Delirium may resemble psychiatric emergency

1
Delirium may resemble psychiatric emergency

• Yana M. Van Arsdale, MD, PhD

2
Is it delirium or psychosis?

• A 67 y/o homeless single caucasian male was
  brought to a ER by the police
• Unkempt, dirty, disheveled, and smells of urine
  and feces
• Does not look at the interviewer
• Does not respond to most of questions

3
Is it delirium or psychosis?

• Knows his name
• Does not know the date
• Can not describe the events that led to his
  admission
• Complains on tooth ache, requests Vicodin

4
Is it delirium or psychosis?

• Appears tense guarded
• Considers that it might be some conspiracy around
  him
• Denies any problems other than toothache
• Denies any drug/alcohol abuse
• Asks to let him go home

5
Is it delirium or psychosis?

• UDS amphetamine, opioids, THC
• BAC neg
• UA ketones, bacteria, leukocytes
• CBC anemia, leukocytosis
• CT head old CVA
• ECG old MI
• MMSE- 8/30, says he cant read/count

6
Definition

• Acute confusional state
• Transient global disorder of cognition
• Generalized cerebral dysfunction
• Not a disease
• A syndrome

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Definition

• Usually reversible
• Multiple causes
• Presents with wide range of neuropsychiatric
  abnormalities

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DSM-IV-TR criteria

• Disturbance of consciousness
• Reduced clarity of awareness of the environment
• Reduced ability to focus, sustain or shift
  attention

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DSM-IV-TR criteria

• A change in cognition
• Memory deficit
• Disorientation
• Language disturbance
• Perceptual disturbance

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DSM-IV-TR criteria

• Disturbance develops over a short period of time
• Hours to days
• Fluctuates during the course of the day

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DSM-IV-TR criteria

• Evidence from the
• History
• Physical examination
• Laboratory findings
• General medical condition (GMC)
• Substance intoxication/withdrawal
• Multiple etiologies

12
Hallmark of delirium

• Waxing and waning type of confusion

13
Challenge

• Delirium is often unrecognized
• Misdiagnosed
• Medical Emergency
• Mistaken for
• acute psychosis
• mania
• depression
• dementia/old age
• dissociation

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Limitations of our presentation

• Dementia
• Depression
• Epidemiology
• Physical examination
• Laboratory findings
• Tx

15
History

• Latin term meaning off track
• Was recognized by Hippocrates
• Sutton described Delirium Tremens in 1813
• Wernicke described acute encephalopathy that
  bears his name

16
Pathophysiology

• Based on the state of arousal
• 3 types are described
• Hyperactive
• Hypoactive
• Mixed

17
Hyperactive delirium

• Alcohol withdrawal
• Alcohol intoxication
• PCP intoxication
• LSD intoxication

18
Hypoactive delirium

• Hepatic encephalopathy
• Hypercapnea

19
Mixed delirium

• Daytime sedation
• Nocturnal agitation
• Sundowning phenomena

20
Mechanism

• Not understood
• Reversible cerebral oxidative metabolism
• Multiple transmitter abnormalities

21
Acetylcholine

• Crucial neurotransmitter
• Decreased activity in the brain
• Anticholinergic activity is increased
• Alzheimer disease particular susceptibility

22
Acetylcholine

• Too many prescribed medications with
  anticholinergic activity most common cause
• Rx Physostigmine salicylate (Antilirium) 1-2 mg
  IV/IM Q15-30 Tx of anticholinergic toxicity

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Neurotransmitters

• Norepinephrine
• Alcohol withdrawal
• Serotonin
• Sepsis
• SSRI
• LSD
• Hepatic encephalopathy

24
Neurotransmitters

• Dopamine relieve with antipsychotic Tx
• Glutamate
• GABA
• Hepatic encephalopathy increase
• Benzodiazepine/alcohol withdrawal - decrease

25
Other mechanisms

• Circadian rhythms disruption
• Cortisol
• Beta endorphines
• Exogenous glucocorticoids

26
Other mechanisms

• Cytokines interleukin-1 (endogenous pyrogen)
  -6
• Head trauma
• Ischemia
• Toxins
• Infection

27
Other mechanisms

• Sleep deprivation
• Psychosocial stress in brain compromise

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Neuroanatomy

• Reticular formation (RF) of the brainstem
• Area regulates
• attention
• arousal
• Locus ceruleus its noradrenergic neurons
  alcohol withdrawal

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Pathway

• Dorsal tegmental
• Projects from the mesencephalic RF to the
• tectum
• thalamus

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Differential Dx

• Schizophreniform DO
• Schizophrenia
• Brief psychotic DO
• Manic episode
• Depressive episode
• Dissociative DO
• Factitious DO
• Malingering

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DDx Factitious DO/ Malingering

• Inconsistency of mental status
• Different behavior without supervision
• Secondary gain/ assuming sick role
• Intentionally produced

32
DDx Schizophreniform DO

• Delusions/hallucinations
• more constant
• better organized
• Level of consciousness / arousal unchanged
• Orientation no change

33
DDx Schizophreniform DO

• VH/ tactile not typical
• Thought disturbances
• loose associations
• tangentiality
• derailment

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Treatment

• Underlying cause
• Precautions, including 1on 1 supervision
• Environmental modification
• Reorientation techniques
• Memory cues
• Family member present
• Explanation of procedures

35
Treatment

• Avoid
• Overstimulation
• Sensory deprivation (black-patch delirium)
• Physical restraints

36
Treatment

• Restraints aggression/agitation
• Chemical
• Physical
• Minimize pharmacotherapy
• Discontinue as many medications as possible
• Sleep
• Fluid nutrition

37
Treatment

• Medical Evaluation
• conclusive - admission
• inconclusive - observation

38
Special concerns

• Alternative medicine products use
• Herbs use / abuse
• Jimson weed
• Mandrake
• Henbane
• Detailed drug/medications Hx imperative
• Delirium may be the ONLY presenting symptom

39
Complications

• Wandering getting lost
• Falls combative behavior injuries
• Seizures
• Malnutrition, fluid electrolyte abnormalities
• Aspiration pneumonia
• Pressure ulcers
• Decreased function mobility

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Prognosis

• Worse
• Poor premorbid cognitive functioning
• Previous Hx delirium
• Brain disease
• Multiple causes / risk factors
• Old age
• Better
• High premorbid cognitive functioning

41
Family/Pt Education

• Etiology course
• Result of medical condition or substance
• Rapid fluctuation of mental condition
• Reversible / temporary most cases
• Risk factors prevention in a future

42
Family/Pt Education

• Out of proportion with premorbid behavior
• Visit the Pt
• One at a time
• Provide reorientation
• Familiar objects (photos, decorations, etc)
• Avoid overstimulation

43
Prevention

• Should be the goal
• High risk close monitoring
• Multicomponent intervention
• Sleep deprivation
• Medical conditions
• Cognitive impairment, etc
• Prescribing practices avoid polypharmacy

44
Legal pitfalls Failure to

• Recognize alcohol withdrawal in the Pt with
  altered mental status (AMS) /or abnormal vital
  signs
• Tx the Pt with AMS
• Exclude other etiologies of delirium
• Admit

45
Legal pitfalls

• Determining whether the PT has the capacity to
  make informed decision
• Capacity is usually not globally impaired unless
  impairment is severe
• Competence is a legal term, determined by the
  judge, not the physician

46
Legal pitfalls

• Surrogate decision-making laws - differ from
  state to state
• Elopement precautions must be taken (The Pt
  might be lost or/ injured)
• Fall / Suicide precautions
• Leaving the hospital AMA - urgent legal assistance