a discussion on delirium medical & psychiatric · • medication induced delirium: this...
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D R . D A V I D R . F A R R I S , D O , A B P N - C N O V E M B E R 1 9 , 2 0 1 4
A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC
OBJECTIVES
• Participants will understand criteria for delirium • Participants will relate characteristics and common
features in the course of delirium • Participants will review strategies to enhance
management of delirium
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DELIRIUM
From the Latin word ... delirare … “out of the furrow”… as in plowing
First recognized and described by Hippocrates
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DELIRIUM – OTHER NAMES
• Encephalopathy…hepatic/metabolic • Acute Mental Status Change • ICU Psychosis/ICU Syndrome • Acute Organic Brain Syndrome • Toxic Psychosis • Febrile Insanity • Acute Confusional State
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DELIRIUM
• Diffuse Cerebral Dysfunction
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MORBIDITY AND MORTALITY
• Morbidity and Mortality of any serious disease is doubled in delirium • Three months mortality rate – 28% • One year mortality rate – 50% • In hospital patients 10% have delirium at any given time
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IMPACT OF DELIRIUM
• Greater utilization of hospital resources • Increased rate of placement in extended care
facilities • Increased length of hospital stay • Frequent complications in medical/post-op
conditions • Poor functional recovery
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INCREASED RISK FOR DELIRIUM IN PATIENTS WITH:
• CNS Disorders • Post-Op States • Alcohol and Sedative Hypnotic Dependence • Underlying Dementia • Mental Retardation • Severe Burns • Sensory Deprivation • Polypharmacy • Very young or very old
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PREVALENCE IN SPECIFIC POPULATIONS
• ER Patients 10-14% • Hospitalized 10-30% • Elderly Hospitalized 10-40% • Burn Patients 20% • Cancer Patients 25% • ICU Patients 30% • Post CABG 30% • Post-Op Patients 10-51% • AIDS Patients 30-40% • Cardiac Surgery Patients <74% • Terminally Ill Patients <80% • Brain Disease Patients <81%
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DSM-5 CRITERIA
• Delirium (596) Substance intoxication delirium Substance withdrawal delirium 292.81 Medication-induced delirium 293.0 Delirium due to another medical
condition; Delirium due to multiple etiologies
780.09 Other Specified Delirium 780.09 Unspecified Delirium
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DSM-5 DEFINITIONS
• Substance withdrawal delirium: This diagnosis should be made instead of substance withdrawal when the symptoms in criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.
• Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication taken as prescribed.
• Delirium due to another medical condition: There is evidence from the history, physical examination, or laboratory findings that the disturbance is attributable to the physiological consequences of another medical condition.
• Delirium due to multiple etiologies: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect).
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SPECIFY TYPE OF DELIRIUM
• Acute Delirium – lasting a few hours or days • Persistent Delirium – lasting weeks or months
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DELIRIUM DIAGNOSTIC CRITERIA
A. A disturbance in attention (i.e. reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception).
D. The disturbances in criteria A and C are not better explained by another preexisting established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies.
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CONSCIOUSNESS
• Awareness of immediate environment and circumstances
• Ability to pay attention, to shift attention, and to focus
Delirium ALWAYS includes impairment of consciousness.
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DIAGNOSTIC CRITERIA
• Substance Intoxication Delirium: This diagnosis should be made instead of substance intoxication when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention.
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DIAGNOSTIC CRITERIA
• Specify state of Delirium: • Hyperactive: The individual has a hyperactive level of
psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care.
• Hypoactive: The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor.
• Mixed level of activity: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates.
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CONTINUUM OF CONSCIOUSNESS
• Coma... • Stuporous... • Obtunded... • Hypersomnulent… • Somnulent... • Relaxed... • Alert... • Attentive...
• Vigilant... • Hypervigilant... • Distractible... • Hyperaroused... • Extreme Excitement... • Relaxed... • Alert...
