DeliriumA Patient-Centered, Evidence-Based Diagnostic and Treatment Process1,2

Kendall L. Stewart, MD, MBA, DLFAPAApril 19, 2013

1My aim is to offer practical clinical insights that you can use right away in caring for patients.2Please let me know whether I have succeeded on your evaluation forms.

Why is this important?

• This is common and it is serious.• 14-56% of hospitalized elderly

patients have delirium.1,2

• 40% of ICU patients are delirious at some point during their stays.

• As many as 42% of post-operative orthopedic patients become delirious.

• As many as 80% of patients become delirious near death.

• Patients who become delirious during their hospitalizations have mortality rates of 22-76%.

• Delirium may produce prolonged hospital stays, increased complications, increased costs and long-term disability.

• After mastering the information in this presentation, you will be able to– Identify the other diagnoses in this

category,– Identify the diagnostic criteria for

delirium,– Specify three disorders that may

produce delirium,– Describe the evaluation of the

patient with delirium,– Discuss a differential diagnosis,– Write a typical treatment plan, and– Explain some of the typical

treatment challenges.

1Hospitalists and others are now deploying protocols for preventing delirium in inpatients.2See Inouye, Sharon, “A Practical Program for Preventing Delirium in Hospitalized Elderly Patients,” Cleveland Clinic Journal of Medicine, November 2004

What other disorders are included in the cognitive disorders category?

• Delirium– Delirium Due to a General Medical Condition– Substance Intoxication Delirium– Substance Withdrawal Delirium– Delirium Due to Multiple Etiologies– Delirium Not Otherwise Specified (NOS)

• Dementia• Amnestic Disorders• Other Cognitive Disorders

How do these patients typically present?1,2

• “Doctor, this is a 74-year-old woman.”

• “She has become increasingly confused, suspicious and agitated this evening.”

• “Her level of consciousness is fluctuating.”

• “She is disoriented and it appears to irritate her when I ask the orientation questions.”

• “She is picking at her gown and the sheet on her bed.”

• “Sometimes, she mumbles incoherently and I cannot understand her.”

• “Her family members have never seen her like this and they are very scared.”

• “She says that her room is full of rats and that they are biting her.”

• “She has not been able to sleep at all.”

• “She has a wild look in her eyes and she appears frightened.”

• “She recognizes her family sometimes and sometimes she doesn’t.”

1Family members or caregivers usually provide the histories.2The diagnosis of delirium is usually easy to make; figuring out what is wrong is another matter altogether.

What are the diagnostic criteria for delirium?• The patient experiences a

disturbance of consciousness with reduced ability to focus, sustain, or shift attention.

• There is a change in cognition (such as a memory impairment, disorientation, problem with language) or the development of a perceptual disturbance that is not better explained by dementia.

• The disturbance develops over a relatively short period of time and tends to fluctuate during the course of the day.

• There is evidence from the history of the cause of the delirium (or there is not).

• (If the etiology cannot be established or strongly suspected, the proper diagnosis is Delirium Not Otherwise Specified).

What are some of the causes of delirium?

• Infection (meningitis, encephalitis, systemic infection)

• Withdrawal (alcohol, benzodiazepines, barbiturates)

• Acute Metabolic Disturbances (electrolyte and acid-base abnormalities, renal disease, hepatic disease, postoperative state)

• Trauma (concussion, heat stroke severe burns)

• CNS pathology (cerebrovascular accident, seizure, subdural or subarachoid hemorrhage, neoplasms, infections)

• Hypoxia (anemia, cardiac failure, respiratory failure, hypotension, pulmonary embolus, carbon monoxide poisoning)

• Deficiencies (vitamin B12, folate, thiamine)

• Endocrinopathies (hyper- or hypothyroidism, hyper- or hypocortisolism, hypoglycemia)

• Acute Vascular (septic shock, hypertensive encephalopathy)

• Toxins or drugs (amphetamines, anticholinergics, anticonvulsants, clonidine, digitalis, hallucinogens)

• Heavy Metals (arsenic, lead, manganese, mercury)

1Every psychiatrist memorizes “I WATCH DEATH” or some similar mnemonic for Board exams.

What about the physical examination of the delirious patient?

Parameter FindingClinical

ImplicationPulse Bradycardia Hypothyroidism

Stokes-Adams syndromeIncreased intracranial pressure

Temperature Fever SepsisThyroid storm

Vasculitis

Blood Pressure Hypotension ShockHypothyroidism

Addison’s disease

Blood Pressure Hypertension EncephalopathyIntracranial mass

Slide 1 of 6

What about the physical examination of the delirious patient?

Parameter FindingClinical

ImplicationRespiration Tachypnea Diabetes

PneumoniaCardiac failure

Fever

Respiration Shallow Alcohol or other substance intoxication

Carotid vessels Bruits or decreased pulse Transient cerebral ischemia

Scalp and face Evidence of trauma Trauma

Slide 2 of 6

What about the physical examination of the delirious patient?

Parameter FindingClinical

ImplicationNeck Evidence of nuchal rigidity Meningitis

Subarachoid hemorrhage

Eyes Papilledema TumorHypertensive encephalopathy

Eyes Pupillary dilatation AnxietyAutonomic hyperactivity

Delirium tremens

Mouth Tongue or cheek lacerations Tonic-clonic seizures

Slide 3 of 6

What about the physical examination of the delirious patient?

