Delirium

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Delirium

• Danielle Hansen, DO
• August 16, 2006

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Objectives

1. The physician will identify common causes of
   delirium.
2. The physician will know how to evaluate patients
   with delirium.
3. The physician will know how to treat delirium.

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Definition

1. Disturbance of consciousness and attention
   difficulties.
2. Change in cognition or development of perceptual
   disturbance.
3. Onset over short time and fluctuates during the
   course of the day.
4. Caused by medical condition, substance
   intoxication, or medication side effect.

DSM-IV
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Epidemiology
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Epidemiology

• Prolonged Hospitalizations
• Functional Decline
• High Risk of Institutionalization
• Mortality 14 and 22 at one month and at six
  months, respectively
• Cole and Primeau, 1993

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Pathogenesis

• Structural Brain Lesions
• Global Cortical Functional Impairment
• Neurotransmitter Dysfunction
• Cytokine Activation

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Structural Brain Lesions

• Ascending Reticular Activating System
• Arousal and Attention
• Parietal and Frontal Lobes
• Attention
• Frontal Lobe
• Insight and Judgment

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Global Cortical Functional Impairment
Normal EEG
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Global Cortical Functional Impairment

• Slowing of dominant alpha rhythm
• Abnormal slow wave activity

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Neurotransmitter Dysfunction

• Acetylcholine
• Neuropeptides
• (ie. Somatostatin)
• Endorphins
• Serotonin
• Norepinephrine
• GABA

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Risk Factors

• History of Dementia or Brain Disease
• Advanced Age
• Sensory Impairment
• Polypharmacy
• Dehydration/Malnutrition
• Immobility
• Infection
• Bladder Catheters

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Causes

• Toxins
• Metabolic Derangements
• Brain Disorders
• Systemic Organ Failure
• Physical Disorders

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Toxins

• Drugs
• Prescription Medications
• Drugs of Abuse
• Infection
• Poisons

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Metabolic Derangements

• Electrolyte Disturbance
• Endocrine Disturbance
• Hyper/Hypoglycemia
• Hypercarbia/Hypoxemia
• Inborn Errors of Metabolism
• Nutritional Deficiencies

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Brain Disorders

• CNS Infections
• Seizures
• Head Injury
• Hypertensive Encephalopathy
• Psychiatric Disorders

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Systemic Organ Failure

• Cardiac
• Hematologic
• Liver
• Pulmonary
• Renal

Icteric sclera
Cyanosis
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Physical Disorders

• Burns
• Electrocution
• Hyper/Hypothermia
• Trauma

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Evaluation

• History
• Physical Exam
• Neurologic Exam
• Diagnostic Instruments
• Medication Review
• Laboratory Testing
• Neuroimaging
• Lumbar Puncture
• EEG

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Confusion Assessment Method
Feature Assessment
1. Acute onset and fluctuating course Usually obtained from a family member or nurse and shown by positive responses to the following questions Is there evidence of an acute change in mental status form the patients baseline? Did the abnormal behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?
2. Inattention Shown by positive response to the following Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?
3. Disorganized thinking Shown by positive response to the following Was the patients thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?
4. Altered level of consciousness Shown by any answer other than alert to the following Overall, how would you rate this patients level of consciousness? Alert/vigilant/lethargic/stupor/coma.
The diagnosis of Delirium requires the presence
of features 1 AND 2 plus 3 OR 4.
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Principles of Prevention and Treatment

1. Avoid aggravating or causative factors.
2. Identify and treat underlying acute illness.
3. Provide supportive and restorative care to
   prevent further physical and cognitive decline.
4. Control dangerous and disruptive behaviors.

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Supportive Care

• Limit number of room changes
• Glasses, hearing devices
• Orienting stimuli
• Hydration/nutrition
• Mobility
• Pain management

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Behavior Management

• Constant observation
• Frequent reassurance and reorientation
• Physical restraints

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Psychotropic Medications

• Haloperidol 0.5-1mg PO/IV/IM
• Low incidence of hypotension or sedation
• Onset of action 30-60 minutes (IM/IV)
• Extra pyramidal side effects
• Lorazepam 0.5-1mg
• Onset of action 5 minutes (IV)
• Worsen confusion and sedation
• Atypical Antipsychotics
• Increase risk of CV events and mortality

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Competency Exam

• 78 y/o white male is brought to the ER from an
  ECF via EMS for reports of mental status change.
  Upon arrival in the ER, the patient is found to
  be pleasantly confused, AO x 1. His vital signs
  are BP 106/70, P 96, R 16, T 96.0. The patient
  is unable to provide a full history but records
  from the ECF accompany him and his daughter
  arrives at the ER shortly after the patient. His
  PMHx is significant for HTN, Afib, DM, OA.

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• All of the following are included in your initial
  work up of this patient except
• A. CBC, CMP
• B. U/A CS
• C. Chest X-ray
• D. Accucheck
• E. Psych Eval

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E. Psych Eval
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• Which of the following could be the etiology of
  this patients mental status change?
• A. Opiate analgesics
• B. Parietal lobe CVA
• C. Urinary Tract Infection
• D. Electrolyte Abnormalities
• E. All of the Above

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E. All of the Above
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• 3. Your workup reveals a urinary tract
  infection. The patient is admitted to the
  general medical floor. At 1100PM, the nurse
  calls you stating the patient is combative and
  has pulled out his IV. After the behavior
  modification failed, you order
• A. Ativan 0.5mg
• B. Haldol 0.5mg
• C. Risperdal 1mg
• D. Soft Wrist Restraints
• E. Pysch Consult

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B. Haldol