Delirium

Delirium is a syndrome not a disease and it has many causes. it is an acute organic mental disorder characterised by impairment of consciousness, disorientation and disturbances in perception and restlessness.

1. Delirium Prepared By: Dhrutigna Patel 1 st Year M.Sc (N) MBNC

2. Introduction Delirium is a syndrome, not a disease and it has many causes. Delirium is under recognized by the health care workers. A temporary state of mental confusion and fluctuating consciousness resulting from high fever, intoxication, shock, or other causes. It is characterized by anxiety, disorientation hallucinations, delusions and incoherent speech.

3. Definition Delirium is an acute organic mental disorder characterized by impairment of consciousness, disorientation and disturbances in perception and restlessness .

4. Classification General medical condition eg infection Substance induced eg cocaine, opioids Substance withdrawal Multiple causes eg head trauma and kidney disease Delirium not otherwise specified eg sleep deprivation

5. Incidence Delirium has the highest incidence among organic mental disorders. About 10 to 25% of medical-surgical inpatients, and about 20 to 40 % of geriatric patients meet the criteria for delirium during hospitalization . This percentage is higher in post-operative patients.

6. Etiology Vascular: hypertensive encephalopathy, cerebral arteriosclerosis , intracranial haemorrhage Infections: encephalitis, meningitis • Neoplastic: space occupying lesions • Intoxication: chronic intoxication or withdrawal effect of sedative-hypnotic drugs • Traumatic: subdural and epidural hematoma, contusion , laceration, post-operative, heatstroke • Vitamin deficiency, e.g. thiamine • Endocrine and metabolic: diabetic coma and shock , uremia , hyperthyroidism, hepatic failure • Metals: heavy metals (lead, manganese,' mercury ), carbon monoxide and toxins • Anoxia: anemia, pulmonary or cardiac failure

7. Clinical features Arousal : Two general patterns of abnormal arousal have been noted in patients with delirium. One pattern is characterized by hyperactivity associated with increased alertness. The other pattern is characterized by hypoactivity associated with decreased alertness. Orientation : Orientation to time, place and person should be tested in a patient with delirium. Orientation to time is commonly lost, even in mild cases of delirium. Orientation to place and ability to recognize other persons may also be impaired in severe cases. A delirious patient rarely loses orientation to self.

8. Language and cognition : Patients with delirium often have abnormalities in language. The abnormalities may include rambling, irrelevant, or incoherent speech and an impaired ability to comprehend speech. Other cognitive functions that may be impaired in a delirious patient include memory and generalized cognitive functions. The ability to register, retain, and recall memories may be impaired, although the recall of remote memories may be preserved. Perception : Patients with delirium often have a generalized inability to discriminate sensory stimuli and to integrate present perceptions with their past experiences. Hallucinations are also relatively common in delirious patients (visual and auditory).

9. Mood : Patients with delirium often have abnormalities in the regulation of mood. The most common symptoms are anger, rage, and unwarranted fear. Other abnormalities of mood seen in delirium are apathy, depression, and euphoria. Associated symptoms Sleep-wake disturbance : The sleep of delirious patients is characteristically disturbed. Patients are often drowsy during the day and can be found napping in their beds or in the bedrooms. However is almost always short and fragmented. Neurological symptoms Patients with delirium commonly have associated neurological symptoms, including dysphasia, tremor, in coordination, and urinary incontinence.

10. Diagnostic criteria for delirium due to general medical condition 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 a preexisting, established or evolving dementia The disturbance develops over a short period of time 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

11. Diagnostic criteria for substance intoxication delirium 1. Disturbance of consciousness ( ie ., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. 2. A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia. 3. The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. There is evidence from history, physical examination, or laboratory findings of either (1) or (2): 1. the symptoms in criteria 1 and 2 developed during substance intoxication 2. medication use is etiologically related to the disturbance.

12. Diagnostic criteria for delirium due to multiple etiologies 1. Disturbance of consciousness ( i.e., reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. 2. A change in cognition (such as memory deficit, disorientation, language disturbance) development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia. 3 . The disturbance develops over a short period of time (usually hours to days)and tends to fluctuate during the course of the day . 4 There is evidence from history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological general medical condition, a general medical condition plus substance intoxication or medication side effect).

