Delirium lecture in the emergency Medicine course.ppsx

The lecture gives informative data about causes, emergency causes, and how to assess and manage a patient with delirium.

1. Delirium
Presented by
Heba Mohamed Tawfik
Associate Professor of Geriatrics and
Gerontology
Co-director of the AGE BRAIN team and
director of the cognitive training lab
ICU course 2023
Faculty of Medicine
Ain-Shams University

2. By the end of this lecture, you should be able to:
Understand causes and risk factors of delirium
Diagnose delirium
Diagnose the cause (s) of delirium
Prevent delirium
Have good knowledge about management

3. Delirium is an acute, transient, usually
reversible neuropsychiatric syndrome, seen
in medical-surgical set-ups.
It is considered to be a serious problem in
acute care settings.
Elderly people are considered a high-risk
group for development of delirium

4. Delirium is 10 times more common in those with dementia.
It can be brief and transient (resolved in 24 hours), but may
persist (30% at a month, 20% at six months) or the person
may not recover at all.
Occurs in up to 50% of hospitalized patients and may reach
up to 80% of patients in ICU especially mechanically
ventilated

5. Delirium can be triggered by a single cause, but in most
cases, it is multifactorial, resulting from the interaction
between predisposing and precipitating factors
Bellelli et al., 2021

6. Pathophysiology????
Not fully understood
•Reversible impairment of cerebral oxidative metabolism
•Neurotransmitter abnormalities, especially cholinergic deficiency
•Generation of inflammatory markers, including CRP, IL-1 beta and 6, and
TNF alpha
•Stress of any kind upregulates sympathetic tone and downregulates
parasympathetic tone, impairing cholinergic function and thus contributing
to delirium. Older people are particularly vulnerable to reduced cholinergic
transmission, increasing their risk of delirium.
Regardless of the cause, arousal mechanisms of the thalamus and brain stem
reticular activating system become impaired.

7. Causes of delirium
May be more than one cause
Use the mnemonics DELIRIUM
D: drugs and toxicity (e.g. opioids , anticholinergics, sedatives ,BZD, Co poisoning) & dehydration
E: electrolyte disturbance (e.g hyponatremia, hypernatremia, hyper or hypocalcemia,
hypomagnesemia)/ epilepsy/ encephalopathy (hepatic, uremic, hypertensive, Wernicke’s),
severe emotional or surgical stress/ environmental as heavy metals
L: lack of drugs (withdrawal of sedatives, alcohol and sleeping medications)/ lack of O2 (hypoxia)
I: infections and sepsis (chest, UTI, COVID-19, Skin, infected PUs, septic arthritis, CNS)
R: reduced sensation/ reduced sleep
I:intracranial ( stroke , hemorrhage, TBI, encephalitis ,meningitis, brain tumor etc.)
U:urinary retention & faecal impaction/ unpleasant sensation (pain)/ undernutrition
M: metabolic and endocrinal (acidosis ,hypoglycemia, hyperglycemia, thyroid disorders, heat
stroke, hypothermia) and myocardial, circulatory and pulmonary causes ( MI , arrhythmia,
pulmonary edema, pulmonary embolism, severe anemia and hypotension)

8. UTI presentation in elderly
people
Symptoms of UTI are atypical , may
include:
Delirium,
Urinary incontinence,
Hypotension,
Tachycardia,
Poor appetite,
Dizziness or drowsiness,
Recurrent falls
Fever may be absent

9. Risk factors for delirium in different healthcare facilities
Wilson et al., 2020

10. Types
Hypoactive
Hyperactive
Mixed

11. How to diagnose? -Diagnosis of delirium •DSM V Criteria
•Confusion assessment method (CAM)
•CAM-ICU - Diagnosis of the cause (s)

12. DSM V criteria for delirium
A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain,
and shift attention) and awareness (reduced orientation to the
environment).
B. The disturbance develops over a short period of time (usually hours to
a few days), represents a change from baseline attention and awareness,
and tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g. memory deficit,
disorientation, language, visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not better explained by a pre-
existing, established or evolving neurocognitive disorder and do not
occur in the context of a severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, substance intoxication or withdrawal, or
exposure to a toxin, or is due to multiple etiologies.
(American Psychiatric Association 2013)

13. Confusion assessment method (CAM)
A positive or negative result depends on four criteria:
1. Acute onset and fluctuating course
Determined by collateral history or repeated clinic assessment
2. Inattention
3. Disorganised thinking
4. Altered levels of consciousness
The CAM is considered to be positive for the presence of delirium if
both features 1 and 2 are present, with at least one of features 3 or 4.

14. The Confusion Assessment
Method for the Intensive Care
Unit (CAM-ICU) flowsheet
The scores included in the 10-point Richmond
Agitation-Sedation Scale (RASS) range from a
high of 4 (combative) to a low of –5 (deeply comatose
and unresponsive).
Under the RASS system, patients who were
spontaneously alert, calm, and not agitated were scored
at 0 (neutral zone).
Anxious or agitated patients received a range of scores
depending on their level of anxiety: 1 for anxious, 2 for
agitated (fighting ventilator), 3 for very agitated (pulling
on or removing catheters), or 4 for combative (violent
and a danger to staff).
The scores –1 to –5 were assigned for patients with
varying degrees of sedation based on their ability to
maintain eye contact: -1 for more than 10 seconds, -2 for
less than 10 seconds, and –3 for eye opening but no eye
contact. If physical stimulation was required, then the
patients were scores as either –4 for eye opening or
movement with physical or painful stimulation or –5 for
no response to physical or painful stimulation.
The RASS has excellent interrater reliability and intraclass
correlation coefficients of 0.95 and 0.97, respectively.
© 2002, E. Wesley Ely, MD, MPH and Vanderbilt University

