Delirium

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Delirium

• Supischa Theerasasawat

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Definition

• an acute mental status change, fluctuating
  course, and abnormal attention

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Clinical characteristics of delirium

• Acute onset of mental status change with
  fluctuating course
• Attentional deficits
• Disorganized thinking
• Altered level of consciousness
• Perceptual disturbances
• Disturbed sleep-wake cycle
• Altered psychomotor activity
• Disorientation and memory impairment
• Other cognitive deficits behavioral and emotional
  abnormalities

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Perceptual disturbances

• Hallucination- most common visual vivid, 3D,
  full color auditory voices commenting unusual

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Disturbed sleep-wake cycle

• Excessive daytime drowsiness and reverse diurnal
  rhythm
• Sundowning restless and cofusion during night

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Disorientation and memory impairment

• Recent memory is disrupted in large part by the
  decreased registration caused by attentional
  problems
• Capgras' syndrome - a familiar person is
  mistakenly thought to be an unfamiliar impostor.

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Mechanic of writing
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PATHOPHYSIOLOGY

• Brain areas involved in attention
• Anterior cingulate gyrus
• Prefrontal cortex
• Temporoparietal junction
• Thalamus
• Upper brainstem

• Cholinergic-dopaminergic imbalance
• Cholinergic deficit
• Dopamine inhibit Ach
• Cytokine alter BBB

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DSM-IV criteria

• 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 pre-existing, established, or
  evolving dementia
• The disturbance develops over a short period 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 the direct physiological
  consequences of a general medical condition

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Confusion Assessment Method

• Acute change in mental status
• AND
• Inattention/fluctuation
• PLUS
• Disorganized thinking
• OR
• Altered level of consciousness
• Sensitivity 94-100
• Specificity 90-95

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Delirium Cognitive Evaluation

• MMSE
• inaccurate tool to diagnose delirium as the
  patient
• fluctuates
• has poor attention/concentration
• helpful tool to demonstrate improvement in
  cognitive status when following patient.

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Predisposing factors

• Vision impairments
• Severity of illness
• Cognitive impairment
• Dehydration

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Precipitating factors

• Physical restraints
• Malnutrition
• Indwelling bladder catheter
• Add gt3 medications within 24 h.
• Iatrogenic medical complication

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Finding the Cause of Delirium

• I Infections UTIs, pneumonia, encephalitis,
  etc.
• W Withdrawal alcohol, benzodiazepines,
  sedative-hypnotics
• A Acute electrolyte disturbance,
  dehydration, acidosis / alkalosis,
  hepatic/renal metabolic failure
• T Toxins, drugs opiates, salycilates,indometha
  cin, dilantin
• C CNS pathology stroke, TIA, tumors,
  seizures, hemorrhage, infection
• H Hypoxia anemia, pulmonary/cardiac
  failure, hypotension
• D Deficiencies Thiamine (with alcohol
  abuse), B12
• E Endocrine thyroid, hypo/hyperglycemia,
  adrenal dysfunction, hyperparathyroid
• A Acute vascular shock, hypertensive
  encephalopathy
• T Trauma head injury, post-operative,
  hypo/hyperthermia
• H Heavy Metals lead, mercury, manganese
  poisoning

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Delirium Management

• Address immediate safety
• Investigate cause
• Identify and remove or treat underlying cause
• Medications to be used only if necessary

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Delirium Nonpharmacological Management

• Provide general supportive measures
• Avoid restraints
• Encourage familiar faces for reassurance
• Fluids, nutrition
• Low stimulation
• Provide orientation
• Correct sensory impairment

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Delirium Pharmacological Management

• Principles
• 1. Use a SINGLE medication
• 2. Start with a low dose
• 3. Choose a drug with low anticholinergic
  activity
• 4. Try to stop the medication as soon as
  possible
• 5. Continue to use Non-Pharmacological
  interventions.

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Delirium Pharmacological Management

• HALDOL
• try to only use for SEVERE agitation
• lowest anticholinergic activity of all major
  neuroleptics
• high potency
• can be used IM/IV
• start with 0.5 - 1 mg initial dose, gradually
  titrating to a maximum of 4 mg/day
• Repeat dose q 2-4 h
• Taper the dose as soon as possible
• Avoid in individuals with Parkinsons Disease

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Benzodiazepines

• May cause distribution/increased agitation.
• Best reserved for Delirium 2o to alcohol /
  Benzodiazepine withdrawal.
• Relatively contraindicated in Delirium from
  Hepatic Encephalopathy.

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Atypical Antipsychotics

• Risperidone, Olanzepine, quetiapine
• low dose Risperidone starting at .25 mg BID
• Olanzapine - 2.5 mg/d as starting dose
• Quetiapine - 12.5 mg/d starting dose

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Pseudodementia
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