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Delirium Pat Oakley. Delirium. Case 1. 17 year old girl with previous label “borderline personality disorder” presents to ED 2200 Argument with parents about boyfriend that evening, went to the mall and then locked herself in her room

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case 1
Case 1
  • 17 year old girl with previous label “borderline personality disorder” presents to ED 2200
  • Argument with parents about boyfriend that evening, went to the mall and then locked herself in her room
  • Parents called ambulance 2 hours later when she was screaming and abusive, intermittently drowsy.
  • Empty packets of tablets: paracetamol, phenergan.
in ed
In ED
  • Carefully assessed re paracetamol toxicity- levels OK
  • Notes record:“Very difficult, abusive, screaming, intermittently drowsy, Malingering?”
  • Activated charcoal
  • Admission for tox review in am
in am
In AM
  • Unhappy, dishevelled young lady
  • OGT in nose
  • IDC has been inserted
  • 37.1 C, HR 90, 110/70. lucid, but wary.
  • ECG N
  • Pupils not dilated, no tremor, armpits dry, not flushed.
  • ECG N
  • Discharged after psychiatric input.
case 2
Case 2
  • F1 call.
  • 90 year old man from home, # NOF ORIF 24 hours ago. Usually independent
  • Hallucinating, yelling at NS, grasping bedrails and climbing out.
  • Bladder scan 900mL.
medications
Medications
  • Pravastatin 40mg
  • Candesartan 12mg
  • Aspirin 100mg
  • Endep 25mg nocte
  • Endone 20mg bd
  • Clexane 20mg
examination
Examination
  • Delirium, no obvious focal neuro deficit
  • Pupils small
  • HR 100, BP 150/90, no fever
  • No obvious septic focus
additional history from family
Additional history from family
  • Usually lucid, but did this last GA
  • Recently a bit forgetful; locked self out of home 3 times in last month
  • Home brewer, intake of alcohol…
slide9
Rx
  • Sedated; diazepam 2.5 mg increments at 10 minute intervals until asleep
  • IDC
  • Workup- CXR (N), msu (N), FBC and EUC (essentially N, Hb 90).
  • Ceased endep
  • Reviewed that evening, still agitated, though less so
  • Accepted quetiapine 25mg o
progress
Progress
  • Remained confused, but less aggro, settling over 5 days. Quetiapine stopped day 6, IDC out,
definition
Definition
  • Disturbance of 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 pre-existing, established, or evolving dementia.
  • The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day.
  • There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by a medical condition, substance intoxication, or medication side effect
definition1
Definition
  • The brain gets sick and stops working because the body is sick…occasionally due to solely CNS pathology/poisoning
delirium
Delirium..
  • Risk
  • Precipitants
  • Assessment
  • management
risk factors
Risk Factors
  • Baseline cognitive function
  • Sensory deprivation

…..Age

precipitant
Precipitant
  • Drugs
    • Ingestion
    • Therapeutic intoxication
    • Withdrawal
    • As cofactors
  • Illness
  • Environment
    • Sleep
    • Noise
    • dehyration
ingestions
Ingestions
  • Anything designed to get into brains..
    • Anticholinergics
    • SSRI (plus serotonergics..SS)
    • Opiates- metabolites
    • Anticonvulsants
    • LiCO3
    • Others..lipophyllic beta blockers, cyclosporin,
    • Or anything that makes you critically ill…
withdrawal
Withdrawal
  • Alcohol
  • Benzodiazepines
  • Opiates- esp longer acting
  • Some anticonvulsants- esp barbiturates
  • Dopamine agonists
  • Centrally acting antihypertensives,
illness look systemically first
Illness- look systemically first
  • Any severe infection
  • Hepatic failure-encephalopathy (look for the signs)
  • Renal failure (look at drug accumulation)
  • CNS infections
  • Hypoxia, electrolyte disturbance (low Na), urine retention, anything painful
slide19
CNS
  • Intracranial pathology- SDH, SAH…
  • Rarely CVA unless complicated by seizure, previous others cva, or mistaken manifestation eg dysphasia
assessment
Assessment
  • Medical history- Risk
  • Drug chart
  • Assess- what medical precipitants are likely here?
  • Ix- look for those precipitants likely to be present….
    • Drug levels and CAT head rarely useful
management
Management
  • The Cause…there will be multiple
    • Cessation of relevant meds
    • Adequate hydration, environment, analgesia
    • Management of alcohol/benzo withdrawal
    • ?Special…if needed for pt safety
management control
Management..control
  • Role of antipsychotics…limited evidence
    • Nil evidence of any real benefit…but difficult
    • Old “typical” agents recommended, EPS, less sedating
    • Atypicals- less EPS, more sedating, longer T1/2, not actually authorised. Quetiapine currently the fashion
  • Role of benzodiazepines
    • Match duration of action to requirements (midazolam doesn’t last)
    • Titrate to effect…ivi diazepam in small aliquots is still a pretty good idea
serotonin syndrome
Serotonin Syndrome
  • Too much serotoinin-Intrasynaptically
  • Usually a synergistic combination of 2 serotonergic drugs; or overdose of SSRI
  • Neuromuscular excitation
    • Clonus
    • Hyperreflexia
    • rigidity
  • CVS
    • Tachycardia, hypertension
  • Autonomic
    • Sweating, diarrhoea, vomiting, Fever
  • Delirium
neuroleptic malignant syndrome
Neuroleptic Malignant Syndrome
  • Dopamine blocking drugs; abrupt cessation of dopaminergics, often a precipitating illness
  • Autonomic
    • Drooling, sweating, sialorrhea
    • Ileus or diarrhoea, urinary retention
    • Hypo/hypertension
    • Tachy/bradycardia
  • EPS
    • Lead pipe rigidity, cogwheeling
    • bradykinesia
  • Fever
    • >37.5
  • Delirium
    • hypoactive
anticholinergic delirium
Anticholinergic Delirium
  • Overdose of Muscarinic ACh blockade; or introduction in a susceptible patient; or new illness in a susceptible patient on anticholinergics
  • Autonomic
    • Pupils
    • Dry armpits
    • Tachycardia
    • Urine retention
    • ileus
  • Delirium
    • Hallucinations prominent