Delirium PLM

Definition
Reversiblefrom step upacute period of cognitive dysfunction due to a medical
disturbance or condition
CausesP. DIMM WIT
Ppost op
Ddehydration and malnutrition
Iinfection (sepsis, meningitis, encephalitis, UTI, etc)
Mmeds and drug intoxications (TCAs, corticosteroids, anticholinergics,
hallucinogens, cocaine)
Mmetals
Wwithdrawals (alcohol, benzodiazepines)
Iinflammation, fever
TTrauma, burns
Also includes causes of ComaSMASHED
S-- Structural brain pathologystroke, stubdural or epidural hematoma
Mmeningitis, mental illness
Aalcohol, acidosis
Sseizures, substrate deficiency
Hhypercapnia, hyperglycemia, hyperthermia; hyponatremia, hypoglycemia,
hypoxia, hypotension/cerebral hypoperfusion, hypothermia
Eendocrine causes, extreme chemistries
Ddrugs (opiates, barbiturates, benzos, other sedatives), dangerous
compunds (CO, cyanide, methanol)
Clinical features
In contrast to both dementia and psychosis, delirium and psychosis, delirum is
characterized by a rapid deterioration in mental status (over hours to days), a
fluctuating level of awareness, disorientation, and frequently, abnormal vitals
May be accompanied by acute abnormalities of perceptionhallucinations
Pts may not nece3ssarily be agitated, but may have a slow, blunted
responseiveness
Diagnosis
Mental status exam, mini mental status exam
Labschem panel, vit b12, thiamine
LPperform in any febrile, delirious pt unles there are contraindications (cerebral
edema)
Treatment
Tx underlying cause
Haloperidolfor agitation/psychotic-like behavior
Supportive
Delirium vs. dementia
Feature Delirium Dementia
Causes Infections Alzheimers
Medications Multi-infarct disease
Post-op delirium Picks disease
Alcoholism
Electrolyte imbalances
Medical conditions
 (stroke, heart disease, ,
seizures, hepatic and renal
disorders)
Level of Altered, fluctuating Preserved
consciousness
Hallucination Frequently present Rarely present
s (visual)
Presence of Sometimes present (eg. Usually absent
tremor Asterixis) unless dementia is due to
parkinsons
Course Rapid onset, waxing and Insidious,
waning progressive
Sundowning (worsening
at night) may be present
Reversibility Almost always reversible Typically
irreversible

