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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

Delirium

Lea C. Watson, MD, MPH

Robert Wood Johnson Clinical Scholar

UNC Department of Psychiatry

slide2
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.”

delirium3
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
4 major causes
4 major causes
  • Underlying medical condition
  • Substance intoxication
  • Substance withdrawal
  • Combination of any or all of these
patients at highest risk
Patients at highest risk
  • Elderly
    • >80 years
    • demented
    • multiple meds
  • Post-cardiac surgery
  • Burns
  • Drug withdrawal
  • AIDS
prevalence
Prevalence
  • Hospitalized medically ill 10-30%
  • Hospitalized elderly 10-40%
  • Postoperative patients up to 50%
  • Near-death terminal patients up to 80%
clinical features
Clinical features

Prodrome

Fluctuating course

Attentional deficits

Arousal /psychomotor disturbance

Impaired cognition

Sleep-wake disturbance

Altered perceptions

Affective disturbances

prodrome
Prodrome
  • Restlessness
  • Anxiety
  • Sleep disturbance
fluctuating course
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
attentional deficits
Attentional deficits
  • Easily distracted by the environment
  • May be able to focus initially, but will not be able to sustain or shift attention
arousal psychomotor disturbance
Arousal/psychomotor disturbance
  • Hyperactive (agitated, hyperalert)
  • Hypoactive (lethargic, hypoalert)
  • Mixed
impaired cognition
Impaired cognition
  • Memory Deficits
  • Language Disturbance
  • Disorganized thinking
  • Disorientation
    • Time of day, date, place, situation, others, self
sleep wake disturbance
Sleep-wake disturbance
  • Fragmented throughout 24-hour period
  • Reversal of normal cycle
altered perceptions
Altered perceptions
  • Illusions
  • Hallucinations

- Visual (most common)

- Auditory

- Tactile, Gustatory, Olfactory

  • Delusions
affective disturbance
Affective disturbance
  • Anxiety / fear
  • Depression
  • Irritability
  • Apathy
  • Euphoria
  • Lability
duration
Duration
  • Typically, symptoms resolve in 10-12 days

- may last up to 2 months

  • Dependent on underlying problem and management
outcome
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
outcome18
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
causes i watch death
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”
i watch death
“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
i watch death21
“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
i watch death22
“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
drugs of abuse
Alcohol

Amphetamines

Cannabis

Cocaine

Hallucinogens

Inhalants

Opiates

Phencyclidine (PCP)

Sedatives

Hypnotics

Drugs of abuse
causes
Causes
  • 44% estimated to have 2 or more etiologies
workup
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?
mini mental state exam
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
workup27
Workup
  • Electrolytes
  • CBC
  • EKG
  • CXR
  • EEG- not usually necessary
workup28
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)
workup29
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)
workup30
Workup
  • Consider:

- Heavy metals

- Lupus workup

- Urinary porphyrins

management
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
management32
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

management33
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
management34
Management
  • Environmental interventions

- “Timelessness”

- Sensory impairment (vision, hearing)

- Orientation cues

- Family members

- Frequent reorientation

- Nightlights

management35
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)

management36
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
management37
Management
  • Benzodiazepines

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

management38
Management
  • Benzodiazepines

- May worsen confusion in delirium

- Behavioral disinhibition, amnesia, ataxia, respiratory depression

- Contraindicated in delirium due to hepatic encephalopathy

what we see common cases
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
summary
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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