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DELIRIUM
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Delirium: Synonyms
Acute confusional state
Acute organic brain syndrome Acute brain failure
Acute toxic psychosis
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Case - Delirium79 year old lady
lives alone, manages own apartment
slightly forgetful (according to daughter) 7 months ago:
started slowing down
losing interest; insomnia
Rx Amitriptyline/Oxazepam
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PMed Hx: HTN
Meds: Hydrochlorothiazide 25 mg OD
Amitriptyline 50 mg qhs Oxazepam 15-30 mg qhs
79-year-old lady
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One week prior to hospitalization
c/o pain in right knee
O/E slightly swollen
prescribed: Naproxen 250 mg BID
79-year-old lady
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Tripped on rug, sustained a hip fracture
Brought to hospital. Spent 12 hours in ER
ORIF the following day 1st POD
climbing over bedrails
shouting all night sleeping in day
pulling out her IVs
79-year-old lady
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All Confusion is
Not DementiaAlways Consider
Delirium
Delirium
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Delirium - Is Often Missed
43% of cases unrecognized by RNs
32%-66% of cases unrecognized by
MDs
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Epidemiology in Elderly
Prevalence :
Hospitalized Medically Ill 10 - 30%
ER 10 -18%
Incidence:
In Hospital 10 - 36%
Post-operatively up to 50%
Cardiac Surgery 17 - 73%
Orthopedic 28 - 52%
D I H
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De r um In Hosp taPrognosis
Course:
Can be quite variable
Prevalence:
Typical 10-12 days
Range 1-8 weeks
Lasting > 30 days 15%
Increased LOS
Discharge to LTC
Hospital cost
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Delirium: Prognosis
40%
25%
25-33%
Recovery
Permanent Cognitive Impairment
Mortality
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Delirium: Prognosis Following recovery, annual incidence
of dementia 20%
Increased Institutionalization rate
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Delirium: Prognosis
Delirium may serve as a marker for future
cognitive decline
Patients need to be FOLLOWED for the
development of dementia.
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Delirium (DSM-IV)
A: Disturbance of consciousness(reduced clarity of
awareness of the environment) with reduced ability to focus,
sustain or shift attention
B: Change in cognition (eg. memory deficit, disorientation,language disturbance) or development of a perceptual
disturbance not due to pre-existing, established or
developing dementia
C: The disturbance develops over a short period of time(hours to days) and tends to fluctuate during the course of
the day.
D. Evidence of aetiology
l
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Delirium: CognitiveEvaluation
Interview patient and caregiver to
determine if any acute changes in
mental status or behaviour
Confusion Assessment Method
f i
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Confusion AssessmentMethod
Acute change in mental statusAND
Inattention/fluctuationPLUS
Disorganized thinkingOR
Altered level of consciousness
Sensitivity 94-100% Specificity 90-95%
Ann Intern Med. 1990; 113:941
Arch Intern Med. 1995; 155:301
C f i A
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Confusion AssessmentMethod
Most Important
1. Acute change in mental status?
2. Disorganized thinking?
3. Altered level of consciousness?4. Inattention/fluctuation?
5. Psychomotor agitation/retardation?
6. Perceptual disturbance?
7. Disorientation?
8. Sleep wake cycle altered?
9. Memory impairment? Least ImportantAnn Intern Med. 1990;113:941
D li i C i i
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Delirium: CognitiveEvaluation
MMSE:
inaccurate tool to diagnose delirium as the
patient: fluctuates
has poor attention/concentration
helpful tool to demonstrate improvement incognitive status when following patient.
C i F f
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Comparative Features ofDelirium and Dementia
Delirium Dementia
ONSET develops abruptly develops slowly
DURATION brief, hours to days chronic, months to yrs
ATTENTION impaired normal, except insevere cases
LOC fluctuating clear
SPEECH incoherent, ordered
disorganized anomic/aphasic
NOTE: Disorientation and memory impairment may be present with both
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Delirium - Core Features
Acute onset and fluctuating course
Inattention; Easily distractible
Disorganized thinking
Altered level of consciousness
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Spectrum Of Delirium
Spectrum of Psychomotor Activity :
HYPOACTIVE delirium (lethargy, excess
somnolence, sluggish)
Individuals often not recognized as they
may not cause a disturbance so theydont get ATTENTION
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Spectrum Of Delirium
HYPERACTIVE delirium
(agitated, hallucinating,inappropriateness)
MIXED - combination of
both
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Delirium: Signs Restlessness, agitation
Picking at the air/clothes...
Myoclonus (often multifocal)
Asterixis (suggests a metabolic cause)
Hallucinations (usually visual, tactile)
M j Ri k F t f th
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Major Risk Factors for theDevelopment of Delirium Dementia
Pre-existing Cognitive Decline
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Delirium (in Hospitalized Elderlypts)
Dehydration
Severe illness
Vision Impairment
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Causes of Delirium:A Checklist
D: Drugs anticholinergics, ETOH
E: Endocrine BS, Na, Ca, Mg, cortisol, etc.
M: Metabolic organ failure, hypoxia, etc.E: Epilepsy or seizures postictal status
N: Neoplasm especially SIADH, CNS
T: Trauma concussion, surgeryI: Infection any
A: Apoplexyany vascular event MI, PE, CVA
Fi di th C f
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Finding the Cause ofDelirium
I: Infections UTIs, pneumonia, encephalitis, etc.
