DELIRIUM:

Gizachew Asnake, MD
Assistant professor of psychiatry
Outline

• Definition
• Characteristics and Risk Factors
• Pathophysiology of delirium
• Diagnostic Criteria for Delirium
• Work- Up
• Management of Delirious patients
• You are called to consult on an agitated patient on the medical unit, The patient
is elderly, confused and pulling out her IV lines. You decide that she must be
tranquilized for her own safety.
• Which of the following drugs would be the best choice?

A)Lorazepam, B) Lithium, C) Haloperidol D) Ziprasidone, E) Thioridazine

Delirium

• “Acute and fluctuating organic mental syndrome characterized by an

alteration in attention, consciousness and cognitive functions …"

• In short: Delirium is acute cognitive impairment!

Epidemiology

• In the US & Europe, it is the 2nd most common presentation on

the C/L service (1st is depression)
• 15-60% of all patients that are hospitalized
• 33% of all ICU patients
• 80% of all intubated patients
• 40% of hospitalized elderly pts >65 yo
• 50% of pts post-hip fracture
• 20% of pts on general medical wards
• 15% of pts on general surgical wards
Features of Delirium

Impaired Information
Consciousness Processing Sleep- Wake
with Deficits Disruption
Inattention
Clinical Characteristics

Acute • Hours- Days

onset

• Waxing & Waning symptom

Fluctuating severity/ 24 hr. period
course • Worse at night
"Sundowning"
 Risk Factors

4 Predisposing Factors 5 Precipitating Factors

1. Cognitive Impairment 1. >3 Medications

2. Severe Illness Added
3. Visual Impairment 2. Catheterization
3. Use of Restraints
4. Dehydration
4. Malnutrition
5. Any Iatrogenic Event
Risk Factors
• Advanced age
• HTN • Multiple Co- Morbidities
• Alcoholism • Transfer to a new
• Severe illness environment
• Previous episode of
• Pre-existing brain insult
delirium
(i.e. CVA, TBI, dementia)
• Severity of illness
• Intubation
• Withdrawal from drugs/
• Poly- pharmacy alcohol
• Visual Impairment • ICU stay
• Dehydration • Male gender
Mechanism of Action

DA

Ach
Withdrawal from GABAA agonists

Glutamate

GABA
i.e. Alcohol, Benzos, Barbs
Other potential players

5- HT NE
NEUROPATHOPHYSIOLOGY

• Identified through lesion studies and functional neuroimaging

• Likely areas involved:
• Prefrontal Cortex,
• R cerebral hemisphere (especially parietal),
• subcortical nuclei (especially R thalamus and caudate)
• eg strokes in anteromedial thalamus or posterior parietal cortex
present with severe delirium
 DSM V CRITERIA
 Disturbance in attention and awareness
 Disturbance develops over a short period of time, represents a
change from baseline attention & awareness, & tends to fluctuate
during the day.
 Disturbance in cognition (memory deficit, disorientation, perception)
 The disturbances are not better explained by another disorder, &
doesn’t occur in the context of a coma
 Evidence from the history, physical exam, or labs that the disturbance
is caused by a medical condition, substance intoxication or w/d, or
medication side effect.
SPECIFIERS

Substance
Intoxication

Multiple Medication
Etiologies Induced

Due to Substance
another MC Withdrawal
 Acute VS. Prolonged

Hours - Days VS. Weeks - Months

SPECIFIERS

Hypoactive

Hyperactive Mixed
 Delirium may take days – weeks to resolve

 Persistent cognition deficits

 A prolonged hospital stay increased likelihood of death in the hospital & in the
6 months following the diagnosis association with a high mortality.

 When under- or misdiagnosed, it can result in a delay of appropriate medical

intervention
Objective Cognitive Tests

1. MMSE -It’s sensitive but NOT specific

2. The Montreal Cognitive Assessment (MoCA): a wider

range of tasks & > sensitivity in identifying mild
cognitive impairment than the MMSE.

3. Confusion Assessment Method (CAM)

MMSE
MoCA
The Confusion Assessment Method (CAM)
Differential Diagnoses

• Delirium is the “great imitator”

• Neurological brain injury
• Status epilepticus
• Psychosis
• Dementia
• Depression
• Mania
 Differentiating features

Features Delirium Dementia

Onset Acute Insidious
Course Fluctuating Progressive
Duration Days – weeks Months - years
Consciousness Altered Clear
Attention Impaired Normal (unless
severe)
Psychomotor Increased or Often normal
changes decreased
Reversibility Usually Rarely
Conditions associated with Delirium
I WATCH DEATH
Category Conditions

Encephalitis, meningitis, syphilis, pneumonia, urinary

Infectious
tract infection
Withdrawal From alcohol or sedative–hypnotics
Acidosis, alkalosis, electrolyte disturbances, liver or
Acute metabolic
kidney failure
Trauma Heat stroke, burns, following surgery

