Delirium.pptx important for psychiatry resident

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1. Delirium Dikendra Sanjyal Department of Psychiatry NMCTH 25/04/2081

2. Contents A Clinical Scenario Different Clinical practice guidelines Definition DSM-5 Criteria Brief history Epidemiology Incidence and prevalence Precipitating factor and predisposing factor Pathophysiology Clinical features Classification Approach to Delirium History taking, Diagnosis, Screening, Investigations Management of Delirium Management of Delirium tremens Conclusion References 25/04/2081 2

3. A Clinical Scenario Mrs. Khadka, a 78-year-old woman, is admitted to the hospital with lower abdominal pain and burning micturition for 2 days. She becomes increasingly confused and agitated , with fluctuating levels of consciousness and sleep disturbances. Despite no history of cognitive impairment, she exhibits disorientation, and difficulty maintaining attention. Laboratory tests reveal pus cells in urinalysis and imaging reveal no acute abnormalities On examination: The patient is conscious, disoriented to time, place, and person General Physical Examination: no significant findings On Mental Status Examination: Decreased attention and concentration, speech increased rate, rhythm, increased psychomotor activity 25/04/2081 3

4. Different Clinical Practice Guidelines National Institute for Health and Care Excellence (NICE),UK- 2023 Indian Psychiatric Society, India- 2018 Canadian Coalition for Seniors' Mental Health (CCSMH), Canada- 2014 American Psychiatric Association (APA), USA- 1999 25/04/2081 4

5. Definition : As defined by DSM-V, is characterized by an acute decline in both the level of awareness and cognition with particular impairment in attention. A life threatening, yet potentially reversible disorder of the central nervous system (CNS), Delirium involves:- Fluctuating disturbance of consciousness Perceptual disturbances Abnormal psychomotor activity Sleep cycle impairment Synonyms: organic brain syndrome, acute confusional state, acute brain failure, acute brain rxn , toxic psychosis, encephalopathy, cerebral insufficiency …etc.

6. 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 an acute 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. 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 . Evidence from the history, Physical evidence or laboratory findings that this represents another medical condition, substance intoxication or withdrawal, toxin exposure or due to multiple etiologies. Diagnostic and statistical manual of mental disorders (DSM-5) criteria for delirium:

7. Specify whether Substance intoxication delirium Substance withdrawal delirium Medication induced delirium Delirium due to another medical condition Delirium due to multiple etiologies Specify if Acute – lasting a few hours or day Persistent – lasting weeks or months Specify if Hyperactive Hypoactive Mixed level of activity Associated feature supporting diagnosis : Disturbance in sleep wake cycle Emotional disturbance like anxiety, fear, depression, euphoria, anger, irritability and apathy. There may be rapid and unpredictable shift from one state to another. Others : other specified delirium, unspecified delirium 25/04/2081 7

8. Brief history : The earliest known references to delirium in medical literature are found in the writings of Hippocrates.(Some 2,400 years ago, in his Book of Epidemics) Celsus , 1st century - first to use the term delirium. C elsus used the term delirium to describe a spectrum of mental disorders ranging from general insanity to acute transient states of mental disturbance, including phrenitis , lethargus , hysteria, melancholia, and mania. The term delirium originates from latin word delirio – to be crazy

9. 2 nd century AD, Galen differentiated between primary and secondary types of delirium. 19 th century emphasis was placed on disturbed consciousness as the hall mark of delirium. George angel and romano -19 th century, demonstrated that delirium is due to reduction in metabolic activity. The first modern standardized criteria for the diagnosis –DSM 3 rd edition (DSM-III) published in 1980. 25/04/2081 9

10. 25/04/2081 10 Substantial alterations of the diagnostic criteria for delirium were made in the 1987 revision of the manual,DSM -IIIR. The 1994 revision, DSM-IV, divides the criteria for diagnosing delirium into five separate categories. DSM-5

11. Epidemiology : Commonest organic mental disorder seen clinical practice. Poor recognition….major challenge !! Highest prevalence among Inpatients …mostly geriatrics population. Among In patients, highest in ICU setting :approx. 70% Prevalence: old people>> younger people -Community(age 55+ 1%)&(age 85+ 13%) -ER department:8-17 % - H ospital admitted:18-35% - Post-operative: 15-53% (open heart surgery: 30%, hip #: 50%) Overall in patient prevalence of delirium: 29-64%

