DELIRIUM

Delirium: Synonyms

Acute confusional state Acute organic brain syndrome Acute brain failure Acute toxic psychosis

Case - Delirium
79 year old lady lives alone, manages own apartment slightly forgetful (according to daughter) 7 months ago: started slowing down losing interest; insomnia Rx Amitriptyline/Oxazepam

79-year-old lady

PMed Hx: HTN Meds: Hydrochlorothiazide 25 mg OD Amitriptyline 50 mg qhs Oxazepam 15-30 mg qhs

79-year-old lady
One week prior to hospitalization

c/o pain in right knee O/E slightly swollen

prescribed: Naproxen 250 mg BID

79-year-old lady

Tripped on rug, sustained a hip fracture Brought to hospital. Spent 12 hours in ER ORIF the following day 1st POD climbing over bedrails shouting all night sleeping in day pulling out her IVs

Delirium
All Confusion is Not Dementia Always Consider Delirium

Delirium - Is Often Missed

43% of cases unrecognized by RNs 32%-66% of cases unrecognized by MDs

Epidemiology in Elderly
Prevalence :

Hospitalized Medically Ill ER In Hospital

10 - 30% 10 -18% 10 - 36%

Incidence:

Post-operatively
Cardiac Surgery Orthopedic

up to 50%
17 - 73% 28 - 52%

Delirium In Hospital Prognosis

Course: Can be quite variable Prevalence: Typical Range Lasting > 30 days Increased

10-12 days 1-8 weeks 15% LOS Discharge to LTC Hospital cost

Delirium: Prognosis
25-33%

40%

25%
Recovery Permanent Cognitive Impairment Mortality

Delirium: Prognosis

Following recovery, annual incidence

of dementia 20%

Increased Institutionalization rate

Delirium: Prognosis

Delirium may serve as a marker for future

cognitive decline

Patients need to be FOLLOWED for the

development of dementia.

Delirium (DSM-IV)
A: Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention B: Change in cognition (eg. memory deficit, disorientation, language disturbance) or development of a perceptual disturbance not due to pre-existing, established or developing dementia C: The disturbance develops over a short period of time (hours to days) and tends to fluctuate during the course of the day. D. Evidence of aetiology

Delirium: Cognitive Evaluation

Interview patient and caregiver to determine if any acute changes in

mental status or behaviour

Confusion Assessment Method

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%

Ann Intern Med. 1990; 113:941 Arch Intern Med. 1995; 155:301

Confusion Assessment Method

1. 2. 3. 4. 5. 6. 7. 8. 9. Acute change in mental status? Disorganized thinking? Altered level of consciousness? Inattention/fluctuation? Psychomotor agitation/retardation? Perceptual disturbance? Disorientation? Sleep wake cycle altered? Memory impairment? Least Important
Most Important

Ann Intern Med. 1990;113:941

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.

Comparative Features of Delirium and Dementia

ONSET DURATION ATTENTION LOC SPEECH Delirium develops abruptly brief, hours to days impaired fluctuating incoherent, disorganized Dementia develops slowly chronic, months to yrs normal, except in severe cases clear ordered anomic/aphasic

NOTE: Disorientation and memory impairment may be present with both

Delirium - Core Features

Acute onset and fluctuating course

Inattention; Easily distractible Disorganized thinking

Altered level of consciousness

Spectrum Of Delirium
Spectrum of Psychomotor Activity :

HYPOACTIVE delirium (lethargy, excess somnolence, sluggish) Individuals often not recognized as they may not cause a disturbance so they dont get ATTENTION

Spectrum Of Delirium

HYPERACTIVE delirium
(agitated, hallucinating, inappropriateness)

MIXED - combination of both

Delirium: Signs

Restlessness, agitation
Picking at the air/clothes...

Myoclonus (often multifocal)

Asterixis (suggests a metabolic cause) Hallucinations (usually visual, tactile)

Major Risk Factors for the Development of Delirium

Dementia Pre-existing Cognitive Decline

Delirium (in Hospitalized Elderly pts)

Dehydration Severe illness Vision Impairment

Causes of Delirium: A Checklist

D: E: M: E: N: T: I: A: Drugs anticholinergics, ETOH Endocrine BS, Na, Ca, Mg, cortisol, etc. Metabolic organ failure, hypoxia, etc. Epilepsy or seizures postictal status Neoplasm especially SIADH, CNS Trauma concussion, surgery Infection any Apoplexy any vascular event MI, PE, CVA

Finding the Cause of Delirium

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

Medications Associated with Delirium

Any drug can potentially cause confusion

Take a careful history of any new drug STARTED or any old drug STOPPED recently

Medications Associated with Delirium

Sedatives - hypnotics; Benzodiazepines - toxicity or withdrawal Narcotics - especially Demerol Anticholinergics Antihistamines eg. Gravol Tricyclic antidepressants eg. Amitriptyline Antiparkinsonian agents Cardiac eg. Digitalis Miscellaneous H2 blockers Lithium Steroids Anticonvulsants Metoclopramide NSAIDs eg. Indocid

Drugs with Anticholinergic Activity

Tricyclic Antidepressants eg. Amitriptyline, Doxepin, Imipramine Dimenhydrinate (Gravol) Ditropan Cogentin Anti-Parkinsonian Drugs eg. Artane/Kemedrin

Medications Associated with Delirium

Herbal/over the counter drugs Cimetidine Cough/Cold Remedies Gravol Sleeping medications eg. Nytol...