Relaxed, Alert, Attentive - Normal Range of Consciousness 17
LUCIDITY
• Clarity of thought • Using cognitive functions to interact with the
environment • Memory registration – storage & retrieval • Comprehension • Reasoning and Judgment • Language skills & ability to communicate
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CONTINUUM OF LUCIDITY
• Disoriented to self • Disoriented to place • Disoriented to time • Confused • Aware • Coherent • Fluent • Organized • Oriented
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IMPAIRMENT IN LUCIDITY OR CONSCIOUSNESS DOES NOT IMPLY IMPAIRMENT IN THE OTHER
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DIFFERENTIALS
Delirium • Acute
• Usually
• Impaired
• Fluctuates
Dementia • Insidious/Chronic
• Usually not
• Not affected
• Normal Range
Onset
Reversible
Attention
Level of Consciousness 21
SUBTYPES OF DELIRIUM
• Hyperactive – 25% • Hypoactive – 25% • Mixed – 35%
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HYPERACTIVE DELIRIUM
• Sympathetic Nervous System Hyperactivity • Psychomotor Agitation • Verbal/Physical Aggression • Motor Preservation • Wandering • Increased alertness to stimuli • Mood Lability • Anger • Euphoria
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HYPOACTIVE DELIRIUM
• Lethargy/Somnolence • Withdrawn/Apathetic • Decreased Response to
Stimuli • Psychomotor Retardation • Inattention • Clouded Consciousness • Slowed Speech • Any Psychiatric Symptoms -
Mood symptoms – lability, depression, euphoria, irritability, agitation
• Psychomotor agitation or retardation
• Nonspecific nonlocalizing neurologic abnormalities – tremor myoclonus
• Disorientation • Visual Constructional
Impairment
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CHARACTERISTICS AND COMMON FEATURES
• Sleep wake cycle disturbance • Language disturbance • Fluctuating course • Altered consciousness • Altered lucidity • Inattention, easily distracted • Psychotic symptoms
• Thought process distortions – loose associations, flight of ideas
• Thought content distortions – hallucinations, delusions
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ONSET OF DELIRIUM
• Acute….typically hours to days • Subacute…can be days to weeks • May be abruptly precipitated
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COURSE OF DELIRIUM
• Fluctuating in severity of symptoms – this is characteristic and suggestive of delirium
• Lucidity is usually better in the mornings • Confusion is worse at night (sundowning) • Worsening symptoms with excessive stimulation or
sensory deprivation
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DURATION OF DELIRIUM
• Typically hours to days… • Can be weeks or even months
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OUTCOME OF DELIRIUM
• Many have full recovery but not usually by the time of discharge
• Persistent cognitive deficits are common • If underlying dementia – now new lower baseline
of cognitive functioning
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PATHOPHYSIOLOGY
• Limited understanding • Disturbances of metabolic function of the brain • Variety of different abnormalities may alter the brain
metabolism – therefore a large list of potential etiologies • Usually causes are multiple and additive • Several theories exist... • Dysfunction of the reticular activating system – arousal and
motivation center of brainstem • Dysfunction of the neurochemical systems – noradrenergic,
GABAergic, dopamine and serotonin systems • Hypofunction of the cholinergic system – anticholinergic drug
toxicity
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ETIOLOGY OF DELIRIUM
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SYSTEMIC CHANGES
• Infectious – febrile or afebrile, sepsis, encephalitis, meningitis, syphilis, HIV, abscess
• Vitamin deficiency – B12, folate, thiamine, niacin • Fecal impaction • Urinary retention • Any abdominal disorder • Acute Vascular – Arrhythmia, shock, hypertensive
encephalopathy
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METABOLIC
• Fluid and Electrolyte Disturbance – Hyper/hyponatremia, acidosis, alkalosis, hyper/hypovolemia
• Renal Failure • Liver Failure • Anemia • Thyroid Dysfunction • Adrenal Dysfunction • Hyper/hypoglycemia • Hyper/hypocalcemia • Hyper/hypomagnesemia • Endocrine Disorders
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CNS PATHOLOGY