Delirum epidemiology
10-15% of general medical inpts are delirious at any given time
30-50% of acutely ill geris become delirious at some point during hosp stay
Freq cause of psych consult in the hospital
Diagnosing
DSM-4 is hard to do
Confusion assessment method (CAM)
Clinically more useful
More than 95% sensitivity and specificity
CAM methodrequires both 1 and 2, and either 3 or 4
Acute change in mental status and fluctuating course
Is there evidence of an acute change in mental status from pts
baseline?
Did the abnormal behavior fluctuate during the day (tend to come and
go, or increase and decrease in severity)
Inattention
Did the pt have difficulty focusing attention (being easily distractible)
or have difficulty keeping track of what was being said?
Disorganized thinking
Was the pts thinking disorganized or incoherent, such as rambling or
irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject
Altered level of consciousness
Overall, how would you rate this pts level of consciousness? (alter
normal, vigilanthyperalert, lethargicdrowsy, easily aroused, stupor
difficult to arouse, or comaunarousable). Pos if any other level of
alert
Make sure to determine btw delirium and dementia (remember dementia pts can
have delirium!)
Dsm-IV criteria
Disturbance of consciousness with reduced ability to focus, sustain or shift attn.
Change in cognition (memory deficit, disorientation, lang disturbance) or a
perceptual disturbance not better accounted by existing dementia
 Development over a short time (hours to days) and fluctuates during day
Evidence that the disturbance is a direct physiologic consequence of a medical
condition or a drug
Delirium vs dementia
Delirium
Rapid onset
Primary defect in attn.
Fluctuates during the day
Visual hallucinations common
Often cannot attend to MMSE or clock draw
Dementia
Insidious onset
Primary defect in sh0ort term memory
Attn. often normal
Does not fluctuate during day
Visual hallucinations less common
Can attend to MMSE or clock draw, but cannot perform well
Delirium takes various forms
Hyperactive or agitated delirium1/4
Mixed1/4
Hypoactive deliriummore than half, but less recognized and appropriately treated
Lethargy
Addl features include emotional lability, psychosis and hallucinations
Predisposing factors
Advanced age
Dementia
Functional impairments in adls
Medical comorbidity
Hx of alcohol abuse
Male sax
Sensory impairment
Hospital?
Lots of medical stuffprecipitating factors!!
Cardiac eventselderly pts dont come to ER with normal presenting sx.
They come in delirious
Acute pulmonary events
Bed rest
Drug withdrawal (sedatives, alcohol)
Fecal impaction leading to urinary retention
Fluid or electrolyte disturbances
Hypoxia
ICU psychosis
Infections/fevers
Meds
Psychoactive
Anticholinergic
Restraints
Severe anemia
 Uncontrolled painesp post- op pts
Urinary retention
Indwelling devices
Epidemiological approach
Delirium caused by sum of predisposing and precipitating factors
The most predisposing factors present, the fewer precipitating factors are needed to
cause delirium
Which med do you stop in the dementia pt with delirium?
Ariceptanticholinesterase
Rochephinantibiotic-- ceftriaxone
Pepcidreflux drugsomething amotadine
Drugs associated with delirium
antiHTN
amphotericin B
antispasmodics
plus a million
recognizing delirium
nurses recognize and document less than 50% cases
physicians recognize and document only 20%
what to do with pt?
keep her on antibioticsrepeat CXR in a day or two
keep her on O2hypoxia can cause delirium
take out the foley if its not needed
take her off the Pepcidit has antihistamine propertieshits cholinergic sites too
neuropathophysiology
cholinergic deficiency
delirium is assoc with inc serum anticholinergic activity
anticholinergic activity is found in delirious pts taking no
anticholinergic drugs
acetylcholine is an ipt NT for cognitive processes
deliriumcaused by anticholinergic drug poisoning, reversed by
physostigmine
serotonin excess or deficiency
cytokines
other neurotransmittersgaba and dopamine
diff mechs may pertain in diff situations
bottom line.. kind of unknown
dont put her on benzos
managementdrugs to reduce or eliminate
alcohol
anticholinergics
anticonvulsants
antideprssants (antichol)
antihistamines (anticholinergics)
antiparkinson
barbituates
benzos
chloral hydrate
 h2 blockers
opiods analgesics (esp meperidine)
antipsychotics
what elsefor safetyambulation, only two side rails, keep personal items within reach,
keep nurses button in reach, restraints?? Only if pt is a harm to themselves
four side rails? Restraint2 isnt
use a self release Velcro belt
keys to effective management
tx the underlying disease
address contributing factors
avoid the complications of delirium
remove indwelling devices ASAP
prevent or tx constipation or urinary retention
encourage proper sleep hygiene, avoid sedatives
optimize medication regimen
further management
orienting stimuli
provide adequate socialization
use eyeglasses and hearing adis
mobilize pt
behavioral problemsmanagement
provide social restraintssitter, allow fam in room
avoid physical or pharma restraints
if absolutely necessary, may use medications
who else can helpvolunteers!
Morbidity associated with delirium
10 fold risk of death in hospital
3-5 fold inc risk of nosocomial complications, prolonged stay, prostacute nursing-
hope placement
Poor functional recovery and inc risk of death up to 2 years following discharge
Persistence of delirium poor long term outcomes
Outcomes
Death8% vs 1%
Inc length of stay
Inc nursing home placement
Functional decline
Iatrogenic probs
Care plan optionssend home, may need phsyio rehab
Mr. Fen
Pre ophes awesome
Incidence and risk for post op delirium
Non cardiac15% chance
Cardiac and hip fracture (invasive long surgeries)50% chance youll develop
delirium
Ddx
Infections
Withdrawal
Acute metabolic
 Trauma
Cns path
Hypoxia
Deficiencies
Endocrinopathies
Acute vascular
Toxins or drugs
Heavy metals
Post op
CAM (1 AND 2 plus 3 OR 4)
Acute change in mental status and fluctuating courseyes! Doesnt know
where hes is
Inattentioneasily distractible
Disorganized thinkingswitches topics, cant count backwards
Altered level of consciousnesslethargicshe said he was alert
What happens post op
Inc risk with preop risk factors
Age
Cognitive impairment
Physical functional impairment
Hx of alc abuse
Abnl serum chems
Intrathoracic and aortic aneurysm surgery
I-2 risk factors10%
More risk factors50%
Can interventions prevent delirium
Pts that had geri consults which identified predisposing and precipitating risk factors
had a lower risk of developing delirium, and lowered length of stay!
Evaluation
History
Focus on time course of cognitive changes, esp their assoc with toher
symptoms or events
Meds review, including OTC and alc
PE
Vitals,
O2 sats
Gen med eval
Neurologic and MSE
Blood
Cbc with Diff (HCT, WBC, MCV, ESR)
Electrolytes (BUN, glu, ca, na, albumin, ammonia, LFTs)
Drug levels (toxic screen, meds)
Arterial blood gasesthink if pt is hypoxic
Urinalysis (acetone and glu)
CXResp if pt is hypoxic
ECGesp if pt is hypoxic
Additional labs
Blood studies
 Heavy metals
Thiamine, folate
Thyroid
Lupus
Ana
Cortisol
Urinary prophobilinogen
LP
CT or MRI of head
Eeg
Post op care
Optimize them medically
Take care of painlook at the indiv pts, most post surg pain requires narcotic

analgesia
For cognitively intact pts, consider a pt-controlled analgesia (PCA) pump
Less severe painacetaminophen with narcotic analgesic
Someone who cant commuinicatestanding order sfor narcotic analgesic with
assessment
Something else
Managint the delirious pt
Identify and correct underlying cause
Protect pt from unintentional self harm
The best management for delirium is PREVENTION
Dont forget about nonpharma things
Case 3

