DeliriumDelirium

Danielle Hansen, DODanielle Hansen, DO

August 16, 2006August 16, 2006

ObjectivesObjectives

1.1. The physician will identify The physician will identify common causes of delirium.common causes of delirium.

2.2. The physician will know how to The physician will know how to evaluate patients with delirium.evaluate patients with delirium.

3.3. The physician will know how to The physician will know how to treat delirium.treat delirium.

DefinitionDefinition

1.1. Disturbance of consciousness and Disturbance of consciousness and attention difficulties.attention difficulties.

2.2. Change in cognition or development of Change in cognition or development of perceptual disturbance.perceptual disturbance.

3.3. Onset over short time and fluctuates Onset over short time and fluctuates during the course of the day.during the course of the day.

4.4. Caused by medical condition, substance Caused by medical condition, substance intoxication, or medication side effect.intoxication, or medication side effect.

DSM-IV

EpidemiologyEpidemiology

0

10

20

30

40

50

60

70

ICU Surgery Hospice Medicine ECF ER

EpidemiologyEpidemiology

Prolonged HospitalizationsProlonged Hospitalizations

Functional DeclineFunctional Decline

High Risk of InstitutionalizationHigh Risk of Institutionalization

Mortality 14% and 22% at one month and Mortality 14% and 22% at one month and at six months, respectivelyat six months, respectively

Cole and Primeau, Cole and Primeau, 19931993

PathogenesisPathogenesis

Structural Brain LesionsStructural Brain Lesions

Global Cortical Functional ImpairmentGlobal Cortical Functional Impairment

Neurotransmitter DysfunctionNeurotransmitter Dysfunction

Cytokine ActivationCytokine Activation

Structural Brain LesionsStructural Brain Lesions

Ascending Reticular Ascending Reticular Activating SystemActivating System Arousal and AttentionArousal and Attention

Parietal and Frontal Parietal and Frontal LobesLobes AttentionAttention

Frontal LobeFrontal Lobe Insight and JudgmentInsight and Judgment

Global Cortical Functional Global Cortical Functional ImpairmentImpairment

Normal EEG

Global Cortical Functional Global Cortical Functional ImpairmentImpairment

Slowing of dominant alpha rhythm Slowing of dominant alpha rhythm

Abnormal slow wave activityAbnormal slow wave activity

Neurotransmitter DysfunctionNeurotransmitter Dysfunction

AcetylcholineAcetylcholine

Neuropeptides Neuropeptides

(ie. Somatostatin)(ie. Somatostatin)

EndorphinsEndorphins

SerotoninSerotonin

NorepinephrineNorepinephrine

GABAGABA

Risk FactorsRisk Factors

History of Dementia or Brain DiseaseHistory of Dementia or Brain DiseaseAdvanced AgeAdvanced AgeSensory ImpairmentSensory ImpairmentPolypharmacyPolypharmacyDehydration/MalnutritionDehydration/MalnutritionImmobilityImmobilityInfectionInfectionBladder CathetersBladder Catheters

CausesCauses

Toxins Toxins

Metabolic DerangementsMetabolic Derangements

Brain DisordersBrain Disorders

Systemic Organ FailureSystemic Organ Failure

Physical DisordersPhysical Disorders

ToxinsToxins

DrugsDrugs Prescription MedicationsPrescription Medications Drugs of AbuseDrugs of Abuse

InfectionInfection

PoisonsPoisons

Metabolic DerangementsMetabolic Derangements

Electrolyte DisturbanceElectrolyte Disturbance

Endocrine DisturbanceEndocrine Disturbance

Hyper/HypoglycemiaHyper/Hypoglycemia

Hypercarbia/HypoxemiaHypercarbia/Hypoxemia

Inborn Errors of MetabolismInborn Errors of Metabolism

Nutritional DeficienciesNutritional Deficiencies

Brain DisordersBrain Disorders

CNS InfectionsCNS InfectionsSeizuresSeizuresHead InjuryHead InjuryHypertensive EncephalopathyHypertensive EncephalopathyPsychiatric DisordersPsychiatric Disorders

Systemic Organ FailureSystemic Organ Failure

Cardiac Cardiac

HematologicHematologic

LiverLiver

PulmonaryPulmonary

RenalRenalIcteric sclera

Cyanosis

Physical DisordersPhysical Disorders

BurnsBurns

ElectrocutionElectrocution

Hyper/HypothermiaHyper/Hypothermia

TraumaTrauma

EvaluationEvaluation

HistoryHistoryPhysical ExamPhysical ExamNeurologic ExamNeurologic ExamDiagnostic InstrumentsDiagnostic InstrumentsMedication ReviewMedication ReviewLaboratory TestingLaboratory TestingNeuroimagingNeuroimagingLumbar PunctureLumbar PunctureEEGEEG

Confusion Assessment MethodConfusion Assessment MethodFeatureFeature AssessmentAssessment

1. Acute onset and fluctuating 1. Acute onset and fluctuating coursecourse

Usually obtained from a family member or nurse and shown Usually obtained from a family member or nurse and shown by positive responses to the following questions: “Is there by positive responses to the following questions: “Is there evidence of an acute change in mental status form the evidence of an acute change in mental status form the patient’s baseline?” “Did the abnormal behavior fluctuate patient’s baseline?” “Did the abnormal behavior fluctuate during the day, that is, tend to come and go, or increase and during the day, that is, tend to come and go, or increase and decrease in severity?decrease in severity?

