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DELIRIUM. Dr Annette Downey Consultant Psychiatrist, Exeter & cognitive analytic therapist MRCPsych Course, Derriford June 2011. Definition. F05 Delirium, not induced by alcohol and other psychoactive substances

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Dr Annette Downey Consultant Psychiatrist, Exeter & cognitive analytic therapist

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Dr annette downey consultant psychiatrist exeter cognitive analytic therapist

DELIRIUM

Dr Annette Downey

Consultant Psychiatrist, Exeter

& cognitive analytic therapist

MRCPsych Course, Derriford

June 2011


Definition

Definition

  • F05 Delirium, not induced by alcohol and other psychoactive substances

  • An etiologically nonspecific organic cerebral syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to very severe. Includes: acute or subacute: · brain syndrome · confusional state (nonalcoholic) · infective psychosis · organic reaction · psycho-organic syndrome

  • Excludes: delirium tremens, alcohol-induced or unspecified ( F10.4 ) F05.0 Delirium not superimposed on dementia, so described F05.1 Delirium superimposed on dementia Conditions meeting the above criteria but developing in the course of a dementia (F00-F03). F05.8 Other delirium Delirium of mixed origin F05.9 Delirium, unspecified


Rates of delirium

Rates of Delirium

  • 30% of hospital inpatients over the age of 65.

  • At least 10% of unselected acute medical admissions in a typical UK hospital.

  • Community prevalence of 1-2%

    • but 14% in the over 85s

  • Usually under diagnosed and unrecognized by clinical staff


Features for diagnosis of delirium

Features for Diagnosis of Delirium

  • Disturbance of consciousness, with reduced ability to focus, sustain or shift attention

  • A change in cognition (memory/orientation/language) or the development of a perceptual disturbance that is not better accounted for by a pre existing /evolving dementia

  • The disturbance is over a short time (usually hours to days) & tends to fluctuate during the course of the day

  • There is evidence from the history, physical examination or lab findings of a direct physiological consequence of a general medical condition, substance intoxication or substance withdrawal.


Historical perspective

Historical Perspective

  • Latin: ‘de’ – ‘out of’; lira – ‘the furrow’.

  • Old English – delire – to go astray, go wrong, rave, to wander in mind or to go mad

  • Hippocrates 2500 years ago recognized a clinical syndrome of symptomatic acute mental disorder associated with fever, which features cognitive & behavioural disturbance as well as sleep disruption, which improved when the fever improved.


Clinical types of delirium

Clinical Types of Delirium

  • Hyperactive (classical) or florid type – increased sympathetic activity – increased HR, sweating, dilated pupils flushed, increased BP; restless & seek reassurance. Keep other patients awake & high falls risk

  • Hypoactive - poor oral intake, slumped over their tray, fall asleep mid-conversation – high risk of pressure sores, malnutrition & dehydration

  • Mixed – fluctuates between the two – behaviour & sleep charts helpful – are often discharged too early


Predisposing precipitating factors

Predisposing & precipitating Factors

  • Usually multi-factorial (isn’t all of psychiatry?!)

  • The more factors the higher the risk

  • Increased vulnerability mentally & physically

  • Age related

  • Dementia/cognitive impairment

  • Severity of illness

  • Metabolic/electrolyte imbalance eg dehydration,malnutrition.

  • Psychoactive medications – neuroleptics/narcotics/anticholinergics, more than 3 medications added

  • Use of a bladder catheter

  • Previous delirium

  • Visual impairment

  • Male

  • Fractures on admission

  • Use of physical restraint


Neuropathophysiology

Neuropathophysiology

  • Neurotransmitters

    • Hypothesis of acetylcholine deficiency

      • BUT – No cholinergic medication can prevent delirium - Is this a causal relationship?

      • ALSO – other neurotransmitters have been implicated eg dopaminergic medications of Parkinsons, as well as dopamine antagonists eg haloperidol treating delirium

      • WHAT about the role of serotonin – ‘The serotonin syndrome’? –seems the same as hyperkinetic delirium.

      • OTHER neurotransmitters – Noradrenalin/ GABA/glutamate/Melatonin; or a neurotransmitter balance?


Glucocorticoids

Glucocorticoids

  • Hypothalamo-pituitary Axis

  • The bodies reaction to physical illness is to produce glucocorticosteroids

  • The hippocampus has high numbers of receptors

  • Hypercortisolism is demonstrated in delirium assoc with LRTI/ Post op delirium/post stroke delirium

  • BUT most patients with delirium have normal not supressed cortisol levels.


Cytokines

Cytokines

  • Interleukin-2 therapy causes delirium & this is dose dependent

  • Mechanism?

Christ in the Storm, Rembrandt


Other types of delirium

Other Types of Delirium

  • Delirium tremens

  • Benzodiazepine withdrawal


Patient experience

Patient Experience

  • ‘I was certainly paranoid in the ICU [delirious I suppose], I was absolutely sure [still am] that an ICU nurse tried to kill me to sell my organs on ebay - heard the whole conversation whilst he was sedating me with serious drugs as I kept ripping ouy my central and trach...’

  • ‘When I was in ICU, after waking-up from a drug-induced coma, I thought I was being held hostage in some kind of medical lab! I had soft restraints on my hands and I remember using my foot to try to pull a machine closer to the bed because I thought I would be able to send out an "email S.O.S." - I am sure it was an ultrasound machine or ECG machine.’


Delirium presents with

Delirium Presents With:

Sudden onset

Poor concentration/attention (WORLD)

Global impairment of time, place and person, recent memory, and slowed thinking.

