Delirium ManagementRecognition is the single
most important step!

• Treat underlying medical disorder
• Support maintain basic vital functions
• Discontinue unnecessary medications
• Remove contributing factors
• Environmental and behavior modifiers
• Avoidance of iatrogenic complications
• Support of the patient and family
• Treat the symptoms of delirium
• Monitor for signs of recovery SE from agents
  used to reverse delirium.

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Environmental Factors and Behavioral Modifiers

• Change of surrounding
• Lighting
• Excessive noise
• Interruptions of rest/sleep
• Correct sensory impairments
• Inability to move

• Fear/anxiety
• Pain
• Visitors
• Nursing care
• Safety

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Use of antipsychotics in the treatment of delirium

• Literature scarce and devoid of randomized and
  controlled studies
• Haldol is the gold standard d/t lack of
  autonomic and hypotensive effects (may cause
  extrapyramidal or anticholinergic SE), available
  as po, IM, IV
• Atypical antipsychotics have potential utility in
  the management of delirium d/t decreased
  incidence of akathisia, EPS little information
  is available on the safety and efficacy of
  atypicals in the treatment of delirium
• Benzo monotherapy should be avoided unless
  delirium is d/t sedative or alcohol withdrawal.

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