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Delirium

Lea C. Watson, MD, MPHRobert Wood Johnson Clinical Scholar

UNC Department of Psychiatry

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Nurse pages med student:

..Mr. Smith pulled out his NG tube and cantseem to sit still. Last night after his surgeryhe was fine, reading the paper and talking to

his familytoday I dont even think heknows where he is can you come seehim?

Med student says:sounds like DELIRIUM - good thing youcalled- Ill be right there.

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Delirium

A sudden and significant decline in mental functioning not better accounted for by a preexisting or evolving dementia

Disturbance of consciousness with reducedability to focus, sustain, and shift attention

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4 major causes

Underlying medical condition Substance intoxication Substance withdrawal Combination of any or all of these

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Patients at highest risk

Elderly >80 years

demented multiple meds

Post-cardiac surgery

Burns Drug withdrawal AIDS

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Prevalence

Hospitalized medically ill 10-30% Hospitalized elderly 10-40% Postoperative patients up to 50% Near-death terminal patients up to 80%

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Clinical features

ProdromeFluctuating course

Attentional deficitsArousal /psychomotor disturbanceImpaired cognition

Sleep-wake disturbanceAltered perceptionsAffective disturbances

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Prodrome

Restlessness Anxiety Sleep disturbance

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Fluctuating course

Develops over a short period (hours to days) Symptoms fluctuate during the course of the

day ( SYMPTOMS WAX AND WANE ) Levels of consciousness Orientation

Agitation Short-term memory Hallucinations

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Attentional deficits

Easily distracted by the environment

May be able to focus initially, but will not be able to sustain or shift attention

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Arousal/psychomotor disturbance

Hyperactive (agitated, hyperalert) Hypoactive (lethargic, hypoalert) Mixed

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Impaired cognition

Memory Deficits Language Disturbance Disorganized thinking Disorientation

Time of day, date, place, situation, others, self

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Sleep-wake disturbance

Fragmented throughout 24-hour period Reversal of normal cycle

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Altered perceptions

Illusions Hallucinations

- Visual (most common)- Auditory

- Tactile, Gustatory, Olfactory Delusions

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Affective disturbance

Anxiety / fear Depression Irritability Apathy

Euphoria Lability

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Duration

Typically, symptoms resolve in 10-12 days- may last up to 2 months

Dependent on underlying problem andmanagement

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Outcome

May progress to stupor, coma, seizures ordeath, particularly if untreated

Increased risk for postoperativecomplications, longer postoperativerecuperation, longer hospital stays, long-

term disability

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Outcome

Elderly patients 22-76% chance of dyingduring that hospitalization

Several studies suggest that up to 25% of all patients with delirium die within 6 months

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Causes: I WATCH DEATH

I nfections W ithdrawal A cute metabolic T rauma C NS pathology H ypoxia

D eficiencies E ndocrinopathies A cute vascular T oxins or drugs H eavy metals

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I WATCH DEATH

CNS pathology : hemorrhage, seizures,stroke, tumor (dont forget metastases)

Hypoxia : CO poisoning, hypoxia, pulmonary or cardiac failure, anemia

Deficiencies : thiamine, niacin, B12 Endocrinopathies : hyper- or hypo-

adrenocortisolism, hyper- or hypoglycemia

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I WATCH DEATH

Acute vascular : hypertensiveencephalopthy and shock

Toxins or drugs: pesticides, solvents,medications, (many!) drugs of abuse

anticholinergics, narcotic analgesics, sedatives

Heavy metals: lead, manganese, mercury

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Drugs of abuse

Alcohol Amphetamines

Cannabis Cocaine Hallucinogens

Inhalants

Opiates Phencyclidine (PCP)

Sedatives Hypnotics

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Causes

44% estimated to have 2 or more etiologies

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Workup

History Interview- also with family, if available Physical, cognitive, and neurological exam Vital signs, fluid status Review of medical record

Anesthesia and medication record review -temporal correlation?

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Mini-mental state exam

Tests orientation, short-term memory,attention, concentration, constructional

ability 30 points is perfect score < 20 points suggestive of problem Not helpful without knowing baseline

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Workup

Electrolytes CBC EKG CXR EEG- not usually necessary

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Workup

Arterial blood gas or Oxygen saturation Urinalysis +/- Culture and sensitivity Urine drug screen Blood alcohol Serum drug levels (digoxin, theophylline,

phenobarbital, cyclosporin, lithium, etc)

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Workup

Arterial blood gas or Oxygen saturation Urinalysis +/- Culture and sensitivity Urine drug screen Blood alcohol Serum drug levels (digoxin, theophylline,

phenobarbital, cyclosporin, lithium, etc)

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Workup

Consider:- Heavy metals- Lupus workup- Urinary porphyrins

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Management

Identify and treat the underlying etiology Increase observation and monitoring vital

signs, fluid intake and output, oxygenation,safety Discontinue or minimize dosing of

nonessential medications Coordinate with other physicians and

providers

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Management

Monitor and assure safety of patient andstaff

- suicidality and violence potential- fall & wandering risk- need for a sitter

- remove potentially dangerous items fromthe environment- restrain when other means not effective

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Management

Assess individual and family psychosocialcharacteristics

Establish and maintain an alliance with thefamily and other clinicians Educate the family temporary and part of

a medical condition not crazy Provide post-delirium education and

processing for patient

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Management

Environmental interventions- Timelessness - Sensory impairment (vision, hearing)- Orientation cues- Family members- Frequent reorientation- Nightlights

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Management

Pharmacologic management of agitation- Low doses of high potency neuroleptics

(i.e. haloperidol) po, im or iv- Atypical antipsychotics (risperidone)- Inapsine (more sedating with more rapid

onset than haloperidol im or iv only monitor for hypotension)

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Management

Haloperidol and inapsine have beenassociated with torsade de pointes and

sudden death by lengthening the QTinterval; avoid or monitor by telemetry ifcorrected QT interval is greater than 450

msec or greater than 25% from a previousEKG

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Management

Benzodiazepines- Treatment of choice for delirium due to

benzodiazepine or alcohol withdrawal

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Management

Benzodiazepines- May worsen confusion in delirium- Behavioral disinhibition, amnesia, ataxia,

respiratory depression- Contraindicated in delirium due to hepatic

encephalopathy

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What we seecommon cases

Homeless male, hx. ETOH abuse, 2 days post-op

82 year-old women with UTI Burn victim after multiple med changes Mildly demented 71 year-old after hip

replacement

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Summary

Delirium is common and is often a harbinger ofdeath- especially in vulnerable populations

It is a sudden change in mental status, with a fluctuating course, marked by decreased attention It is caused by underlying medical problems, drug

intoxication/withdrawal, or a combination Recognizing delirium and searching for the cause

can save the patients life