Definition:

Delirium is a sudden, fluctuating, and usually reversible disturbance of mental function. DSM IV 4 key features:
1.

2.

3.

4.

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. A change in level of awareness and abilty to focus, sustain or shift attention. 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. Examiner should be sensitive to the pts flow of thought and not attribute tangential or disorganized speech to age, dementia, or fatigue Appearance pts appear drowsy, lethargic, or even semi-comatose in advanced cases. Extreme opposite hyper vigilance seen in alcohol or sedative withdrawal but this presentation is less common in elderly

Symptoms of Delirium cont

D)

Changes in cognition memory loss, disorientation, 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. May be accompanied by vague delusions of harm. Hallucinations can be visual, auditory of somatosensory, usually with a lack of insight (believe they are real)

E)

Symptoms of Delirium Cont

Temporal Course develop over hours days and typically persists for days to months Prodromal phase most likely in elderly patients. 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

Subtypes of Delirium

Hypoactive delirium sleepy Hyperactive delirium agitated

Mixed fluctuation between hypoactive and hyperactive delirium

Dementia Vs Delirium
Dementia Develops over months - 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, evidence of behavior change should be actively solicited from all staff, especially those that work the evening and night shifts Sundowning should be presumed to be delirium if its a new pattern. 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, reduced staff, shift changes

Delirium vs Mania

Mania can be confused with hyperactive delirium with agitation, delusions and psychotic behavior. However, mania is associated with a history of previous episodes of mania or depression

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

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, lack of judgment, problems with recent/working memory, blunted or labile emotions and incontinence will require neuroimaging to differentiate frontal lesions from delirium

Risk factor

Advanced age Underlying brain disease (dementia, CVA, Parkinsons etc) Polypharmacy particularly psychiatric drugs Decreased oral intake (e.g. dehydration) Advanced cancer Undertreated pain Immobility - including from the use of physical restraints Bladder catheters Limb fractures Sleep deprivation

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, 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, state of hydration, skin condition and potential infection foci

Dusky appearance- chronic pulmonary disease Jaundiced hepatic failure Needle tracks drug abuse Cherry red lips possible carbon monoxide poisoning Breath may smell of alcohol, fator hepaticus, uremic fetor or ketones Examine for any skull fractures Retinal hemorrhages intracranial bleed ex rupture berry aneurysm

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

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, CHF or other potential causes of hypoxia Drug levels for pts on digoxin, lithium, quinidine or if ETOH abuse suspected ECG to r/o MI can also have a coronary angiogram Arterial blood gas to evaluate hypoxia, hypercarbia and or lactate (the latter for r/o sepsis)

You still have no clue

Neurological imaging CT &/or MRI

Do not get if cause is medically treatable, no evidence of trauma, 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, headache and meningismus

EEG to r/o seizure activity and encephalopathy

useful in excluding seizures, especially nonconvulsive or subclinical seizures Certain metabolic encephalopathies or infectious encephalitides have a characteristic EEG pattern

Treatment

Thiamine for all! Physical restraints should be used only as a last resort, if at all, as they frequently increase agitation and create additional problems, such as loss of mobility, pressure ulcers, aspiration, and prolonged delirium Frequent reassurance, touch, 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. low-dose haloperidol 0.5 to 1.0 mg po or IM

Treatment Cont

Benzodiazepines have a limited role in the treatment of delirium; they are primarily indicated in cases of sedative drug and alcohol withdrawal. 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

Other treatments

NMDA antagonists * Memantine * Others (Ginkgo biloba, caffeine, nicotine, methylphenidate, NSAIDs)

Outcomes

Pts with delirium experience prolonged hospitalizations, functional and cognitive decline, higher mortality and higher risk for institutionalization even after adjusting for baseline differences in age, co morbid illness or dementia

Signs of delirium may persist for 12 months of longer, 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, it is a harbinger of future problems for frail and elderly patients

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