DELIRIUM

1
DELIRIUM

• Daniel W. Hicks MD DFAPA, FAPM
• Associate Professor, Psychiatry
• Director, Psychosomatic Medicine

2
Definition

• Disturbance of Consciousness with reduced ability
  to sustain or shift attention
• Change in cognition or perceptual disturbance (
  ie hallucinations or delusions)
• Develops over hours to days
• Evidence form history, physical exam, or labs
  that there is a direct physiological cause

3

• Encephalopathy
• Acute brain failure
• Normal delirium after head injury ( ie
  football game), post-op, waking up from coma
• Usually reversible

4
Subtypes

• Hypoactive subdued, quiet, confused, may answer
  simple questions, cant eat
• Hyperactive agitated, restless, pulling out
  lines, trying to get up
• Mixed some elements of each or alternating

5
Risk Factors

• Hospitalization
• Elderly
• Brain damaged dementia, traumatic brain injury,
  seizure, stroke, tumor, retardation
• Multiple illnesses and multiple meds
• Liver or renal disease
• Post-surgical and burns

6
Mortality

• Fairly low if able to treat underlying cause
  quickly and reverse delirium
• ? Due to underlying medical disease that causes
  delirium being life-threatening
• ? Due to neurochemical, hormonal, and
  immunological changes caused by delirium itself

7
Mortality (Cont.)

• High mortality in those whose delirium does not
  resolve completely (25-33)
• Often sign of underlying brain disease
• Significant mortality in follow-up of elderly
  patients, controlling for other factors
• Higher costs due to delirium (16,000-64,000/patie
  nt) with 38-152 billion cost to health care
  system

8
Diagnosis

• Clinical Signs and Symptoms
• Slowing on EEG
• Mini-Mental Status Exam
• Clock-Drawing
• Memorial Delirium Scale (MDAS)

9
Mnemonic I WATCH DEATH

• Infection
• Withdrawal (Alcohol, Sedatives)
• Acute Metabolic ( hyponatremia, uremia, liver
  failure, hypo or hyper glycemia, electrolyte or
  acid-base abnormalities
• Trauma
• CNS Pathology
• Hypoxia (Anemia, COPD, Cardiac, CO)
• Deficiencies Vitamin B-12, folate
• Endocrinopathies
• Acute Vascular
• Toxins or Drugs
• Heavy Metals

10
Assessment

• History and Mental Status
• Physical and Neurological
• Review of medication, including anesthesia
• Labs CBC, electrolytes, glucose, liver and
  kidney function, Ca, Phos, Mg, TP, Alb, B-12,
  Folate, RPR, TSH, Tox screen
• O2 Sat or ABG and EKG
• Serum drug levels
• Urinalysis and CS, Chest X-ray, Blood cultures

11
Additional Tests If Indicated

• HIV, ANA, LE, Heavy metals
• CT/MRI
• EEG
• LP

12
Treatment

• Non-Pharmacologic
• Preventive
• Education of patient and care-giver
• Adequate nutrition and hydration
• Adequate sleep normalize sleep/wake cycle
• Address sensory and cognitive impairment
• Assure safety
• Use family, friends or sitters consistent staff
  if possible
• Orientation cues calendars, night lights,
  pictures
• Minimize unnecessary noise
• Eyeglasses and hearing aids if needed
• Physical restraints are last resort to keep
  patient from pulling out lines, airways, hitting
  staff, trying to get out of bed
• Should be used with sedation inhuman to restrain
  someone who is awake and alert

13
Treatment

• Pharmacologic
• Avoid benzos, opiates, anticholinergic meds,
  steroids
• Benzos only indicated for alcohol or sedative
  withdrawal with impaired brain, cause
  disinhibition and increased confusion
• Fentanyl and Propofol often used for sedation,
  cause rebound delirium, confusion
• Maldonado dexmedetomidine (Precedex)causes only
  5 delirium compared to propofol 54 and fentanyl
  46

14
Treatment

• Haloperidol IV is still treatment of choice
  (handout) start low, then double, can add
  lorazepam
• Less likely to cause dystonia or EPS in IV form
• Can cause Torsades, monitor daily EKGs and stop
  if approach 500 QTC
• Has been used in continuous drip up to 1,000
  mg/24hours!

15
Treatment

• Medication do not reverse delirium, just help
  with symptoms until underlying cause(s) are found
  and treated
• Atypical antipsychotics give us many more choices
• Zyprexa (Olanzapine) sedating, can give 5-10
  mg. up to max of 30 mg./day can be given Zydis
  or IM (not on formulary)
• Leads to weight gain, diabetes in chronic use
• Seroquel (Quetiapine) least D2 blockade (less
  NMS, EPS), very sedating, can give 25-50-100 mg.
  every 6 hours up to 800 mg.24 hours
• Main drawback is sedation and orthostasis, some
  QTC change

16
Treatment

• Geodon (Ziprasidone) can be given IM 10mg, max
  20 mg. in 24 hours. Calming, not that sedating,
  watch QTC
• Risperidal(Risperidone) Discmelt and liquid as
  well as tabs, 0.5-1.0 mg up to 6 mg/day. More
  potent for confusion or psychosis, less sedating
  for agitation
• Abilify (aripiprazole) dopamine agonist and
  antagonist, generally not that helpful for
  delirium, but now available in IM form which can
  help with agitation

17
DECISION-MAKING CAPACITY

• Competency is a legal determination
• Decision-making capacity is a medical
  determination, based on patients ability to make
  rational decisions about specific medical care or
  refusal of care
• Life-threatening situation, doctors provide care
  without consent
• Emergency situation, two physicians can determine
  patient has impaired decision-making
• At Georgetown, if not emergency, generally
  psychiatry called to evaluate patient

18
Decision-Making Capacity

• Able to hear and understand the risks and
  benefits of the procedure, treatment, etc.
  alternative treatments, if any, and risk of no
  treatment or refusal
• Able to manipulate and process this information
  in a rational manner and demonstrate this
• Able to communicate that they have understood,
  processed rationally and made a clear choice

19
Decision-Making Capcity

• If family members available, they become the
  medical decision-maker by default, unless there
  is an advance directive giving authority to
  someone else
• Each jurisdiction has a different order for
  decision maker, ie spouse, parent, adult
  children, siblings, etc.
• If no family or decision-maker, must turn to
  court for emergent or long-term guardian to decide

20
Testing Decision-Making