W: Withdrawal alcohol, benzodiazepines, sedative-hypnotics
A: Acute electrolyte disturbance, dehydration, acidosis /
alkalosis, hepatic/renal metabolic failure
T: Toxins, drugs opiates, salycilates,indomethacin, dilantinC: CNS pathology stroke, TIA, tumors, seizures, hemorrhage, infection
H: Hypoxia anemia, pulmonary/cardiac failure, hypotension
D: Deficiencies Thiamine (with alcohol abuse), B12
E: Endocrine thyroid, hypo/hyperglycemia, adrenal dysfunction,
hyperparathyroid
A: Acute vascular shock, hypertensive encephalopathy
T: Trauma head injury, post-operative, hypo/hyperthermia
H: Heavy Metals lead, mercury, manganese poisoning
M di i A i d i h
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Any drug can potentially cause
confusion
Take a careful history of any new drug
STARTED or any old drug STOPPEDrecently
Medications Associated with
Delirium
d d h
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Medications Associated withDelirium
Sedatives - hypnotics; Benzodiazepines - toxicity or withdrawal
Narcotics - especially Demerol
Anticholinergics
Antihistamines eg. Gravol Tricyclic antidepressants eg. Amitriptyline
Antiparkinsonian agents
Cardiac eg. Digitalis
Miscellaneous H2 blockers Lithium
Steroids Anticonvulsants
Metoclopramide NSAIDs eg. Indocid
D ith A ti h li i
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Drugs with AnticholinergicActivity
Tricyclic Antidepressants
eg. Amitriptyline, Doxepin, Imipramine
Dimenhydrinate (Gravol)
Ditropan
Cogentin
Anti-Parkinsonian Drugs
eg. Artane/Kemedrin
Medications Associated with
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Medications Associated withDelirium
Herbal/over the counter drugs
Cimetidine
Cough/Cold Remedies
Gravol
Sleeping medications eg. Nytol...
Miscellaneous Causes of
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Miscellaneous Causes ofDelirium
Pain
Fecal Impaction
Urinary Retention
Alcohol Intoxication or withdrawal
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Delirium: Evaluation
It is a clinical diagnosis
It requires a COMPREHENSIVE
ASSESSMENT
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Delirium: Etiology
Good Physical Exam
Assess Hydration Status
? New localizing Neurological findings
? CHF/Pneumonia
Rectal Exam to R/O Impaction
? Distended Bladder
? Infected Ulcer
Delirium: Search for
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Delirium: Search forUnderlying Etiology
Review medication list Measurement of serum levels of
medications eg. Digoxin/phenytoin...
Metabolic work up CBC
lytes/BUN/creat/glucose
Ca, albumin liver function tests
R/O infection eg. CXR; urine C&S
O2saturation/ABGs to R/O pCO2 Delirium: Search for
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Delirium: Search forUnderlying Etiology
ECG to R/O silent MI
CXR to R/O pneumonia as physical exam
often difficult/inaccurate
CNS work-up (if indicated): ie. CT Head
Delirium: Search for
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Delirium: Search forUnderlying Etiology
Positive urine cultures
Common in the elderly
Should only be used as the cause for
a delirium when patient has new
urinary symptoms.
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Prevention of Delirium Multi component intervention strategy
targeted to 6 delirium risk factors
Ref: Inouye SK, NEJM. 1999;340:669-676
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Delirium: Management
Address immediate safety
Investigate cause(s)
Identify and remove or treat underlying
cause(s)
Medications (eg. Benzodiazepines /Neuroleptics) to be used only if necessary
Nonpharmacological
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NonpharmacologicalManagement
Provide general supportive measures:
Avoid restraints
Encourage familiar faces for reassurance eg.family members
Fluids, nutrition
Low stimulation - avoid excessive noise Provide orientation (calendar, clock)
Correct sensory impairment eg. vision, hearing
Delirium: Pharmacological
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Delirium: PharmacologicalManagement
Principles
1. Use a SINGLE medication rather than two,to decrease the potential for side effects/druginteractions.
2. Start with a low dose.
3. Choose a drug with low anticholinergic activity.
4. Try to stop the medication as soon as possible,
focusing on correcting the underlying cause for thedelirium.
5. Continue to use Non-Pharmacologicalinterventions.
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Delirium: Pharmacological
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Delirium: PharmacologicalManagement
Atypical Antipsychotics (Risperidone, Olanzepine,
quetiapine)
No controlled studies at present of their use indelirium (just case reports)
MAY TRY:
low dose Risperidone starting at .25 mg BID
Olanzapine - 2.5 mg/d as starting dose
Quetiapine - 12.5 mg/d starting dose
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Suggested Readings
1. Cole MG, McCusker J, Dendukuri N, Han L. Symptoms of
delirium among elderly medical inpatients with or without
dementia. J Neuropsychiatry Clin Neurosci 2002;
14(2):167-75.
2. Francis J. Martin D, Kkapoor WN. A prospective study of
delirium in hospitalized elderly. JAMA 1990;263(8):1097-
101.
3. Pompei P, Foreman M, Rudberg MA, Inouye SK, Braund V,Cassel CK. Delirium in hospitalized older persons:
Outcomes and predictors. J Am Geriatr Soc 1994; 2(8):809-15.
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Suggested Readings
4. Inouye SK. The dilemma of delirium: Clinical and research
controversies regarding diagnosis and evaluation of delirium
in hospitalized elderly medical patients. AM J Med 1994;
97(3):278-88.
5. Inouye, SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP,
Horwitz RI. Clarifying confusion: The confusion assessment
method. A new method for detection of delirium. Ann Intern
Med 1990; 113(12):941-8.
6. Inouye SK, A Multicomponent Intervention to PreventionDelirium in Hospitalized Older Patients. NEJM.
1999;340:669-676