Organic mental disorders DELIRIUM also called acute confusional state.pptx

delirium is a state of acute confusional state that is characterised with clouding of conciousness

1. MANAGEMENT OF DELIRIUM ANIFOWOSE TEMITOPE TOYIB MBChB(Hons) IFE REGISTRAR INTERNAL MEDICINE

2. OUTLINE INTRODUCTION DEFINITION EPIDEMIOLOGY AETIOPATHOPHYSIOLOGY DIAGNOSIS MANAGEMENT COMPLICATIONS DIFFERENTIALS CONCLUSION

3. INTRODUCTION Despite first being described more than 2500 years ago, delirium remains frequently unrecognised and poorly understood condition . It is derived from the Latin word delirare, meaning ‘to go out of the furrow’, that is, deviate from a straight line, to be deranged It is a common, serious, and often-fatal syndrome It is preventable in 30–40% of cases.

4. It is a medical and psychiatric emergency and is characterized by global impairment of consciousness , resulting in reduced level of alertness, attention, and perception of the environment, and cognitive performance. A number of other terms, such as acute confusional state, acute brain failure, and acute organic syndrome, have also been used, but delirium is the preferred term in both ICD- 10 and DSM- 5. Delirium is variable in duration, with most episodes lasting a few days but in about 20% episodes can persist for weeks or months

5. EPIDEMIOLOGY The prevalence of delirium in the elderly is 1– 2% in community samples, 8– 17% in emergency departments, 18– 35% on admission to hospital, with an overall occurrence in inpatients of 29– 64% . It is much more common in the elderly than in younger people, and in individuals with diminished ‘cerebral reserve’, notably those with pre- existing dementia. It costs more than US$164 billion per year in the USA and more than $182 billion per year in 18 European countries combined.

6. AETIOPATHOPHYSIOLOGY

7. PREDISPOSING FACTOR Dementia Previous episode of delirium Sensory impairment History of cerebrovascular disease Alcohol misuse Older age

8. PRECIPITATING FACTOR Substance- related Physiological causes Neurological causes Use of physical restraints Bladder catheter Pain Sleep deprivation Constipation

9. PATHOPHYSIOLOGY Neurotransmitter Inflammation Vasculature dysfunction

10. CLINICAL FEATURES Clouding of consciousness Impaired attention Impaired memory Perceptual disturbances Delusions Behavioural and other symptoms Agitation and Irritability Reversal of sleep– wake cycle

11. DIAGNOSIS

12. TYPES Hyperactive Hypoactive Mixed

13. INVESTIGATIONS GENERAL SPECIAL

14. General Full blood count Urea and electrolytes Liver function tests Calcium Random blood glucose Blood cultures Arterial blood gas Urinalysi s Chest Xray

15. Special Cardiac enzymes MRI or CT brain scan EEG Lumbar puncture Drug screen

16. MANAGEMENT Non Pharmacological Pharmacological

17. MANAGEMENT Early identification Treatment of Underlying cause Ensuring patient safety Prevention

18. EARLY IDENTIFICATION Assessment of episodic delirium in non- ICU settings :4T, CAM Monitoring for new- onset delirium in inpatients:RASS,NEWS2 Delirium assessment in the ICU: CAM-ICU,ICDSC Ultra- brief screening tools:SQEEC

19. Treatment of Underlying Cause Drug Reviews Treatment of Infections Adequate pain control Laxatives

20. Ensuring Patient Safety and Supportive Care Nurse with familiar staff in relaxed environment Educate patient and family/carer on delirium and prognosis Involve family/carer in hospital care routine Repeatedly reorient and reassure the patien t Prevent complications, e.g. falls,

21. Ensure adequate hydration and nutrition Encourage general activity, mobility and activities of daily living . Use visual/hearing aids to facilitate communication

22. PHARMACOLOGICAL Not recommended Severe agitation and self harm Low dose antipsychotic

23. PREVENTION General setting ICU

24. COMPLICATIONS Malnutrition, fluid and electrolyte abnormalities Aspiration pneumonia Falls and combative behavior leading to injuries and fractures Wandering and getting lost Long-term cognitive impairment

25. PROGNOSIS AGE TYPE COMORBIDITY DURATION

26. DIFFERENTIALS DEMENTIA DEPRESSION ACUTE PSYCHOTIC DISORDER NON CONVULSIVE STATUS

27. CONCLUSION Delirium is a medical emergency with profound effect on quality of life and high mortality It is a very common disorder in the elders that is preventable Efforts must be directed at prevention and early identification at all level of care.

28. REFERENCES Shorter Oxford Textbook of Psychiatry Seventh Edition Medscape; Delirium by Kannayiram Alagiakkrishnan updated in 2019 Delirium in elderly people,Inuoye et al, The lancet 383(9920), 991-922, 2014 Nature Reviews|Disease Primers| Jo Ellen Wilson et all, (2020) 6:90 Advances in Psychiatric treatment(2014),vol 20,380-389

29. THANKS