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About Delirium Delirium is acute brain failure It is a clinical diagnosis, often
unrecognized and easily overlooked Recognition necessitates brief cognitive
screening and astute clinical observation Validated bedside assessment tools exist Diagnosis of exclusion - no definitive lab,
imaging, neurophysiological tests 5
Key Diagnostic Features Acute onset and fluctuating course of
symptoms Inattention Impaired consciousness Disturbance of cognition Disorientation, memory impairment, language
changes
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Supportive Features Disturbance in sleep-wake cycle Perceptual disturbances Hallucinations or illusions
Delusions Psychomotor disturbance Hypo- or hyperactivity
Inappropriate behavior Emotional lability
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Predisposing Factors Dementia Cognitive impairment History of delirium Functional impairment Visual impairment Hearing impairment
Comorbidity or severity of illness
Depression History of TIA or
stroke Alcohol abuse Older age (≥75 years)
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Precipitating Factors Drugs Physiological Increased BUN Increased
BUN/creatinine ratio Abnormal serum
albumin Abnormal sodium,
glucose, etc. Metabolic acidosis
Physical restraints Urinary catheter Infection Any iatrogenic event Surgery Trauma admission Urgent admission Coma
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High Risk Drugs Anticholinergics Antihistamines, muscle relaxants,
antipsychotics, antispasmodics, others Benzodiazepines Dopamine agonists Meperidine (Demerol)
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Moderate to Low Risk Drugs Antibiotics Anticonvulsants Antidizziness agents Antiemetics Antihypertensives Antivirals Corticosteroids Low-potency
antihistamines
Metoclopramide (Reglan)
Narcotics other than meperidine
NSAIDs Sedatives/hypnotics Tricyclic
antidepressants
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History
Exam
Diagnostic Tests
Principles of Management Drug adjustments Address acute medical issues Reorientation strategies Maintain safe mobility Normalize sleep-wake cycle Pharmacological management
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Delirium Dx and Rx Assess all elderly inpatients for delirium Reduce psychoactive drugs whenever possible Use non-pharmacological methods to manage
sleep, anxiety, and agitation if possible Use drugs to treat severe agitation or psychosis Inform/involve patients and family members Avoid bed rest and encourage mobility Ensure patients have glasses, hearing aids,
dentures 23
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ICU-Acquired Cognitive Deficits Patients treated in ICUs were at high risk
for new cognitive impairment during 12 months of follow-up 24% had deficits similar in severity to
those with mild Alzheimer’s disease Duration of delirium was associated with
worse cognitive scores Sedative or analgesic use was not
associated with worse cognitive scores 25
Essential Points - 1 Delirium is common but not usually
diagnosed, especially if hypoactive Interferes with rehab New delirium is a medical emergency,
requiring evaluation Analogous to new chest pain
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Essential Points - 2 Do not under-treat severe pain for fear of
causing delirium Hand-feeding is better than a tube and
less likely to cause delirium, but requires a lot of time by nursing aide Preserving function in hospitalized elders
is key to good management Get out of bed and ambulate
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Essential Points - 3 Antipsychotics are okay if needed to
permit necessary medical interventions, but should be used at the lowest doses for the shortest time They are not effective for preventing or
treating delirium, only for sedation They are the first-line drugs Do not use benzodiazepines except for
benzodiazepine or alcohol withdrawal 28
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