12. Incidence and Prevalence of Delirium in Various Settings comprehensive textbook of psychiatry ,tenth edition Population Prevalence Range (%) Incidence Range (%) General medical inpatients 10–30 3-16 Medical and surgical inpatients 5-15 10-55 General surgical inpatients N/A 9-15 post operatively Critical care unit patients 16 16-83 Cardiac surgery inpatients 16-34 7-34 Orthopedic surgery patients 33 18-50 Emergency department 7-10 N/A Terminally ill cancer patients 23-28 83 Institutionalized elderly 44 33

13. Predisposing factors : Past history of delirium Pre-existing brain damage or dementia Extremes of age (very old, very young) and male sex Alcohol or drug dependence Chronic medical illness Generalized/focal cerebral lesions Surgical procedure /post op period Sensory impairment Functional impairment(immobility, h/o falls) Past history of head injury or CV diseases Treatment with psychotropic medication

14. Etiology /precipitating factors: Causes Substance induced conditions General Medical Conditions Infection Metabolic Disorders Hepatic or renal failure Seizure Head injury Dehydration Malnutrition Drug intoxication Drug withdrawal

15. Precipitating Factors : a)Metabolic causes: c)Neurological causes : Hypoxia, CO2 narcosis -epilepsy(post ictal states) Hypoglycemia -head injury…..SDH, SAH Hepatic/uremic encephalopathy - brain SOLs Metabolic acidosis/alkalosis -intracranial infections Water and electrolyte imbalance - stroke(acute phase) Shock b) Physiological cause: d)Drugs: Septicemia -digitalis, steroid, diuretics Organ failure -psychotropic medications…sedatives, Fever, infection, anemia, dehydration hypnotics, opiates Carcinoid syndrome, porphyria -TCAs, Anti depressants, Disulfiram , Cardiac arrhythmia, cardiac arrest anti psychotics, alcohol abuse

16. d ) Drugs …. contd f) Miscellaneous causes: -antic convlsants , L-dopa -sleep deprivation -heavy metals,penicillin,Insulin,methylalcohol -post operative status -pain, heat, electricity e) Nutritional deficiency: - restraints, indwelling catheter - Thiamine,niacin,pyridoxine,folic acid, protein f)Endocrine causes : - hyper/hypo thyroidism hyper/hypo parathyroidism hyper/hypo adrenism hyper/hypo pituiterism

17. Pathophysiology

18. Clinical features: Essential features Variable features Acute onset Fluctuating course Disorientation Inattention Disorganized thinking and speech Clouding of consciousness Cognitive defects Perceptual disturbance Hyperactive/hypoactive Altered sleep wake cycle Emotional disturbance

19. cont … Examination signs Autonomic dysfunction Dysarthria Dysnomia Dysgraphia Aphasia Nystagmus Ataxia Tremor , asterixis myoclonus Tachycardia Hypertension Sweating Flushing Dilated pupils

20. Recognizing warning signs of Delirium Acute changes in mental status Presence of medical illness Visual hallucinations Fluctuating levels of consciousness Acute onset of psychiatric symptoms without prior history of psychiatric illness Acute onset of new or different psychiatric symptoms with history of prior psychiatric illness Patient described as “ confused” or “disoriented” Diffuse slow waves or epileptiform discharges on EEG 25/04/2081 22

21. Classification Clinically delirium can be divided into the following three categories: Hyperactive Delirium (30%) Hypoactive Delirium (25%) Mixed Delirium(45%)

22. Hyperactive subtype(30%) There is association with increased use of benzodiazepines, over sedation, use of restraints and falls. Patients are : agitated and hyper alert repetitive behaviors Wandering and restless hallucinations and aggression. uncooperative and often combative Psychotic and responding to internal stimuli Loud and fast speech Appear intoxicated

23. Hypoactive subtype(25%) Patients are quiet and withdrawn which is often; missed on a busy medical ward leading to increased length of stay, Associated with more severe complications. Patients: Somnolent, inattentive, and uninterested Poor memory and cognitive abilities Will be described as having lapses or variable behavior Reduced amount and rate of speech Often missed because they can be left alone

24. Mixed subtype(45%) Fluctuating pattern seen . Combination of both. Hypoactive and mixed account for about 70% of all cases.