2. Inattention2. Inattention Shown by positive response to the following: “Did the patient Shown by positive response to the following: “Did the patient have difficulty focusing attention, for example, being easily have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was distractible or having difficulty keeping track of what was being said?”being said?”

3. Disorganized thinking3. Disorganized thinking Shown by positive response to the following: “Was the Shown by positive response to the following: “Was the patient’s thinking disorganized or incoherent, such as patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?”ideas, or unpredictable switching from subject to subject?”

4. Altered level of consciousness4. Altered level of consciousness Shown by any answer other than “alert” to the following: Shown by any answer other than “alert” to the following: “Overall, how would you rate this patient’s level of “Overall, how would you rate this patient’s level of consciousness?” Alert/vigilant/lethargic/stupor/coma.consciousness?” Alert/vigilant/lethargic/stupor/coma.

The diagnosis of Delirium requires the presence of features 1 AND 2 plus 3 OR 4.

Principles of Prevention and Principles of Prevention and TreatmentTreatment

1.1. Avoid aggravating or causative factors.Avoid aggravating or causative factors.

2.2. Identify and treat underlying acute Identify and treat underlying acute illness.illness.

3.3. Provide supportive and restorative care Provide supportive and restorative care to prevent further physical and cognitive to prevent further physical and cognitive decline.decline.

4.4. Control dangerous and disruptive Control dangerous and disruptive behaviors.behaviors.

Supportive CareSupportive Care

Limit number of room changesLimit number of room changes

Glasses, hearing devicesGlasses, hearing devices

Orienting stimuliOrienting stimuli

Hydration/nutritionHydration/nutrition

MobilityMobility

Pain managementPain management

Behavior ManagementBehavior Management

Constant observationConstant observation

Frequent reassurance and reorientationFrequent reassurance and reorientation

Physical restraintsPhysical restraints

Psychotropic MedicationsPsychotropic Medications

Haloperidol 0.5-1mg PO/IV/IMHaloperidol 0.5-1mg PO/IV/IM Low incidence of hypotension or sedationLow incidence of hypotension or sedation Onset of action 30-60 minutes (IM/IV)Onset of action 30-60 minutes (IM/IV) Extra pyramidal side effectsExtra pyramidal side effects

Lorazepam 0.5-1mgLorazepam 0.5-1mg Onset of action 5 minutes (IV)Onset of action 5 minutes (IV) Worsen confusion and sedationWorsen confusion and sedation

Atypical AntipsychoticsAtypical Antipsychotics Increase risk of CV events and mortalityIncrease risk of CV events and mortality

Competency ExamCompetency Exam

78 y/o white male is brought to the ER from an 78 y/o white male is brought to the ER from an ECF via EMS for reports of mental status ECF via EMS for reports of mental status change. Upon arrival in the ER, the patient is change. Upon arrival in the ER, the patient is found to be pleasantly confused, A&O x 1. His found to be pleasantly confused, A&O x 1. His vital signs are: BP 106/70, P 96, R 16, T 96.0. vital signs are: BP 106/70, P 96, R 16, T 96.0. The patient is unable to provide a full history but The patient is unable to provide a full history but records from the ECF accompany him and his records from the ECF accompany him and his daughter arrives at the ER shortly after the daughter arrives at the ER shortly after the patient. His PMHx is significant for HTN, Afib, patient. His PMHx is significant for HTN, Afib, DM, OA.DM, OA.

1.1. All of the following are included in your All of the following are included in your initial work up of this patient except:initial work up of this patient except:

A.A. CBC, CMPCBC, CMP

B.B. U/A C&SU/A C&S

C.C. Chest X-rayChest X-ray

D.D. AccucheckAccucheck

E.E. Psych EvalPsych Eval

E. Psych EvalE. Psych Eval

2.2. Which of the following could be the Which of the following could be the etiology of this patient’s “mental status etiology of this patient’s “mental status change?”change?”

A.A. Opiate analgesicsOpiate analgesics

B.B. Parietal lobe CVAParietal lobe CVA

C.C. Urinary Tract InfectionUrinary Tract Infection

D.D. Electrolyte AbnormalitiesElectrolyte Abnormalities

E.E. All of the AboveAll of the Above

E. All of the AboveE. All of the Above

3.3. Your workup reveals a urinary tract infection. Your workup reveals a urinary tract infection. The patient is admitted to the general medical The patient is admitted to the general medical floor. At 11:00PM, the nurse calls you stating floor. At 11:00PM, the nurse calls you stating the patient is combative and has pulled out his the patient is combative and has pulled out his IV. After the behavior modification failed, you IV. After the behavior modification failed, you order:order:

A. Ativan 0.5mgA. Ativan 0.5mgB. Haldol 0.5mgB. Haldol 0.5mgC. Risperdal 1mgC. Risperdal 1mgD. Soft Wrist RestraintsD. Soft Wrist RestraintsE. Pysch ConsultE. Pysch Consult

B. HaldolB. Haldol