13. Diagnostic criteria for delirium not otherwise specified This category should be used to diagnose a delirium that does not meet criteria for any of the specific types of delirium 1. A clinical presentation of delirium that is suspected to be due to a general medical condition or substance use but for which there is insufficient evidence to establish a specific etiology. 2. Delirium due to causes not listed, for e.g., sensory deprivation.

14. Physical and laboratory examination Delirium is usually diagnosed at the bedside and characterized by the sudden onset of symptoms. The use of bedside mental status examination-such as mini mental status examination. The MSE or the Face-Hand Test- can be useful in documenting the cognitive impairment and providing a baseline from which to measure the patient's clinical course. The physical examination often reveals clues to the delirium. The presence of a known physical illness or a history of head trauma or alcohol or other substance dependence increases the likelihood of the diagnosis.

15. Course and prognosis Although the onset of delirium is usually sudden, prodromal symptoms ( for e.g. restlessness and fearfulness) may occur in the days preceding the onset of florid symptoms. The symptoms of delirium usually last as long as the casually relevant factors are present, although delirium generally lasts less than a week.

16. Treatment The primary goal is to treat the underlying condition that is causing the delirium. When the condition is anti-cholinergic toxicity, the use of physostigmine salicylate ( Antilithium ) 1 to 2 mg IV or IM, with repeated doses in 15 to 30 minutes, may be indicated. The other important goal of treatment is the provision of physical, sensory and environmental support. Physical support is necessary so that delirious patient do not get into situations in which they may have accidents.

17. Pharmacological treatment The two major symptoms of delirium that may require pharmacological treatment are psychosis and insomnia. The drug of choice for psychosis is Haloperidol, butyrophenone anti psychotic drug. Depending on patients age, weight and physical condition initial dose may range from 2 to 10 mg IM. Droperidol is butyrophenone a that is available s an alternative IV formulation. Insomnia is best treated with either benzodiazepines with short half-lives or hydroxyzine, 25 to 100 mg.

18. Nursing management 1 . Assessment Nursing assessment of the client with delirium is based knowledge of the symptomatology associated with the various disorders. Subjective and objective data are gathered by various members of the health-care team. Clinicians report use of a variety of methods for obtaining assessment information. 2. The client history: Nurses play a significant role in acquiring the client history, including the specific mental and physical changes that have occurred and the age at which changes begar From the client history, nurses should assess the following areas of concern: (1) type, frequency, and severity of mood swings, personality and behavioral changes, and catastrophic emotional reactions. (2) Cognitive changes, such as problems with attention span, thinking process, problem-solving, and memory.

19. (3) Language difficulties. (4) Orientation to person, place, time, and situation. (5) Appropriates of social behavior 3 . Physical examination : Signs of damage to the nervous system and Evidence of diseases of other organs that could affect mental function. Diagnostic laboratory evaluations .

20. Nursing Intervention 1. Providing safe environment: • R estrict environmental stimuli, keep unit calm and well-illuminated • There should always be somebody at the patient's bedside reassuring and supporting • As the patient is responding to a terrifying unrealistic world of hallucinatory illusions and delusions, special precautions are needed to protect him from himself and to protect others

21. 2. Alleviating patient's fear and anxiety: • Remove any object in the room that seems to be a source of misinterpreted perception • As much as possible have the same person all the time by the patient's bedside • Keep the room well lighted especially at night

22. 3. Meeting the physical needs of the patient: • Appropriate care should be provided after physical assessment • Use appropriate nursing measures to reduce high fever, if present • Maintain intake and output chart • Mouth and skin should be taken care of • Monitor vital signs • Observe the patient for any extreme drowsiness and sleep as this may be an indication that the patient is slipping into a coma

23. 4. Facilitate orientation : • Repeatedly explain to the patient where he is and what date, day and time it is introduce people with name even if the patient misidentifies the people • Have a calendar in the room and tell him what day it is • When the acute stage is over take the patient out and introduce him to others