Delirium'

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Delirium.

• Int ???
• 95.01.12

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Definition.

• Hallmark symptom of delirium is an impairment of
  consciousness.
• Usually accompany by global impairment of
  cognitive functions
• General associated with emotional
  lability,hallucinations or illusion and
  inappropriate,impulsive,irrational or violence
  behavior.

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Epidemiology.

• Common among hospitalized patients about 10 of
  all hospitalized patients.
• 20 of Pt with burns
• 30 of ICU patients.
• 30 of hospitalized AIDS Pt.

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• Very young and elderly pts are more susceptible
  to delirium.
• Pt with Hx of delirium or brain damage are more
  likely to have an episode of delirium than the
  general population.

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Etiology.

• Delirium may be thought of as a common pathway
  for any brain insult.
• Major causes including systems disease(cardiac
  failure)CNS disease(seizure)and either
  intoxication. With or withdrawal from prescribed
  pharmacological agents or drug of abuse.

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• Delirium is thought to involve dysfunction of the
  reticular formation and acetylcholine
  transmission.
• The dorsal tegmental pathway projecting from the
  reticular formation to the tectum and the
  thalamus has been implicated as the major pathway
  in delirium.

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• Noradrenergic hyperactivity of the locus ceruleus
  has been associated with alcohol withdrawal
  delirium.

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Diagnosis,signs and symptoms

• Delirium due to a medical condition.
• Substance intoxication delirium.
• Substance withdrawal delirium
• Delirium NOS

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• Key features including altered consciousness with
  hyperarousal or hypoarousal with agitation or
  apathy

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• disorientationmemory impairmentillogical
  speechperceptual disturbances,including AH,VH
  and tactile hallucination.

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• Severe emotional labilityand reversed sleep-wake
  cycle or fragmented sleep.
• Associated neurological symptoms may include
  incoordination,dsyphasia,tremor,
  asterixis,ataxia, and apraxia.

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Lab. tests

• The workup should include vital sign,CBC and
  DC,e-,complete blood chemistries,liver and renal
  function tests,urinalyusis,urine
  toxication,ECG,chest roentgenograpy,CT of the
  head and lumber puncture(if indicated).
• The EEG showed diffuse slowing throughout or
  focal area of hyperactivity.

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Differential diagnosis
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• Dementia.
• Schizophrenia and mania.
• Dissociated disorder.

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Course and prognosis.

• Three months mortality rate of 23-33 in
  patients who have an epsiode of delirium
• 1 yeas mortality rate of 50
• The course is usually rapid.

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• Symptoms usually recede 3 to 7 days after the
  causable factor is treatsymptom resolution may
  take 2 weeks.
• In some case,the delirium may spontaneously clear.

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Treatment.

• Identify the underlying cause.
• Correct metabolic abnormalities
• Ensure proper hydration.
• Electrolyte balance,and nutritionidentify and
  where possible discontinue causative
  medicationoptimize the sensory environment for
  the pt.

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• Low doses of a high potency antipsychotic may be
  used for agitation(eg 2 to 5 mg haloperidol
  orally or IM every 4 hr)
• BZD(eg 1 to 2 mg ativan every 4 hr)can be used
  orally or IM every 4 hr as need and can also be
  used for agitation,especially in pt who may be
  at risk of seizure(eg a pt suffered form alcohol
  or sedative-hypnotic withdrawal).