25. Diagnosis 33-95 % of in hospital cases are missed or misdiagnosed as depression, psychosis or dementia Look very much like…depression 60% dysphoric 52% thoughts of death or suicide 68% feel “worthless” Up to 42% of cases referred for psychiatry consult services for depression are delirious Farrell Arch Intern Med. 1995 155:22 Farrell Arch Intern Med. 1995 155:22

26. Course and prognosis By the 3 rd hospital day, approximately one-half the patients who are diagnosed with delirium have been diagnosed. Symptoms of delirium usually last 3 to 5 days, but there is slow resolution of symptoms contributing to persistent symptoms of delirium at 6 to 8 weeks for severely ill patients. Symptom resolution is frequently incomplete by hospital discharge, with as many as 15 percent of patients remaining symptomatic of delirium at 6 months. In general, studies suggest that the increased mortality risk a/w delirium was maintained at 12,24,and 36 months with ratio of at least 2 at all time points. Additionally, at 24 months, the increased risk of cognitive and functional impairment remained. 25/04/2081 28

27. Approach to Delirium Initial Assessment: History taking Examination Evaluation of underlying risk factors Investigations: baseline and specific Substance use (especially alcohol) Grover S, Avasthi A. Clinical Practice Guidelines for Management of Delirium in Elderly. Indian J Psychiatry. 2018 Feb;60(Suppl 3):S329-S340. doi : 10.4103/0019-5545.224473. PMID: 29535468; PMCID: PMC5840908. 25/04/2081 29

28. History Taking Obtaining a good history is key and should be the first step when seeing a patient with delirium The following points on history should always be obtained: History of Presenting Illness (HOPI): onset and course of confusion/agitation , history of previous episodes of delirium (and treatment response), sleep patterns Medical and Psychiatric History: sensory impairments (hearing/vision), bowel and bladder Habit, recent surgeries, medication history (prescription, OTC drugs) Substance use history (especially for alcohol) Previous cognitive functioning Social history 25/04/2081 30

29. Diagnostic Criteria ICD-10 (F05 Delirium, not induced by alcohol and other psychoactive substances) For a definite diagnosis, symptoms, mild or severe, should be present in each one of the following areas: Impairment of consciousness and attention Global disturbance of cognition Psychomotor disturbances Disturbance of the sleep - wake cycle Emotional disturbances ICD-11( 6D70 Delirium) DSM-5 25/04/2081 31

30. Why Is It Important to Identify Delirium? Delirium has a fluctuating course and can overlap with dementia , which makes it hard to detect Delirium is also under appreciated in terms of its importance and consequences Patients with ongoing delirium have a significantly higher risk of mortality, significant increases in length of stay, increased costs of hospitalization, and increased chance of nursing home placement Doctors and nurses do a poor job of identifying delirium 25/04/2081 32

31. Assessment scales for delirium 25/04/2081 33 Grover S, Avasthi A. Clinical Practice Guidelines for Management of Delirium in Elderly. Indian J Psychiatry. 2018 Feb;60( Suppl 3):S329-S340. doi : 10.4103/0019-5545.224473. PMID: 29535468; PMCID: PMC5840908.