15. In Attention
If the patient has a
problem in following
numbers, show the
patient 5 pictures,
each for 3 seconds in
step A then Step B
show him 10 pictures
and he should
recognize the 5
pictures seen before
by asking him to say
yes or no or by head
nodding

16. Differential diagnosis
Dementia, depression, and acute psychiatric syndromes should
all be considered in the differential diagnoses for delirium; these
syndromes often co-occur, and patients may have more than one.
In the absence of clear documentation from medical records or
reports from family members that the patient’s mental status is
consistent with his or her baseline, it is always safest to assume
delirium , witnessed fluctuations over a period of minutes to
hours, or an abnormal level of consciousness fulfil CAM criteria
and make delirium more likely.
Severe hypoactive and hyperactive delirium can be confused with
depression and mania, respectively. It is prudent to evaluate
these patients for delirium rather than attributing the
presentation to psychiatric disease and missing important medical
problems.

17. Image adopted from https://sjrhem.ca/delirium-vs-
dementia-different-side-on-the-same-coin/

18. Evaluation and
management
of delirium
Marcantonio, 2017

19. Pharmacologic treatment may be required for
distressing perceptual disturbances or
delusional thoughts when verbal reassurance
is not successful or for behavior that is
dangerous to the patient or others; on an as
needed basis.
Patients with prolonged delirium may need
continual scheduled dosing (e.g., once, twice,
or three times daily). As with physical
restraints, these drugs should be stopped as
soon as possible.
Remember: black box warning of
antipsychotics
Marcantonio, 2017

20. Thorough
assessment of of
delirium
Grover and Avasthi, 2018

21. Assessment of
delirium
Grover and Avasthi, 2018

22. Don’t forget
Urgent assessment of Vital
signs : Blood pressure/ pulse/
RR
Check: So2, blood sugar,
acidosis

23. Don’t forget
To ask about adding new
medications, changing dose , over
the counter medications and herbs
To ask about drug abuse as
tramadol, cannabis, heroin….etc.
To ask about sleeping and pain
medications

24. What is
ABCDEF
bundle?

25. The ABCDEF bundle
represents an evidence-based
guide for clinicians to approach
the organizational changes
needed for optimizing ICU
patient recovery and outcomes.
Trogrlic´ et al., 2015
Image adapted from Wilson et
al., 2020

26. Medications used in agitated delirium
Caution with QTc > 450 ms or increases by 25% or more from baseline /
Not recommended if QTc > 500 ms
Benzodiazepines should be given if delirium is due to alcohol withdrawal
Adapted from Marcantonio, 2017

27. References
Grover S, Avasthi A. Clinical Practice Guidelines for Management of Delirium in Elderly. Indian J Psychiatry 2018;60:329-40.
Bellelli G, Brathwaite JS and Mazzola P (2021) Delirium: A Marker of Vulnerability in Older People. Front. Aging Neurosci. 13:626127. doi:
10.3389/fnagi.2021.626127.
https://www.msdmanuals.com/professional/neurologic-disorders/delirium-and-dementia
Maldonado JR. Delirium pathophysiology: An updated hypothesis of the etiology of acute brain failure. Int J Geriatr Psychiatry. 2018 Nov;33(11):1428-1457. doi:
10.1002/gps.4823. Epub 2017 Dec 26. PMID: 29278283.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: APA.
Thom RP, Levy-Carrick NC, Bui M, Silbersweig D. TREATMENT IN PSYCHIATRY :Delirium. Am J Psychiatry 176:10, October 2019.
https://www.bgs.org.uk/resources/end-of-life-care-in-frailty-delirium.
Dutta C, Pasha K, Paul S, Abbas MS, Nassar ST, Tasha T, Desai A, Bajgain A, Ali A, Mohammed L. Urinary Tract Infection Induced Delirium in
Elderly Patients: A Systematic Review. Cureus. 2022 Dec 8;14(12):e32321. doi: 10.7759/cureus.32321. PMID: 36632270; PMCID:
PMC9827929.
Inouye, Sharon K. (1990-12-15). "Clarifying Confusion: The Confusion Assessment Method". Annals of Internal Medicine. 113 (12): 941–948. doi:10.7326/0003-
4819-113-12-941. ISSN 0003-4819. PMID 2240918.
Ely, E.W., Inouye, S.K., Bernard, G.R., Gordon, S., Francis, J., May, L., Truman, B., Speroff, T., Gautam, S., Margolin, R., Hart, R.P., & Dittus, R. (2001). Delirium in
mechanically ventilated patients: Validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA, 286(21), 2703-2710.
Table 1,p. 2705. © American Medical Association.
https://www.icudelirium.org/language-translations/Arabic.
https://sjrhem.ca/delirium-vs-dementia-different-side-on-the-same-coin/
Marcantonio ER. Delirium in Hospitalized Older Adults. N Engl J Med. 2017 Oct 12;377(15):1456-1466. doi: 10.1056/NEJMcp1605501. PMID: 29020579; PMCID:
PMC5706782.
Collin C Wade D. Assessing motor impairment after stroke: a pilot reliability study. J Neurology Neurosurg Psychiatry. 1990; 53: 576-579
Trogrlic´, Z. et
 al. A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical
outcomes. Crit. Care 19, 157 (2015).
Wilson, J.E., Mart, M.F., Cunningham, C. et al. Delirium. Nat Rev Dis Primers 6, 90 (2020). https://doi.org/10.1038/s41572-020-00223-4.