This action might not be possible to undo. Are you sure you want to continue?
Delirium is a sudden, fluctuating, and usually reversible disturbance of mental function. DSM IV – 4 key features:
Disturbances in consciousness with reduced ability to focus, sustain or shift attention A change in cognition or the development of a perceptual disturbance that is not better accounted for by a preexisting, established or evolving dementia The disturbance develops over a short period of time (usually hours – days) and tends to fluctuate during the course of the day There is evidence from history. Physical exam, or lab results that the disturbance is caused by a medical condition, substance intoxication or medication side effect
How common is delirium? 30% of older patients experience delirium at some time during hospitalization 50% of elderly patients in the ICU 10 – > 50% of elderly patients who have had surgery – (ex complex cardiac surgery) Delirium superimposed on dementia rates up to 89% .
Symptoms of Delirium A) Disturbances of consciousness – usually earliest manifestation. lethargic. Extreme opposite – hyper vigilance seen in alcohol or sedative withdrawal but this presentation is less common in elderly . Usually a subtle change and may precede the more flagrant signs of delirium by a day or more “isnt acting quite right” B) C) Distractibility – evident in conversation. dementia. A change in level of awareness and abilty to focus. Examiner should be sensitive to the pts flow of thought and not attribute tangential or disorganized speech to age. or fatigue Appearance – pts appear drowsy. sustain or shift attention. or even semi-comatose in advanced cases.
usually with a lack of insight (believe they are real) E) . Hallucinations can be visual.Symptoms of Delirium con’t D) Changes in cognition – memory loss. May be accompanied by vague delusions of harm. difficulty with language and speech – can use formal status testing but the score is not nearly as important as the overall accessibility and attentiveness when answering questions – good time to get collateral to compare with baseline functioning Problems with perception – pt may misidentify the clinician or believe that objects or shadows in the room represent a person. disorientation. auditory of somatosensory.
Usually presents as quiet hypoactive delirium or erupts into an agitated confusional state. Complaints to look for in the prodromal phase: Fatigue Sleep disturbances (excessive daytime somnolence or insomnia) Depression Anxiety Restlessness Irritability Hypersensitivity to light or sound .Symptoms of Delirium Con’t Temporal Course – develop over hours – days and typically persists for days to months Prodromal phase – most likely in elderly patients.
Subtypes of Delirium Hypoactive delirium – sleepy Hyperactive delirium – agitated Mixed – fluctuation between hypoactive and hyperactive delirium .
reduced staff. shift changes .years Enduring Delirium Develops over hours-days Temporary Fluctuating through the course of the day – worse in the evening Pt may be very lucid in the morning Clinicians are apt to miss the the diagnosis of if they rely upon only a single point assessment. Patients with established sundowning and no obvious medical illness may be suffering from effects of impaired circadian regulation or nocturnal factors in the hospital – noise. especially those that work the evening and night shifts “Sundowning” should be presumed to be delirium if it’s a new pattern.Dementia Vs Delirium Dementia Develops over months . evidence of behavior change should be actively solicited from all staff.
mania is associated with a history of previous episodes of mania or depression . However.Delirium vs Mania Mania can be confused with hyperactive delirium with agitation. delusions and psychotic behavior.
Delirium Vs Schizophrenia In schizophrenia the delusions are highly systemized – the history is longer and the sensorium is otherwise clear Hallucinations in delirium are most commonly visual .
lack of judgment. blunted or labile emotions and incontinence will require neuroimaging to differentiate frontal lesions from delirium . problems with recent/working memory.Delirium vs Focal neurological syndromes Temporal parietal – Pts with Wernickes aphasia – may appear delirious as they do not comprehend or obey and seem confused – however the problem is restricted to language Bitemporal dysfunction – transient global amnesia – deficit is restricted to memory Occipital – Antons syndrome cortical blindness and confabulation may look like delirium but an exam will reveal a lack of vision Frontal akinetic mutism.
g.Risk factor Advanced age Underlying brain disease (dementia. dehydration) Advanced cancer Undertreated pain Immobility . CVA.including from the use of physical restraints Bladder catheters Limb fractures Sleep deprivation . Parkinsons etc) Polypharmacy – particularly psychiatric drugs Decreased oral intake (e.