32. Screening Confusion Assessment Method (CAM) Inouye SK et al, 1990 It allows clinicians to identify and recognize delirium quickly and accurately in both clinical and research settings It has a sensitivity of 94‐100% and specificity of 90‐95% 25/04/2081 34

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34. Levels of consciousness Agitated (out of control) Hyperalert (vigilant) Alert (normal) Drowsy (lethargic) Obtunded (difficult to wake) Stuporous (v. difficult to wake) Comatose (unable to wake)

35. Investigations: Routine investigations: CBC, electrolytes(Na, Cl, Ca, Mg, phosphate), CK LFTs, RFTs, BUN/Cr, Random glucose TSH, free T3, free T4 Urinalysis (cultures) ABGs Imaging: Chest X-Ray (CXR), Abdominal X-Ray(erect and supine) , CT Head ECG, EEG Infectious etiology work up including serology Urine drug screen 25/04/2081 37

36. Differential diagnosis Depression Dementia Schizophrenia Adjustment disorders Anxiety disorders Agitated depression Mania 25/04/2081 38

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38. General Principles for Assessment of cause of delirium 25/04/2081 40

39. Management of Delirium Appropriate measures for underlying causes Non-Pharmacological measures Pharmacological management Monitoring Grover S, Avasthi A. Clinical Practice Guidelines for Management of Delirium in Elderly. Indian J Psychiatry. 2018 Feb;60(Suppl 3):S329-S340. doi : 10.4103/0019-5545.224473. PMID: 29535468; PMCID: PMC5840908. 25/04/2081 41

40. Management of Underlying Cause(s) 25/04/2081 42

41. Non-Pharmacological measures Orient the patient by having a clock, watch, or calendar Warm drinks, relaxation tapes, back massages at night, coordinate schedules (drugs, vitals, procedures) to allow uninterrupted sleep at night Early mobilization including ambulation or active range of motion exercises Minimize use of catheters, IVs, and restraints Visual aids such as glasses, and other adaptive equipment for people with visual impairment Hearing aids , portable amplifying devices, earwax removal if needed for people with hearing impairment Early recognition of dehydration and repletion with fluids Avoid putting delirious patients in the same room together, and minimize room changes 25/04/2081 43

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43. Educate the family about delirium 25/04/2081 46

44. Pharmacological Management Pharmacologic management should only be used if the symptoms of delirium threaten the patient's own safety, the safety of others, or would result in the interruption of essential therapy Always start low and go slow Remember that no drug is currently approved by any regulatory agency for the treatment of hospital-associated delirium Never forget to order a baseline ECG for a QTc, especially if plan is to start on Haloperidol Generally, no any pharmacological measures are taken for hypoactive delirium 25/04/2081 47

45. Anti-psychotics Antipsychotic medications should not be used as standard treatment for delirium, and should only be considered for patients with delirium experiencing severe agitation or distress Haloperidol (at doses < 3.5 mg daily), risperidone, quetiapine , and olanzapine are all equally effective in managing delirium Antipsychotics if prescribed, should be at the lowest effective dose for the shortest possible duration and be reevaluated at or shortly after discharge The adverse effects of antipsychotic medications include sedation, hypotension, falls, parkinsonism, QT interval prolongation and aspiration pneumonia 25/04/2081 48

46. Medication Recommended Dosing Side Effects Haloperidol 0.5‐1 mg PO/IM BD Extrapyramidal Symptoms (EPS) at higher doses (> 3mg), QTc prolongation, and neuroleptic malignant syndrome, somnolence, falls Risperidone 0.5 mg PO BD Extrapyramidal Symptoms (EPS) (less likely than typical like haloperidol, but still a risk, especially at higher doses), QTc prolongation, neuroleptic malignant syndrome, somnolence, falls Olanzapine 2.5‐5 mg PO daily Same as risperidone Quetiapine 25 mg PO BD Same as risperidone 25/04/2081 49

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48. General Principles of use of antipsychotics in Delirium 25/04/2081 51

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50. Grover S, Avasthi A. Clinical Practice Guidelines for Management of Delirium in Elderly. Indian J Psychiatry. 2018 Feb;60(Suppl 3):S329-S340. doi : 10.4103/0019-5545.224473. PMID: 29535468; PMCID: PMC5840908. 25/04/2081 Fig 2 53

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53. Management of Delirium Tremens(DTs) Admission and Monitoring History, Examination, Investigations Rating withdrawal: CIWA- Ar Pharmacological and Non-pharmacological measures Supportive treatment Grover S, Avasthi A. Clinical Practice Guidelines for Management of Delirium in Elderly. Indian J Psychiatry. 2018 Feb;60(Suppl 3):S329-S340. doi : 10.4103/0019-5545.224473. PMID: 29535468; PMCID: PMC5840908. 25/04/2081 56