Psychomotor disturbance – either reduced or agitated

Disturbed sleeping pattern – eg up all night

Emotional lability

Hallucinations – often visual and complex

  • 13

June 2011


Confusion assessment method cam for delirium

Confusion Assessment method (CAM) for Delirium

Inouye, S. Ann Int Med 1990;113:941-948.

Criteria:

  • 1. Acute change in mental status,

  • AND Observation by a family member, caregiver, or primary care physician

  • 2. Symptoms that fluctuate over minutes or hours,

  • AND Observation by nursing staff or other caregiver

  • 3. Inattention -Patient history, Poor digit recall, inability to recite months of year backwards

  • PLUS4. Altered level of consciousness,

  • OR Hyper-alertness, drowsiness, stupor, or coma

  • 5. Disorganized thinking, Rambling or incoherent speech

  • The first 3 criteria PLUS the fourth OR the fifth criterion must be present to confirm a diagnosis of delirium.


Video demonstration of the cam method

Video demonstration of the CAM method


Delirium differential

Delirium Differential

Depression (pseudodementia)

Dementia (chronic confusion)

Motor slowness (Parkinsons /ism)

General physical frailty

Learning disability

Dissociative states/personality (pseudodementia also).

Impoverished Social Environment

Iatrogenic (eg secondary to medication)

Cognitive Impairment not dementia

  • 16

June 2011


Differentiating delirium and dementia

Differentiating: Delirium and Dementia

Acute often at night

Fluctuates with lucid periods

Lasts hours /days

Reduced awareness

Impaired attention

Disorientated for time

Visual illusions and hallucinations

Disrupted sleep

Insidious onset

Stable over a day

Lasts months/years

Clear awareness

Good Attention

Disorientation in later stages

Impoverished thinking

Sleep is usually normal

Annette Downey

June 2011


Causes of delirium

Infection

Stroke

Drugs

MI

Fractures

Carcinoma

Electrolytes

Heart failure

Diabetes

Peripheral vascular disease/gangrene

Alcohol withdrawal

GI bleed

Respiratory failure

PE

Anaemia

Perforated DU

Subdural

Brain tumour

Causes of Delirium


Management begins with obtaining a full history

Management begins with obtaining a full history

Informant History – relatives & carers for baseline status

Record chronological progression

Wide symptom variation

Length of symptoms

Insidious or rapid onset

Gradual or stepwise progression

Day to day fluctuations

Describe a typical day

Consider effect of symptoms on function

Annette Downey

June 2011


Initial clinical management

Initial Clinical management

  • Establish baseline status

  • Medical investigations – FBC, glucose, urea, electrolytes, Ca, LFTs, TFTs, inflammatory markers, urine dipstick, +/-MSU

  • Blood cultures indicated?

  • ABG/ CXR/ ECG

  • Rectal examination?

  • Prompt rehydration/antibiotics & O2

  • SC fluids may be a good idea

  • Are medications being taken or discarded?

  • Accurate fluid & nutritional charting

  • Watch out for pressure sores/pneumonia/DVTs


Supportive behavioural management

Appropriate lighting levels for the time of day

Regular & repeated cues to orientation

Clocks/calandars

Hearing aids/spectacles

Continuity of care from nursing staff

Encourage mobility & activity

Approach & handle gently

Turn off noisy alarms etc

Analgesia regularly

Warm milky drinks, relative quiet & single cubicle if poss

Encourage family visits

Explain the confusion to family

Fluid & food intake

Adequate CNS oxygen delivery (sats above 95%)

Sleep hygeine

Avoid ward & hospital transfers

Avoid physical restraint

Rx constipation

Avoid anticholinergics

Avoid catheters where poss

Supportive & behavioural management


Medication

Medication

  • Review the ongoing need for

    repeat prescriptions

  • Consider omitting respiridone, olanzapine/ quetiapine.

  • Do Not Stop AChEIs such as donepezil, rivastigmine, galantamine

  • Scrutinize opiates – tramadol

  • Follow your local hospital guidelines for the use of prn sedative medications ie rapid tranquilization policy for mental health trusts.


Medical treatment there is not much research to support clinical practice

Medical treatmentThere is not much research to support clinical practice

Haloperidol PO 0.5 mg at 2 hourly intervals (max of 5 mg per day) or IM 1-2 mg

Anxiolytics especially for lewy body dementia & patients with parkinsons

–lorazepam PO 0.5-1mg (max 3 mg per day)

-clonazepam

Avoid polypharmacy

Side effects are common

Titrate slowly and monitor carefully

Dosette boxes and blister packs very helpful in agreement with carers

Annette Downey

June 2011


Communication

Communication

  • Frightening confusing experience for patients

  • Use lucid periods opportunistically

  • Warn that it might recur & advise early attendance at GP surgery

  • With relatives/carers – family meetings on the ward – again opportunistically

    • Initially information gathering

    • Then education/explanation

      about delirium

      Help with orientation – photos,

      assist at meal times, playing card games,

      talking about past times.

      Discussing the future


Prognosis

Prognosis

  • Delirium is a marker for physical & cognitive decline

  • It is an independent risk factor for poorer outcomes following admission

  • There is a trend to longer inpatient stays

  • Increased risk of falls, pressure sores, urinary incontinence

  • Higher readmission rates

  • Increased long term institutionalism

  • Increased mortality


Dr annette downey consultant psychiatrist exeter cognitive analytic therapist

Adopt A Person Centred Approach

Annette Downey

June 2011


Dr annette downey consultant psychiatrist exeter cognitive analytic therapist

Each person has a unique life history, set of relationships and preferences

The persons actions are not under their control

Important to avoid getting angry and frustrated; avoid challenging the person.

Annette Downey

June 2011


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