Abscesses, hemorrhage, seizure, stroke, tumor,

CNS pathology
vasculitis, or normal-pressure hydrocephalus

Anemia, carbon monoxide poisoning, hypotension,

Hypoxia
pulmonary embolus, lung or heart failure

Deficiencies Of vitamin B12, niacin, or thiamine

Hyper- or hypoglycemia, hyper- or

Endocrinopathies hypoadrenocorticism, hyper- or hypothyroidism,
hyper- or hypoparathyroidism

Acute vascular Hypertensive encephalopathy or shock

Toxins or drugs Medications, pesticides, or solvents

Heavy metals Lead, manganese, or mercury
LIFE THREATENING CAUSES OF Delirium

WWHHHHIMPS
Wernicke’s disease
Withdrawals
Hypoxia
Hypoglycemia
Hypertensive encephalopathy
Hyperthermia or hypothermia
Intracerebral hemorrhage
Meningitis or encephalitis
Poisoning (exogenous or iatrogenic)
Status epilepticus
 Delirium Work- Up

Examine the entire medical record: review scheduled /

PRN meds, VS

Collateral history, look at the overall time course

Evaluate for med. changes, recent infections, substance

use/ w/d

Examine the pt. (MSE)

Labs/Diags: CBC, LFT,RFT, TSH, RPR, vitamins B 12, 6 &1,
iron/TIBC, Folic acid, & thiamine, ethanol level, HIV

Add’l tests if clinically indicated: urine, blood, & sputum cx,

ammonia, head CT, brain MRI, EEG
Treatment

Treat with both

Find & correct the behavioral
exact etiology (ies) interventions +
pharmacotherapy
TREATMENT
• Four basic principles
Avoiding factors known to cause/aggravate delirium
Identifying & treat the underlying acute illness
Providing supportive & restorative care to prevent further physical
& cognitive decline
Controlling dangerous & disruptive behaviors
Behavioral Interventions

Avoid all benzos,

Reassure, barbs, Zolpidem &
Reorient to
distract, & anticholinergics as
environment they may worsen
redirect
the clinical picture

Provide 1:1 Match pt. with

supervision staff
 Pharmacological Treatment

• Neuroleptics are the agents of choice

• No drug has an official indication for treating behavioral symptoms of

delirium

• Haloperidol is the agent that has been most studied through the years
demonstrating efficacy for acute agitation
Why Haloperidol??

• First line agent in psychiatry and critical care practice guidelines –

but not FDA approved, and no RCTs for efficacy and safety in
critically ill patients to date
• Minimal anticholinergic side effects
• No active metabolites
• Can be administered in 3 different formulations- PO, IM & IV. IV
form less likely to cause EPS
• Less sedation than others
• Rare CV side effects
• > prolonged QT interval & may lead to Torsades de Pointes in
IV formulation
• usually high doses (>35mg/day)
• obtain baseline EKG and monitor QTc interval
Treatment-Haloperidol

• Goal: calm is the desired outcome, not SEDATION

• PO dose has about half the potency of the parenteral dose, so 10 mg of PO haloperidol
corresponds to 5 mg given IV or IM

• Initial bolus dose of haloperidol usually varies from 0.5 to 20 mg;

• usually 0.5 mg (for an elderly person) to 2 mg is used for mild agitation,
• 5 mg is used for moderate agitation,
• 10 mg for severe agitation

• A higher initial dose should be used only when the patient has already been unsuccessfully
treated with reasonable doses of haloperidol.
Can other atypical antipsychotics be used?

Ziprasidone

Quetiapine Haloperidol Olanzapine

Risperidone
Ziprasidone (21 msec.) >
Quetiapine (15 msec.) >
Hierarchy
Paliperidone (12 msec.) > of QTc prolongation
Risperidone (10 msec.)>
Olanzapine (6msec.) >
Haldol PO (5msec.)>
Aripiprazole (1 msec.)
*Haloperidol IV
Exception

Antipsychotics are the agent of choice to

block the dopamine blockade, EXCEPT
when related to w/d from GABA-A
agonists (Benzodiazepines, barbiturates,
alcohol)
Specific Diseases

• Pts with HIV/AIDS & Lewy body disease are more

susceptible to EPS & NMS
• Because of the dopamine blockade aggravating the
condition of Parkinson disease patients, Clozapine is
the preferred medication as it has less dopaminergic
activity. Quetiapine is used anecdotally due to less
frequent blood draws and compliance issues.
Summary
• Identify all of the risk factors of delirium
• Treat quickly to reduce its consequences
• Always consider delirium in your differential diagnosis if it’s acute
• Remember that the effects of delirium may be prolonged,
especially if the pt already has multiple risk factors present.
• Delirium is reversible by identifying & correcting contributing
factors
Thank you