54. Considerations Alcohol and benzodiazepine withdrawal are the two substance withdrawals that can be fatal Withdrawal seizures can be the initial clinical presentation Benzodiazepines must be used and are the first-line treatment Non benzodiazepine anti-epileptics do not work to prevent alcohol-related seizures Antipsychotics can lower the seizure threshold, so are generally avoided The best treatment for DTs is prevention 25/04/2081 57

55. CIWA- Ar Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA- Ar ) CIWA- Toronto, Canada in the 1980s Revised by Sullivan et.al. in 1989 Total score less than 8 indicate minimal to mild withdrawal 8 to 15 indicate moderate withdrawal 15 or more indicate severe withdrawal Sullivan, J.T.; Sykora , K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA- Ar ). British Journal of Addiction 84:1353-1357, 1989. 25/04/2081 58

56. Pharmacological Management Withdrawal seizures: Diazepam IV 0.15mg/kg at 2.5mg/min Delirium tremens: Lorazepam IV 0.1mg/kg at 2.0 mg/min or Chlordiazepoxide 50-100mg PO 4hrly Give until patient is calm; subsequent doses depends on each individual and titration In our clinical setting, Injection Diazepam 10mg IV 3/4/6hrly and SOS with Injection Thiamine 100-200mg IV BD 25/04/2081 59 Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s Synopsis of psychiatry, 11th ed. Philadelphia: Wolters Kluwer, 2015

57. Supportive Management Physical restraint if needed Dehydration correction by IV fluids, Thiamine 100-200mg in each pint of fluid A high calorie, high carbohydrate diet supplemented by multivitamins Warm, supportive psychotherapy 25/04/2081 60

58. Preventive measures Effective measures to prevent delirium including : -avoiding possible precipitating factors -treating underlying causes -providing supportive and restorative care Some drugs tried for prevention : -Anticholinesterase drugs: eg Rivastigmine , Galantamine , Donepezil -NMDA antagonist: memantine - Dexmedetomidine -Melatonin -Gabapentin

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60. Algorithm for prevention of delirium 25/04/2081 63

61. Conclusion: Delirium is acute alteration in cognitive functioning with fluctuations in attention span and other symptoms Delirium is a serious, though under-recognized condition Management involves maximization of medical condition while minimization of poly pharmacy Prevention, detection and education are key to managing delirium 25/04/2081 64

62. Delirium is complex neuropsychiatric syndrome that is common in all health care setting. The field is hampered by poor detection. Psychiatrists can play a pivotal role in the diagnosis and treatment of delirious patients. Typical neuroleptic drugs remain the cornerstone of treatment. 25/04/2081 65

63. Cognitive impairment of delirium is not entirely reversible in all patients . During delirium there is significant risk for progression of underlying dementia . Symptoms of delirium frequently persists beyond the acute phase of treatment, therefore post-discharge treatment plans must focus on reducing ongoing risk factors and managing residual functional impairment. 25/04/2081 66

64. Take home message ! Delirium is always an emergency C ommon in all health care settings. Always review medication and substance use Use antipsychotics only when necessary, behavioral measures should be used first Prevention is more effective than treatment

65. References Grover S, Avasthi A. Clinical Practice Guidelines for Management of Delirium in Elderly . Indian J Psychiatry. 2018 Feb;60(Suppl 3):S329-S340. doi : 10.4103/0019-5545.224473. PMID: 29535468; PMCID: PMC5840908 Young J, Murthy L, Westby M, Akunne A, O’Mahony R. Diagnosis, prevention, and management of delirium: summary of NICE guidance . Bmj . 2010 Jul 28;341 Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s Comprehensive textbook of psychiatry, 10th ed. Philadelphia: Wolters Kluwer, 2009 Sadock BJ, Sadock VA, Ruiz P. Kaplan and Sadock’s Synopsis of psychiatry , 11th ed. Philadelphia: Wolters Kluwer, 2015 Oxford shorter textbook of psychiatry The Maudsley Prescribing Guidelines in Psychiatry 13 th edition 25/04/2081 68

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