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Delirium. Lea C. Watson, MD, MPH Robert Wood Johnson Clinical Scholar UNC Department of Psychiatry. Nurse pages med student:

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Delirium l.jpg

Delirium

Lea C. Watson, MD, MPH

Robert Wood Johnson Clinical Scholar

UNC Department of Psychiatry


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Nurse pages med student:

“..Mr. Smith pulled out his NG tube and can’t seem to sit still. Last night after his surgery he was fine, reading the paper and talking to his family…today I don’t even think he knows where he is… can you come see him?”

Med student says:

“…sounds like DELIRIUM- good thing you called- I’ll be right there.”


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Delirium

  • A sudden and significant decline in mental functioning not better accounted for by a preexisting or evolving dementia

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


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4 major causes

  • Underlying medical condition

  • Substance intoxication

  • Substance withdrawal

  • Combination of any or all of these


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Patients at highest risk

  • Elderly

    • >80 years

    • demented

    • multiple meds

  • Post-cardiac surgery

  • Burns

  • Drug withdrawal

  • AIDS


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Prevalence

  • Hospitalized medically ill 10-30%

  • Hospitalized elderly 10-40%

  • Postoperative patients up to 50%

  • Near-death terminal patients up to 80%


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Clinical features

Prodrome

Fluctuating course

Attentional deficits

Arousal /psychomotor disturbance

Impaired cognition

Sleep-wake disturbance

Altered perceptions

Affective disturbances


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Prodrome

  • Restlessness

  • Anxiety

  • Sleep disturbance


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Fluctuating course

  • Develops over a short period (hours to days)

  • Symptoms fluctuate during the course of the day (SYMPTOMS WAX AND WANE)

    • Levels of consciousness

    • Orientation

    • Agitation

    • Short-term memory

    • Hallucinations


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Attentional deficits

  • Easily distracted by the environment

  • May be able to focus initially, but will not be able to sustain or shift attention


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Arousal/psychomotor disturbance

  • Hyperactive (agitated, hyperalert)

  • Hypoactive (lethargic, hypoalert)

  • Mixed


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Impaired cognition

  • Memory Deficits

  • Language Disturbance

  • Disorganized thinking

  • Disorientation

    • Time of day, date, place, situation, others, self


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Sleep-wake disturbance

  • Fragmented throughout 24-hour period

  • Reversal of normal cycle


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Altered perceptions

  • Illusions

  • Hallucinations

    - Visual (most common)

    - Auditory

    - Tactile, Gustatory, Olfactory

  • Delusions


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Affective disturbance

  • Anxiety / fear

  • Depression

  • Irritability

  • Apathy

  • Euphoria

  • Lability


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Duration

  • Typically, symptoms resolve in 10-12 days

    - may last up to 2 months

  • Dependent on underlying problem and management


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Outcome

  • May progress to stupor, coma, seizures or death, particularly if untreated

  • Increased risk for postoperative complications, longer postoperative recuperation, longer hospital stays, long-term disability


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Outcome

  • Elderly patients 22-76% chance of dying during that hospitalization

  • Several studies suggest that up to 25% of all patients with delirium die within 6 months


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I nfections

W ithdrawal

A cute metabolic

T rauma

C NS pathology

H ypoxia

D eficiencies

E ndocrinopathies

A cute vascular

T oxins or drugs

H eavy metals

Causes: “I WATCH DEATH”


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“I WATCH DEATH”

  • Infections: encephalitis, meningitis, sepsis

  • Withdrawal: ETOH, sedative-hypnotics, barbiturates

  • Acute metabolic: acid-base, electrolytes, liver or renal failure

  • Trauma: brain injury, burns


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“I WATCH DEATH”

  • CNS pathology: hemorrhage, seizures, stroke, tumor (don’t forget metastases)

  • Hypoxia: CO poisoning, hypoxia, pulmonary or cardiac failure, anemia

  • Deficiencies: thiamine, niacin, B12

  • Endocrinopathies: hyper- or hypo- adrenocortisolism, hyper- or hypoglycemia


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“I WATCH DEATH”

