Delirium Lea C. Watson, MD, MPH Robert Wood Johnson Clinical Scholar UNC Department of Psychiatry

Delirium

Lea C. Watson, MD, MPH

Robert Wood Johnson Clinical Scholar

UNC Department of Psychiatry

Nurse pages med student:

“..Mr. Smith pulled out his NG tube and can’t seem to sit still. Last night after his surgery he was fine, reading the paper and talking to his family…today I don’t even think he knows where he is… can you come see him?”

Med student says:

“…sounds like DELIRIUM- good thing you called- I’ll be right there.”

Delirium

• 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

4 major causes

• Underlying medical condition

• Substance intoxication

• Substance withdrawal

• Combination of any or all of these

Patients at highest risk

• Elderly– >80 years– demented– multiple meds

• Post-cardiac surgery• Burns• Drug withdrawal• AIDS

Prevalence

• Hospitalized medically ill 10-30%

• Hospitalized elderly 10-40%

• Postoperative patients up to 50%

• Near-death terminal patients up to 80%

Clinical features

Prodrome

Fluctuating course

Attentional deficits

Arousal /psychomotor disturbance

Impaired cognition

Sleep-wake disturbance

Altered perceptions

Affective disturbances

Prodrome

• Restlessness

• Anxiety

• Sleep disturbance

Fluctuating course

• 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

Attentional deficits

• Easily distracted by the environment

• May be able to focus initially, but will not be able to sustain or shift attention

Arousal/psychomotor disturbance

• Hyperactive (agitated, hyperalert)

• Hypoactive (lethargic, hypoalert)

• Mixed

Impaired cognition

• Memory Deficits

• Language Disturbance

• Disorganized thinking

• Disorientation– Time of day, date, place, situation, others, self

Sleep-wake disturbance

• Fragmented throughout 24-hour period

• Reversal of normal cycle

Altered perceptions

• Illusions

• Hallucinations

- Visual (most common)

- Auditory

- Tactile, Gustatory, Olfactory

• Delusions

Affective disturbance

• Anxiety / fear

• Depression

• Irritability

• Apathy

• Euphoria

• Lability

Duration

• Typically, symptoms resolve in 10-12 days

- may last up to 2 months

• Dependent on underlying problem and management

Outcome

• 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

Outcome

• 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

Causes: “I WATCH DEATH”

• 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

“I WATCH DEATH”

• Infections: encephalitis, meningitis, sepsis

• Withdrawal: ETOH, sedative-hypnotics, barbiturates

• Acute metabolic: acid-base, electrolytes, liver or renal failure

• Trauma: brain injury, burns

“I WATCH DEATH”

• 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

“I WATCH DEATH”

• 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

Drugs of abuse

• Alcohol• Amphetamines• Cannabis• Cocaine• Hallucinogens• Inhalants

• Opiates• Phencyclidine (PCP)• Sedatives• Hypnotics

Causes

• 44% estimated to have 2 or more etiologies

Workup

• 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?

Mini-mental state exam

• Tests orientation, short-term memory, attention, concentration, constructional ability

• 30 points is perfect score

• < 20 points suggestive of problem

• Not helpful without knowing baseline

Workup

• Electrolytes

• CBC

• EKG

• CXR

• EEG- not usually necessary

Workup

• Arterial blood gas or Oxygen saturation

• Urinalysis +/- Culture and sensitivity

• Urine drug screen

• Blood alcohol

• Serum drug levels (digoxin, theophylline, phenobarbital, cyclosporin, lithium, etc)

Workup

• Arterial blood gas or Oxygen saturation

• Urinalysis +/- Culture and sensitivity

• Urine drug screen

• Blood alcohol

• Serum drug levels (digoxin, theophylline, phenobarbital, cyclosporin, lithium, etc)

Workup

• Consider:

- Heavy metals

- Lupus workup

- Urinary porphyrins

Management

• 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

Management

• 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

Management

• 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

Management

• Environmental interventions

- “Timelessness”

- Sensory impairment (vision, hearing)

- Orientation cues

- Family members

- Frequent reorientation

- Nightlights

Management

• Pharmacologic management of agitation

- Low doses of high potency neuroleptics (i.e. haloperidol) – po, im or iv

- Atypical antipsychotics (risperidone)

- Inapsine (more sedating with more rapid onset than haloperidol – im or iv only

– monitor for hypotension)

Management

• 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

Management

• Benzodiazepines

- Treatment of choice for delirium due to benzodiazepine or alcohol withdrawal

Management

• Benzodiazepines

- May worsen confusion in delirium

- Behavioral disinhibition, amnesia, ataxia, respiratory depression

- Contraindicated in delirium due to hepatic encephalopathy

What we see…common cases

• Homeless male, hx. ETOH abuse, 2 days post-op

• 82 year-old women with UTI

• Burn victim after multiple med changes

• Mildly demented 71 year-old after hip replacement

Summary

• 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