Parameter FindingClinical

ImplicationThyroid Enlarged Hyperthyroidism

Heart Arrhythmia Inadequate cardiac outputPossible emboli

Heart Cardiomegaly Heart failureHypertension disease

Lungs Congestion Primary pulmonary failurePulmonary edema

Pneumonia

Slide 4 of 6

What about the physical examination of the delirious patient?

Parameter FindingClinical

ImplicationBreath Alcohol

KetonesDiabetes

Liver Enlargement CirrhosisLiver failure

ReflexesMuscle stretch

Asymmetry with Babinski’s signs

Mass lesionCerebrovascular disease

Pre-existing dementia

Reflexes Snout Reflex Frontal massBilateral posterior cerebral

artery occlusion

Slide 5 of 6

What about the physical examination of the delirious patient?

Parameter FindingClinical

ImplicationSixth cranial nerve Weakness in lateral gaze Increased intracranial pressure

Limb strength Asymmetrical Mass lesionCerebrovascular disease

Autonomic Hyperactivity Anxiety Delirium

Slide 6 of 6

What should be included in the laboratory workup for delirium?

• Standard studies– Blood chemistries (including electrolytes, renal and hepatic

indexes, and glucose)– Complete blood count with white cell differential– Thyroid function tests– Serologic tests for syphilis– Human immunodeficiency virus (HIV) antibody test– Urinalysis– Electrocardiogram– Chest radiograph– Blood and urine drug screens

• When indicated– Blood, urine, and cerebrospinal fluid (CSF) cultures– B12, folic acid levels– Computed tomography or magnetic resonance imaging brain scan– Lumbar puncture and CSF examination

What are some of the differential diagnoses?

• Dementia• Delirium

– Due to a general medical condition

– Due to substance intoxication– Due to substance withdrawal– Due to multiple etiologies– Not otherwise specified

• Substance Intoxication• Substance Withdrawal

• Brief Psychotic Disorder• Schizophrenia• Mood Disorder with

Psychotic Features• Acute Stress Disorder• Anxiety Disorder• Malingering• Factitious Disorder• Cognitive Disorder Not

Otherwise Specified

What are the differences between delirium and dementia?

Features Delirium Dementia

Onset Acute Insidious

Course Fluctuating Progressive

Duration Days to Weeks Months to Years

Consciousness Altered Clear

Attention Impaired Normal until dementia is severe

Psychomotor Changes Increased or decreased Often normal

Reversibility Usually Rarely

What might be included in a typical treatment plan?

• General Principles– Treat the underlying cause.– This often means stopping some of

the patient’s medications.– Avoid adding medication if possible.– Sedate if necessary.– Observe the patient briefly to

confirm the presence of delirium, then obtain a history from family members or caregivers.

– Reassure family members.1,2

– Provide physical, sensory and environmental support.

– Arrange for a relative or friend sit with them.

– Provide soft lighting and orientation cues.

• Pharmacotherapy– Haloperidol (Haldol) 2-10 mg IM

repeated hourly is still pretty much the gold standard.

– Avoid the phenothiazines because of their anticholinergic toxicity.

– Physostigmine salicylate (Antilirium) IM or IV can be repeated every 15-30 minutes for anticholinergic toxicity.

– Avoid over-sedation.– Use short half-life benzodiazepines

such as lorazepam (Ativan) 1-2 mg if necessary for sleep. Avoid the long half-life benzodiazepines.

– The benzodiazepines are particularly helpful in alcohol withdrawal syndromes.

1The last time I came to the hospital in the middle of the night was to treat a delirious patient.2When I left, I felt I had really made a difference.

What are some of the typical treatment challenges?• These patients usually cannot

contribute meaningfully to the history.

• Questioning them just causes more agitation.

• Families are usually very upset, scared and sometimes panicked, distracted and suspicious.

• It is rarely clear what exactly is causing the problem.

• These patients cause real management problems for nurses and other caregivers.

• The problem is usually worse at night, i.e., “sun downing” (This problem is not specific to delirium.)

• A delirium is a relative emergency.

• Restless, fearfulness and mild paranoia are frequent harbingers of worse things to come.

• Patients’ memories are spotty afterwards and embarrassment is common.1,2

• Irritability encourages hatefulness and hurt feelings often result.

1What appears to be an obvious delusion sometimes turns out to be reality.2I patient in the ICU once told me he had worked on his electric fence the prior evening.

The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Treatment Process

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment

plan while making sure that I understand.• Repeatedly invite my clarifying questions.• Be patient with me.• Provide me with the appropriate

educational resources.• Invite me to call you with any additional

questions I may have.• Make a follow up appointment.• Communicate with my other physicians.

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some

routine demographic questions.• Ask me to list all of my problems and

concerns.• Using my problem list as a guide, ask me

clarifying questions about my current illness(es).

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status

examination.

1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

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Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 20081

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 20072

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January

2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

Where can you find evidence-based information about mental disorders?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008.

You can read this text online here.• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007• Stead, L, Stead, SM and Kaufman, M,

First Aid© for the Psychiatry Clerkship, Second Edition, March 2005• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition,

March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000• Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.

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