DELIRIUM

DR VIREN SOLANKI
SECOND YEAR RESIDENT
PSYCHIATRY, BMC
 INTRODUCTION
• Delirium as defined by DSM-5 is characterized by an
ACUTE decline in both the level of awareness and
cognition with particular impairment in ATTENTION.
• Often involves perceptual disturbance, abnormal
psychomotor activity, sleep cycle impairment.
• Life threatning , medical emergency, high mortality
rate.
• Potentially reversible brain dysfunction
 INTRODUCTION
• Psychiatric manifestations are purely of
organic etiology
• Most common consultation liation conditition
• Often under- recognized.
• Often under- treated.
• Cause burden on health care system.
 BURDEN OF DELIRIUM
• Increased MORTALITY
• Increased lenth of care
• Increased nursing care
• Increased risk of cognitive & functional decline
• Prevention of early rehabilitation
• Increase distress to care givers
 OTHER TERMS FOR DELIRIUM
• Intensive care unit psychosis
• Acute Brain failure
• Acute confusional state
• Toxic metabolic state
• Sundowning
• Central nervous system toxicity
• Encephalitis
 HOW COMMON IT IS ?
POPULATION PREVALENCE RANGE (%)

Institutionalized elderly 44%

Orthopedic surgery patient 33%

Terminally ill cancer patient 23-28%

Cardiac surgery patient 16-34%

Critical care unit patient 16%

Emergrncy deoartment 7-10%

 PREDESPOSING FACTORS FOR
DELIRIUM
• Age 65 and older
• Male sex
• Dementia
• History of delirium
• Hearing & vision impairment
• History of fall
• Low level of activity
• Dehydration
• Alcohol abuse
• Coexsisting medical conditition
 PRECIPITATING FACTORS FOR
DELIRIUM
• DRUGS- sedative hypnotics , Narcotics ,
anticholinergic drugs, poly farmacy,
Alcohol or drug withdrawl
• PRIMARY NEUROLOGICAL DISEASES- stroke,
intracranial bleeding , meningitis or
encephalitis
• INTERCURRENT ILLNESSES- infection , sepsis
dehydration, shock , hypoxia , poor nutritional
status , metabolic derangement
 PRECIPITATING FACTORS FOR
DELIRIUM
• SURGERY- orthopedic surgery , Cardiac surgery
, prolong cardio pulmonary bypass
• ENVIRONMENTAL - prolong sleep deprivation,
use of physical restraints , use of bladder
catheter , pain , emotional stress , use of
multiple procedures
 WHY DOSE DELIRIUM OCCUR ?
• Pathophysiology is not clearly understood yet.
• Impaired oxygen supply associated with all
delirium.
• Common hypothesis to describe delirium:
1) Neurotransmitter imbalance hypothesis
2) Neuro-inflammatory hypothesis
3) Substance withdrawal induced delirium
NEUROTRANSMITTER IMBALANCE
NEUROTRANSMITTER IMBALANCE
• ACETYLCHOLINE DEFICIENCY
- core neurotransmitter involved in delirium.
- ACH is necessary for REM sleep, attention,
arousal, memory.
- loss of cholinergic neuron are strongly
associated with delirium.
- some clinical scenario .
NEUROTRANSMITTER IMBALANCE
• DOPAMINE
- excess
- dopamine antagonist effective
• GLUTAMATE
- act on NMDA receptor , excess
- exito-toxicity
• GABA
- delirium secondary to alcohol & BZD withdrawal
HOW DOSE IT MANIFEST ?
 HOW DOSE IT MANIFEST ?
• Inattention
• Disturbance of consciousness
• Disturbance of Orientation & memory
• Perceptual disturbance
• Fluctuation
• Disruption of sleep wakefulness
• Disorder of thought and language
 INATTENTION
• Forgets instructions.
• Repeatedly asks the same questions.
• Gives different replies to same questions.
• Distraction to seeming irrelevant stimuli.
 DISTURBANCE OF CONSCIOUSNESS

• Falling asleep during interview.

• Conflicting reports about awake mental state
of the patient provided by various caregivers.
 DISORDERS OF ORIENTATION&MEMORY

• Not aware about time , place , person &self.

• Misidentified people around.
• Talking as if a home or workplace.
• Talking about dead relatives.
• Forgetting about meals, medicine , visitors ,
etc
 PERCEPTUAL DISTURBANCE
• Both hallucinations and illusion are seen.
• Visual hallucination more common , which
indicate organic etiology.
• Tactile and auditory hallucinations can be
seen.
 DISORDERS OF THOUGHT
• Abnormalities in form and content of thinking
are prominent.
• Thinking may become bizarre or illogical.
• Delusion of persecution are common.
TYPES OF DELIRIUM
 TYPES OF DELIRIUM
• HYPERACTIVE :
- increase psychomotor activity (agitation).
- easily recognized.
- common in drug intoxication and
withdrawal, with adverse effect of anti
cholinergic drugs.
- Hallucination and illusion present.
 TYPES OF DELIRIUM
• HYPOACTIVE DELIRIUM:
- Decrease psychomotor activity (retardation).
- More common than hyperactive delirium in
older patient.
- Often unrecognized.
- Metabolic causes are commonly associated.
• MIXED:
- Fluctuation between both.
 EXAMINATION IN THE PATIENT WITH
DELIRIUM
• Physical examination.
• Assess hydration , nutritional status.
• Evidence of sepsis.
• Consider differential diagnosis.
• Confirm the Diagnosis.
• Rate the severity of delirium.
• Rate the subtype of delirium.
PHYSICAL EXAMINATIONS
HOW TO DIAGNOSE ?