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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