• Hemorrhage • Abscess • Hydrocephalus • Intracranial bleed – subdural hematoma • Seizures • Infarction – CVA • Tumors • Metastasis • Vasculitis • Sleep deprivation
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HYPOXIA
• Anemia • Carbon monoxide poisoning • Hypotension • Pulmonary failure • Cardiac failure • Hypercarbia
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TRAUMA
• Closed head injury • Heat stroke • Severe burns • Postoperative states
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PHYSICAL & ENVIRONMENTAL
• Stress of any type • Surgery…anesthesia • Pain • Fever or hypothermia
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HEAVY METALS
• Lead • Mercury • Manganese
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DRUGS OR TOXINS
• Anticholinergic • Anticonvulsants • Antidepressants • Antihypertensives • Antiparkinsonians • Anxiolytics • Methyldopa • Clonidine • Beta blockers • Phenytoin • Digoxin • Cimetidine • Ranitidine • Narcotics • Nifedipine • Muscle relaxants
• Hallucinogens • Furosimide • Inhalants • Opiates • Steroids • Cocaine • Ethanol • ASA • NSAIDS • Cardiac Glycosides • Amphetamines • Theophylline • Captopril • Antivirals • Lithium • Antibiotics • And many more……
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EVALUATION OF DELIRIUM
• Obtain careful history – Onset, duration, symptoms, change from baseline functioning
• Physical Examination • Mental Status Examination – Folstein Mini Mental
Status Exam • Medication Analysis • Laboratory Data – CMP, CBC, LFTs, EKG, CXR, ABGs,
pulse ox, UDS, UA, blood/urine cultures, serum drug levels, B12/Folate, Thyroid panel, EEG, Brain CT/MRI, LP, ESR, heavy metal screen, ANA, HIV, RPR/VDRL
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MANAGEMENT OF DELIRIUM
• First and foremost….Treat the underlying medical cause • Review and discontinue nonessential medications • Monitor Vitals • Regulate Sleep • Prevent and Manage Behavior – May need sitter
• Safety issues – Lower the bed, clear environment of other patients, equipment, overstimulating instruments, restrain if necessary
• Antipsychotic for agitation – Haldol, risperdal, seroquel
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MANAGEMENT OF DELIRIUM
• Avoid Benzodiazepines/Sedative Hypnotics – Unless the patient is in withdrawal from alcohol or sedative hypnotics
• Avoid Narcotics – Unless in severe pain then avoid meperedine which can cause seizures, worsening delirium and serotonin syndrome
• Avoid Anticholinergic Medications – Additive effect • Facilitate Reality Testing – Clock, calendar, orient
patient repetitively, familiar cues, encourage family visits, maintain day/night lighting, maintain consistency, avoid overstimulation, repeatedly reassure patient, ensure use of hearing aids and glasses
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MEDICATIONS
• Agitation: • Haldol 1mg to 2mg IV q 2-4 hours
• Sedation: • Seroquel 12.5 to 25mg PO q 8-12 hours • Zyprexa 2.5 to 10mg IM/PO q 12 hours • Ativan 1 to 2mg IV/PO/IM q 4-6 hours
*In the elderly minimize the dose; use the lower end of dose regime or cut the dose in half
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COMPLICATIONS OF MEDICATIONS
• Antipsychotics can lead to an increase in the QT interval – prolongation >450msec or 25% over previous EKG, increases risk of Torsades de Pointes
• May lower seizure threshold • Extrapyramidal side effects (IV has lower risk of EPS)
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COMPLICATIONS OF MEDICATIONS
• Benzodiazepines – Additive effect on delirium, cognitive impairment intensified
• Respiratory depression • Use in combination with antipsychotics, do not use
alone • Use for alcohol and sedative hypnotic withdrawal • Use benzodiazepines that are glucouronidated,
bypass the liver, renal elimination, lorazepam, oxazepam, temazepam
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EXTREME CASES OF DELIRIUM
• Extreme cases my need sedation, paralytics, and ventilation
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IN SUMMARY
• Delirium is a common clinical syndrome • Delirium is frequently missed and misdiagnosed • Delirium results in increased morbidity, mortality, and
costs to the health care system
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QUESTION & ANSWER SESSION
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