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DR. DAVID R. FARRIS, DO, ABPN-C NOVEMBER 19, 2014 A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC

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Page 1: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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

Page 2: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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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Page 3: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

DELIRIUM

From the Latin word ... delirare … “out of the furrow”… as in plowing

First recognized and described by Hippocrates

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Page 4: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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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Page 5: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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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Page 9: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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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Page 10: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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

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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

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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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Page 25: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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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Page 26: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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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Page 40: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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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Page 44: A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC · • Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication

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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SURVEY

• https://www.surveymonkey.com/s/11-19-2014

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