  • Acute vascular: hypertensive encephalopthy and shock

  • Toxins or drugs: pesticides, solvents, medications, (many!) drugs of abuse

    • anticholinergics, narcotic analgesics, sedatives

  • Heavy metals: lead, manganese, mercury


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Alcohol

Amphetamines

Cannabis

Cocaine

Hallucinogens

Inhalants

Opiates

Phencyclidine (PCP)

Sedatives

Hypnotics

Drugs of abuse


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Causes

  • 44% estimated to have 2 or more etiologies


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Workup

  • History

  • Interview- also with family, if available

  • Physical, cognitive, and neurological exam

  • Vital signs, fluid status

  • Review of medical record

    • Anesthesia and medication record review - temporal correlation?


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Mini-mental state exam

  • Tests orientation, short-term memory, attention, concentration, constructional ability

  • 30 points is perfect score

  • < 20 points suggestive of problem

  • Not helpful without knowing baseline


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Workup

  • Electrolytes

  • CBC

  • EKG

  • CXR

  • EEG- not usually necessary


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Workup

  • Arterial blood gas or Oxygen saturation

  • Urinalysis +/- Culture and sensitivity

  • Urine drug screen

  • Blood alcohol

  • Serum drug levels (digoxin, theophylline, phenobarbital, cyclosporin, lithium, etc)


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Workup

  • Arterial blood gas or Oxygen saturation

  • Urinalysis +/- Culture and sensitivity

  • Urine drug screen

  • Blood alcohol

  • Serum drug levels (digoxin, theophylline, phenobarbital, cyclosporin, lithium, etc)


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Workup

  • Consider:

    - Heavy metals

    - Lupus workup

    - Urinary porphyrins


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Management

  • Identify and treat the underlying etiology

  • Increase observation and monitoring – vital signs, fluid intake and output, oxygenation, safety

  • Discontinue or minimize dosing of nonessential medications

  • Coordinate with other physicians and providers


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Management

  • Monitor and assure safety of patient and staff

    - suicidality and violence potential

    - fall & wandering risk

    - need for a sitter

    - remove potentially dangerous items from the environment

    - restrain when other means not effective


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Management

  • Assess individual and family psychosocial characteristics

  • Establish and maintain an alliance with the family and other clinicians

  • Educate the family – temporary and part of a medical condition – not “crazy”

  • Provide post-delirium education and processing for patient


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Management

  • Environmental interventions

    - “Timelessness”

    - Sensory impairment (vision, hearing)

    - Orientation cues

    - Family members

    - Frequent reorientation

    - Nightlights


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Management

  • Pharmacologic management of agitation

    - Low doses of high potency neuroleptics (i.e. haloperidol) – po, im or iv

    - Atypical antipsychotics (risperidone)

    - Inapsine (more sedating with more rapid onset than haloperidol – im or iv only – monitor for hypotension)


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Management

  • Haloperidol and inapsine have been associated with torsade de pointes and sudden death by lengthening the QT interval; avoid or monitor by telemetry if corrected QT interval is greater than 450 msec or greater than 25% from a previous EKG


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Management

  • Benzodiazepines

    - Treatment of choice for delirium due to benzodiazepine or alcohol withdrawal


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Management

  • Benzodiazepines

    - May worsen confusion in delirium

    - Behavioral disinhibition, amnesia, ataxia, respiratory depression

    - Contraindicated in delirium due to hepatic encephalopathy


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What we see…common cases

  • Homeless male, hx. ETOH abuse, 2 days post-op

  • 82 year-old women with UTI

  • Burn victim after multiple med changes

  • Mildly demented 71 year-old after hip replacement


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Summary

  • Delirium is common and is often a harbinger of death- especially in vulnerable populations

  • It is a sudden change in mental status, with a fluctuating course, marked by decreased attention

  • It is caused by underlying medical problems, drug intoxication/withdrawal, or a combination

  • Recognizing delirium and searching for the cause can save the patient’s life


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