skin condition and potential infection foci Dusky appearance. state of hydration.Evaluation Recognizing the disorder. Some studies estimate that up to 70% of cases of delirium go unrecognized. Behavioral/cognitive impairment wrongly attributed to the patients age. uremic fetor or ketones Examine for any skull fractures Retinal hemorrhages – intracranial bleed ex rupture berry aneurysm . fator hepaticus.chronic pulmonary disease Jaundiced – hepatic failure Needle tracks – drug abuse Cherry red lips – possible carbon monoxide poisoning Breath – may smell of alcohol. to dementia or other mental disorders In one study over 40% of consults to psychiatrists for depression were ultimately found to have delirium General exam should be focused on vital signs.
Delirium Tremens Alcohol/sedative withdrawal characterized by autonomic nervous system activation Tachycardia Sweating Flushing Dilated pupils These signs are obvious in younger populations. but are blunted or absent in the geriatric population .
lithium. CHF or other potential causes of hypoxia Drug levels for pts on digoxin.Investigations CBC to r/o infection or anemia Chem panel to r/o metabolic disturbances or hepatic encephalopathy UA to r/o infection CXR to r/o PNA. hypercarbia and or lactate (the latter for r/o sepsis) . quinidine or if ETOH abuse suspected ECG to r/o MI – can also have a coronary angiogram Arterial blood gas to evaluate hypoxia.
no new focal neurological deficits present or if the patient is arousable and able to follow simple commands – DO get if patient does not improve as expected Lumbar puncture to r/o meningitis and encephalitis Geriatric patients are more likely to present with delirium rather than the classic triad of fever.You still have no clue… Neurological imaging – CT &/or MRI Do not get if cause is medically treatable. especially nonconvulsive or subclinical seizures Certain metabolic encephalopathies or infectious encephalitides have a characteristic EEG pattern . headache and meningismus EEG to r/o seizure activity and encephalopathy useful in excluding seizures. no evidence of trauma.
pressure ulcers. and verbal orientation from familiar persons lessen disruptive behaviors cautious trial of psychotropic medication is warranted for treatment of severe agitation or psychosis with the potential for harm.Treatment Thiamine for all! Physical restraints should be used only as a last resort. low-dose haloperidol 0.0 mg po or IM . touch. if at all. and prolonged delirium Frequent reassurance.5 to 1. as they frequently increase agitation and create additional problems. aspiration. such as loss of mobility.
they are primarily indicated in cases of sedative drug and alcohol withdrawal.Treatment Con’t Benzodiazepines have a limited role in the treatment of delirium. They may also be useful adjuncts to neuroleptics to promote light sedation and reduce extrapyramidal side effects .
Prevention Orientation protocol and cognitive stimulation for patients with cognitive impairment Environmental modification and non pharmalogical sleep aids for patients with insomnia Early mobilization and minimizing use of physical restraints for patients with limited mobility Visual and hearing aids for patients with these impairments Early volume repletion for patients with dehydration Avoid use of restraints .
Non-pharmacologic Interventions Social activities Adequate sleep Adherence to a strict schedule Maintenance of a proper stimulation level Adequate hydration Reformatting task (occupation therapy) Support caregivers .
Pharmacologic Interventions Neuroleptic medications (low dose haloperidol)– effective in symptomatic patients but not as a preventative measure Atypical antipsychotics – Risperadone. olanzapine Benzodiazepine – rapid onset vs antispsychotics but can worsen confusion and sedation Anticholinesterase inhibitors do not have good efficacy .
NSAIDs) .Other treatments NMDA antagonists * Memantine * Others (Ginkgo biloba. caffeine. methylphenidate. nicotine.
co morbid illness or dementia Signs of delirium may persist for 12 months of longer. higher mortality and higher risk for institutionalization even after adjusting for baseline differences in age. functional and cognitive decline. particularly in those with underlying dementia 1 study found – 2 years after hospitalization only 1/3 of pts who experianced delirium still lived independantly in the community – so while “reversible”.Outcomes Pts with delirium experience prolonged hospitalizations. it is a harbinger of future problems for frail and elderly patients .
THANK YOU! .
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.