Acute delirium

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Acute delirium

• R1 ???
• ???? ???
• 2008/09/22

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EPIDEMIOLOGY

• Nearly 30 percent of older medical patients
  experience delirium at some time during
  hospitalization.
• Among older surgical patients, the risk for
  delirium varies from 10 to greater than 50
  percent
• Signs of delirium may persist for 12 months or
  longer, particularly in those with underlying
  dementia
• Over 40 percent of patients referred to a
  consulting liaison psychiatrist for the
  evaluation or treatment of depression ultimately
  were found to have delirium

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Characters of acute delirium

• Disturbance of consciousness with reduced ability
  to focus, sustain, or shift attention.
• A change in cognition 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 a medical condition,
  substance intoxication, or medication side
  effect.

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Uptodate 2008
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Uptodate 2008
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Evaluation

• Fluid and electrolyte disturbances
• Infections
• Drug or alcohol toxicity
• Withdrawal from alcohol
• Withdrawal from barbiturates, benzodiazepines,
  and selective serotonin reuptake inhibitors
• Metabolic disorders (hypoglycemia, hypercalcemia,
  uremia, liver failure, thyrotoxicosis)
• Low perfusion states (shock, heart failure)
• Postoperative states, especially in the elderly

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LAB

• Serum electrolytes, creatinine, glucose, calcium,
  complete blood count, and urinalysis
• Drug levels (digoxin, litheium, quinidine )
• Blood gas
• Lumbar puncture 
• EEG testing  (Exclude seizures, metabolic
  encephalopathies, or infectious encephalitides )

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Treatment

• Treat underlying disorders
• Supportive care
• Managing behavior (esp agitation and combative
  behavior, falling, wandering off, or
  inadvertently removing intravenous lines )
• Psychotropic medications

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Psychotropic medications

• Low dose Haloperidol
• Resperidone, Quetiapine, Olanzapine
• Extrapyramidal side effects were higher in
  patients treated with high-dose haloperidol
  (gt4.5mg per day)
• Benzodiazepines (eg, lorazepam 0.5 to 1.0 mg)
  have a more rapid onset of action, but they
  commonly worsen confusion and sedation

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Thanks for your attention!