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DELIRIUM
DELIRIUM
PRESENTER : D r. VA R A D A P
C H A I R P E R S O N : D r. D R U H I N A V
PLAN
• Introduction
• Etymology
• History
• Nosology
• Criteria
• Risk factors
• Pathophysiology
• Types
• Management
• Recent developments
INTRODUCTION
• Common in elderly
• Rate varies based on settings
• Community studies- 1% of elderly population of age 55 or more have delirium
• Elderly ER room subjects- 5-10% prevalence
• Mostly underdiagnosed
• Mortality -22 -76% in hospitalized patients
INCIDENCE AND PREVALENCE OF
DELIRIUM IN VARIOUS SETTINGS
RISK FACTORS FOR DELIRIUM
P R E D I S P O S I N G FAC TO R S P R E C I P I TAT I N G FAC TO R S
1. Acetylcholine
2. Dopamine
3. Glutamate
4. GABA
5. Serotonin
ACETYL CHOLINE
• Evidence of cholinergic deficiency in delirium
• ACh involved in REM sleep , arousal , attention and memory
• Anticholinergic drugs worsen delirium
• Serum cholinergic deficiency was demonstrated
• Cholinergic agents like physostigmine improves delirium
DOPAMINE:
Dopaminergic excess
Probably due to regulatory influence on acetyl choline
Involvemnet in maintaining and shifting attention
Dopaminergic drugs(levodopa,bupropion)-causes delirium
Antidopaminergic drugs(antipsychotics) – used in treatment of delirium
GLUTAMATE :
• causes delirium due to excitatory neurotoxicity effect through NMDA
receptors
• Proposed mechanism for Wernicke’s encephalopathy
GABA :
• Implicated in delirium secondary to benzodiazepine and alcohol withdrawal
• Increased GABA levels in hepatic encephalopathy
Alterations in other neurotransmitters like norepinephrine , melatonin,
serotonin- implicated in causation of delirium
presents with severe flu like symptoms , gastro intestinal cramping, diarrhea,
diaphoresis, autonomic hyperactivity and craving
delirium- with switching from transdermal fentanyl to morphine
POSTOPERATIVE DELIRIUM
Hyperactive delirium:
• Most commonly recognized
• May exhibit agitation, psychosis and mood lability
• Refuse to cooperate with medical care
• Disruptive behavior
• May sustain injuries
Hypoactive delirium
• More common than hyperactive but less recognized
• Mostly associated metabolic causes
• Appear sluggish, lethargic as well as confused
• Disruptive, bizarre and injurious behavior absent
• Stronger stimuli needed for arousal
MIXED
1)SEPSIS
2 TEMPERATURE FEVER 2)THYROID STORM
3)VASCULITIS
1)SHOCK
HYPOTENSION 2)HYPOTHYROIDISM
3)ADDISON’S DISEASE
BLOOD
3 PRESSURE
1)ENCEPHALOPATHY
HYPERTENSION
2)INTRACRANIAL MASS
PHYSICAL EXAMINATION
1)DIABETES
2)PNEUMONIA
TACHYPNOEA 3)CARDIAC FAILURE
4)FEVER
5)ACIDOSIS
4 RESPIRATION
ALCOHOL OR OTHER
SHALLOW
SUBSTANCE INTOXICATION
EVIDENCE OF NUCHAL
7 NECK RIGIDITY
MENINGITIS
PHYSICAL EXAMINATION
TUMOUR
PAPILLOEDEMA HYPERTENSIVE
ENCEPHALOPATHY
8 EYES
ANXIETY
PUPILLARY
DILATATION AUTONOMIC
HYPERACTIVITY
TONGUE OR CHEEK
9 MOUTH LACERATIONS
EVIDENCE OF GTCS
INADEQUATE
CARDIAC OUTPUT
ARRHYTHMIA
POSSIBILITY OF
EMBOLI
11 HEART
HEART FAILURE
CARDIOMEGALY HYPERTENSIVE
DISEASE
PHYSICAL EXAMINATION
1)PRIMARY
PULMONARY FAILURE
12 LUNGS CONGESTION
2)PULMONARY EDEMA
3)PNEUMONIA
ALCOHOL
13 BREATH
KETONES DIABETES
1)CIRRHOSIS
14 LIVER ENLARGEMENT
2)LIVER FAILURE
PHYSICAL EXAMINATION
MASS LESION
ASYMMETRY WITH CVA
BABINSKI’S SIGN PREEXISTING
DEMENTIA
REFLEXES
FRONTAL MASS
SNOUT
B/L PCA OCCLUSION
ABDUCENT WEAKNESS IN
INCREASED IN ICP
NERVOUS NERVE LATERAL GAZE
15 SYSTEM
MASS LESION
LIMB STRENGTH ASYMMETRICAL CEREBROVASCULAR
DISEASE
ANXIETY
AUTONOMIC HYPERACTIVITY
DELIRIUM
LABORATORY EXAMINATION
DIFFERENTIAL DIAGNOSIS
• Dementia
• Depression
• Schizophrenia
• Anxiety
DIFFERENTIAL DIAGNOSIS
RATING SCALES
PHARMACOLOGICAL
MANAGEMENT OF
DELIRIUM
NONPHARMACOLOGICAL
PHARMACOLOGICAL MANAGEMENT
• ECT:
• When other approaches have failed
• Usually given en bloc or daily for several days, sometimes multiple treatments
per day
• Should be monitored closely
TREATMENT IN SPECIAL POPULATION
In Parkinson’s disease
• Often antiparkinsonian drugs are implicated
• Reducing the dosage of drugs
• If symptoms persists clozapine
• If not tolerated quetiapine is being tried
Terminally ill patients
• Focus is on palliation, comfort and assistance with dying
In those with concomitant dementia
• Both modalities are less effective
• Neuroleptics to be avoided in lewy body dementia and vascular dementia
• Lower dose of antipsychotics should be used
• Monitoring of adverse effects
• Prolonged use should be avoided
NONPHARMACOLOGICAL
MANAGEMENT
• Treatment of underlying cause for delirium
• Maximizing safety of environment and providing psychosocial support
• Patient’s ability to interpret environment should not be affected-those with glasses or hearing
aid should be given those
• Paper and pen to improve communication if intubated
• Modifying the environment to reduce fear and agitation- avoid extremes of sensory input
• Maintenance of patient comfort
• Adequate pain control
• Initiation of physical activity
Enhance orientation using visual cues like clock,calendar or windows
Restoration of normal sleep wake cycle by daytime activity
Decreased interruption of sleep
Adequate nutrition
Psychosocial support by staff and family members (avoiding unnecessary
conversations near the patient, helping in reorientation and reassurance
Minimal use of physical restraint
RECENT DEVELOPMENTS