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Delirium Select Specialty Hospitals Denver William A Locy, Ed.D. Rocky Mountain Rehabilitation Medicine, P.C. Delirium

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delirium

Delirium

Select Specialty Hospitals Denver

William A Locy, Ed.D.

Rocky Mountain Rehabilitation Medicine, P.C.

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Delirium
  • DSM-IV definition: “The essential feature of delirium is disturbance in consciousness that is accompanied by a change in cognition that cannot be better accounted for by a preexisting or evolving dementia.”
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Delirium
  • Acute confusional state
  • Acute brain syndrome
  • Metabolic encephalopathy
  • Toxic psychosis
  • Acute brain failure
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Delirium
  • 10 to 15% general surgical wards
  • 15 to 25% general medical wards
  • Geriatric population: 30 to 40% hospitalized patients over 65 have experienced delirium
  • 30% patients in surgical and cardiac intensive care units
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Delirium
  • 40 to 50% of patients recovering from surgery from hip fractures
  • 30 to 40% hospitalized AIDS
  • 38.5% following cardiac surgery
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Delirium
  • Pathophysiology
  • Susceptible areas: reticular activating system; hippocampus; cortex
  • Cerebellum is relatively spared
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Delirium
  • Excessive dopamine release (hypoxia)
  • Cholinergic overactivity in neurons in the RAS, cortex, cortex
  • Neuronal hyperpolarization
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Delirium
  • Rapid development
  • A few hours to days
  • Fluctuating presentation (serial examinations)
  • Disturbances range from mild to severe and global
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Delirium
  • Disturbance in sleep wake cycle (early symptom)
  • Perceptual disturbance (IV tubing a snake) to hallucinations (most common visual but any sensory modality)
  • Attention and concentration
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Delirium
  • Memory
  • Restlessness agitation
  • Frank delusions or paranoia
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Delirium
  • Differential diagnosis
  • Dementia
  • Depression
  • Psychotic disorders (schizophrenia)
  • Substance intoxication
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Delirium
  • Geriatric population is more susceptible to delirium
  • Patients with any brain insult (TBI, Hypoxia, CVA, Tumor) are more susceptible to delirium
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Delirium
  • Rapid diagnosis
  • Medical management (e.g. resolve infection, change in respiratory status, drug toxicity, fluid/electrolyte imbalance)
  • Pertinent laboratory and radiologic tests
  • Collateral information (premorbid status)
  • Thorough review of medications
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Delirium
  • Intervention resolve the underlying causal factors
  • Prolonged delirium may require medication intervention
  • Benzodiazapines with few exceptions (alcohol/sedative hypnotics withdrawal) is used as adjunctive in low doses of fast metabolizing medications)
  • Antipsychotics
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Delirium
  • Environmental interventions
  • Routine
  • Assist in the regulation of sleep wake cycle
  • Manage stimulation
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Delirium
  • Nursing education
  • Communication
  • Psychiatric
  • Neuropsychological
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Delirium
  • Outcomes
  • Increased mortality 3 month 25% 1 year as high as 50%
  • Increased patient family suffering
  • Increased cost