Miscellaneous Causes of Delirium

Pain
Fecal Impaction Urinary Retention

Alcohol Intoxication or withdrawal

Delirium: Evaluation

It is a clinical diagnosis
It requires a COMPREHENSIVE ASSESSMENT

Delirium: Etiology

Good Physical Exam Assess Hydration Status ? New localizing Neurological findings ? CHF/Pneumonia Rectal Exam to R/O Impaction ? Distended Bladder ? Infected Ulcer

Delirium: Search for Underlying Etiology

Review medication list Measurement of serum levels of medications eg. Digoxin/phenytoin... Metabolic work up

CBC lytes/BUN/creat/glucose Ca, albumin liver function tests

R/O infection eg. CXR; urine C&S O2 saturation/ABGs to R/O pCO2

Delirium: Search for Underlying Etiology

ECG to R/O silent MI CXR to R/O pneumonia as physical exam often difficult/inaccurate

CNS work-up (if indicated): ie. CT Head

Delirium: Search for Underlying Etiology

Positive urine cultures Common in the elderly Should only be used as the cause for a delirium when patient has new urinary symptoms.

Prevention of Delirium

Multi component intervention strategy

targeted to 6 delirium risk factors

Ref: Inouye SK, NEJM. 1999;340:669-676

Risk Factors Intervention

Cognitive Impairment Reality orientation / therapeutic activities program Vision/Hearing impairment Vision / hearing aids / adaptive equipment Immobilization Early mobilization / Reduce immobilizing equipment Psychoactive medication Non pharmacologic approaches to sleep / anxiety / Restricted use of sleeping medication Dehydration Early recognition / Volume expansion Sleep deprivation Noise reduction strategies/sleep enhancement program
Ref: Inouye SK, NEJM. 1999;340:669-676

Delirium: Management

Address immediate safety Investigate cause(s) Identify and remove or treat underlying cause(s) Medications (eg. Benzodiazepines / Neuroleptics) to be used only if necessary

Nonpharmacological Management

Provide general supportive measures: Avoid restraints Encourage familiar faces for reassurance eg. family members Fluids, nutrition Low stimulation - avoid excessive noise Provide orientation (calendar, clock) Correct sensory impairment eg. vision, hearing

Delirium: Pharmacological Management

Principles 1. Use a SINGLE medication rather than two, to decrease the potential for side effects/drug interactions. 2. Start with a low dose. 3. Choose a drug with low anticholinergic activity. 4. Try to stop the medication as soon as possible, focusing on correcting the underlying cause for the delirium. 5. Continue to use Non-Pharmacological interventions.

Delirium: Pharmacological Interventions

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 once initial dose is given, wait approximately 2 -4 hours before repeating the dose. Taper the dose as soon as possible Avoid in individuals with Parkinsons Disease

Benzodiazepines
1. 2. 3. 4. Avoid use in combination with antipsychotics - SINGLE drug is better. May cause distribution/increased agitation. Best reserved for Delirium 2o to alcohol / Benzodiazepine withdrawal. Relatively contraindicated in Delirium from Hepatic Encephalopathy.

Delirium: Pharmacological Management

Atypical Antipsychotics (Risperidone, Olanzepine, quetiapine)

No controlled studies at present of their use in delirium (just case reports) MAY TRY:

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

Delirium - Conclusions

A medical emergency!!
Common but under-recognized Treatment: Address the underlying cause

Suggested Readings
1. Cole MG, McCusker J, Dendukuri N, Han L. Symptoms of delirium among elderly medical inpatients with or without dementia. J Neuropsychiatry Clin Neurosci 2002; 14(2):167-75. Francis J. Martin D, Kkapoor WN. A prospective study of delirium in hospitalized elderly. JAMA 1990;263(8):1097101. Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V, Cassel CK. Delirium in hospitalized older persons: Outcomes and predictors. J Am Geriatr Soc 1994; 2(8):809-15.

2.

3.

Suggested Readings
4.

5.

6.

Inouye SK. The dilemma of delirium: Clinical and research controversies regarding diagnosis and evaluation of delirium in hospitalized elderly medical patients. AM J Med 1994; 97(3):278-88. Inouye, SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: The confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113(12):941-8. Inouye SK, A Multicomponent Intervention to Prevention Delirium in Hospitalized Older Patients. NEJM. 1999;340:669-676