Delirium , detection, features, management, outcome

presentation on delirium ., a medical emergency

1. Dr .G.K.Vankar
Department of Psychiatry
Parul Institute of Medicak Sciences
Vocational
3 rd Year

2. A sudden and significant decline in mental
functioning not better accounted for by a
preexisting or evolving dementia
Disturbance of consciousness with reduced
ability to focus, sustain, and shift attention

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

4. Elderly
◦>80 years
◦demented
◦multiple meds
Post-cardiac surgery
Burns
Drug withdrawal
AIDS

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

6. Prodrome
Fluctuating course
Attentional deficits
Arousal /psychomotor disturbance
Impaired cognition
Sleep-wake disturbance
Altered perceptions
Affective disturbances

7. Restlessness
Anxiety
Sleep disturbance

8. 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

9. Easily distracted by the environment
May be able to focus initially, but will not be
able to sustain or shift attention

10. Hyperactive (agitated, hyperalert)
Hypoactive (lethargic, hypoalert)
Mixed

11. Memory Deficits
Language Disturbance
Disorganized thinking
Disorientation
◦Time of day, date, place, situation, others, self

12. Fragmented throughout 24-hour period
Reversal of normal cycle

13. Illusions
Hallucinations
- Visual (most common)
- Auditory
- Tactile, Gustatory, Olfactory
Delusions

14. Anxiety / fear
Depression
Irritability
Apathy
Euphoria
Lability

15. Typically, symptoms resolve in 10-12 days
- may last up to 2 months
Dependent on underlying problem and
management

16. May progress to stupor, coma, seizures or
death, particularly if untreated
Increased risk for postoperative complications,
longer postoperative recuperation, longer
hospital stays, long-term disability

17. Elderly patients 22-76% chance of dying during
that hospitalization
Several studies suggest that up to 25% of all
patients with delirium die within 6 months

18. 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

19. Infections: encephalitis, meningitis, sepsis
Withdrawal: ETOH, sedative-hypnotics,
barbiturates
Acute metabolic: acid-base, electrolytes, liver
or renal failure
Trauma: brain injury, burns

20. CNS pathology: hemorrhage, seizures, stroke,
tumor (don’t forget metastases)
Hypoxia: CO poisoning, hypoxia, pulmonary or
cardiac failure, anemia
Deficiencies: thiamine, niacin, B12
Endocrinopathies: hyper- or hypo-
adrenocortisolism, hyper- or hypoglycemia

21. Acute vascular: hypertensive encephalopthy
and shock
Toxins or drugs: pesticides, solvents,
medications, (many!) drugs of abuse
◦anticholinergics, narcotic analgesics, sedatives
Heavy metals: lead, manganese, mercury

22. Alcohol
Amphetamines
Cannabis
Cocaine
Hallucinogens
Inhalants
Opiates
Phencyclidine (PCP)
Sedatives
Hypnotics

23. 44% estimated to have 2 or more etiologies

24. 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?

25. Tests orientation, short-term memory,
attention, concentration, constructional ability
30 points is perfect score
< 20 points suggestive of problem
Not helpful without knowing baseline

26. Electrolytes
CBC
EKG
CXR
EEG- not usually necessary

27. Oxygen saturation
Urinalysis +/- Culture and sensitivity
Urine drug screen
Blood alcohol
Serum drug levels (digoxin, theophylline,
phenobarbital, cyclosporin, lithium, etc)

28. Consider:
- Heavy metals
- Lupus workup
- Urinary porphyrins

29. 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

30. Monitor and assure safety of patient and staff
- suicidality and violence potential
- fall & wandering risk
- need for a sitter
- remove potentially dangerous items from
the environment
- restrain when other means not effective

31. Assess individual and family psychosocial
characteristics
Establish and maintain an alliance with the
family and other clinicians
Educate the family – temporary and part of a
medical condition – not “crazy”
Provide post-delirium education and
processing for patient

32. Environmental interventions
- “Timelessness”
- Sensory impairment (vision, hearing)
- Orientation cues
- Family members
- Frequent reorientation
- Nightlights

33. Pharmacologic management of agitation
- Low doses of high potency neuroleptics
(i.e. haloperidol) – po, im or iv
- Atypical antipsychotics (risperidone)

34. Haloperidol and inapsine have been associated
with torsade de pointes and sudden death by
lengthening the QT interval; avoid or monitor
by telemetry if corrected QT interval is greater
than 450 msec or greater than 25% from a
previous EKG

35. Benzodiazepines
- Treatment of choice for delirium due to
benzodiazepine or alcohol withdrawal

36. Benzodiazepines
- May worsen confusion in delirium
- Behavioral disinhibition, amnesia, ataxia,
respiratory depression
- Contraindicated in delirium due to hepatic
encephalopathy

37. Delirium is common and is often a harbinger
of death- 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 patient’s life