Pt 30 hr post op following hernia repair. Pt is confused, agitated with pulse of 150, bilateral
course tremor. Given Haldol.
Hes 45 yo teacher, no hx of med or psych probs. Hyperactive DTRs, normal fundo, no
babinskis, CBCmacrocytosis but not anemia. LFTs are elevated esp GGT
What would be your diagnosis?
Dementia
Medication induced delirium
Psychosis
Delirium NOS
Alcohol withdrawal induced deliriumwhat I picked (theyre accepting this)
Social worker is able to obtain addl info from pts wife. She says he has gradually inc
drinking, and over the past two years, he has drinking every day. Collegues say hes short
tempered
What would be the immediate treatment for the pt?
Antidepressants to address the underlying depression
Antipsychotics
Benzoswhen someone is in alcohol withdrawal!! Diazepam (long acting)
Rehab
Case 4

65 yo with depressed mood, severe insomnia after spouse died 2 mo ago. Starts on first
gen psychotic and a TCA (perphenazine and amitriptyline). She says shes sleeping better,
 but has more anxiety. Cant sit still. PCP thinks shes having EPS (akathisia). Starts her on
anticholinergic?
Now shes inc confused, disoriented, particularly at night, called popo. PCP says shes
disoriented to ime and place, dry mucous membranes
What is the most likely cause of this pts current symptomatology?
Schizophrenia
Major depression with psychosis
Dementia
Neuroleptic malignant syndrome typical antipsychotics
Substance induced delirium
Anticholinergic side effects
NT ch acts on nicotinic and muscarinic receptos
Nicotineicskeletal mm nerge--- get these notes
Blind as a bat
Mad as a hatter
Red as a beet
Hot as hell
Dry as a bone
The bowel and bladder lose their tone
The heart runs alone
Beer criteria
Potentially inappropriate meds in elderly
Delirium
All TCAs
Anticholinergics
Benzos
Chlopromazine
Corticosteroids
H2 receptor antagonist
Meperidine
Sedative hypnotics
Thioridazine
Strong anticholoinergic properties
Antihistamines
Antiparkinsons
Skeletal mm relaxants
Antidepressants
Antipsychotics
Antimuscarinics
Antispasmodics
Case 5

72 yo for elective hp preplacement. COPD and OA, smoker. Medsca, vit d,

ipratropium/albuterol, o2 while sleeping. Oral corticosteroids. Vitals are ok o2 sat87%,
goes up to 93% on 2 L nasal o2, wheezes (expiratory). CXRplate like atelectasis, chronic
scarring, no infiltrates
Pt is very congused. CAM3. Taking out o2, falls asleep, cant be redirecteddelirious
 Which of the following in addn to oxygen therapy and ipratropium albuterol
nebulizer tx, would you recommend to minimize the risks of post op pulmonary
complications and delirium
Corticosteroids and chest PTdoesnt need abxclear CXR, no fever
Corticosteroids and abx
Corticosteroids, abx and theophylline (long acting, and not used acutely)
Chest PT, antibiotics, and theophyllinewhat I picked
Corticosteroids and antipsychotic meds
Case 6

Mrs. M is a 70 yo woman with hx of thalamic CVA, bipolar illness, chronic pain and OA. She
takes Tylenol with codeine, valproate, lithium, conjugated estrogens with progesterone and
aspirin. 2 mo ago, her daughter died unexpectedly and she has been more depressed. One
week ago, she became agitated and uncooperative. She was seen in the ER where labs
and CXR were normal. A consulting psychiatrist recommended clonezapam, a
benzodiazepine.
Despite the benzo, she worsened and became uncontrollable at home. Back to ER,
fluctuating level of consciouness, dioritented and inattentive. Everything normal except
EKG shos LBBB (old). Slight ST changes from last EKT. Troponin high. Further questioning
had SOB previous 5 days earlier.
Whats the cause of the delirium
Anticholinergics
Cardiac ischemia
Psychiatric illness
Hypoxemia
Benzo
Persantine thalliumlarge fixed inferior defect, no reversible disease. Tx with aspirin and
beta blocer. Derlium due to cardiac prob
Pt ischemia is treated with meds, a cardiac cath and stent. Complicated post op and in
cCU. Clears, but stays there
Develops derlium with CAM score of 4
After all nonpharma tx have been tried, you recommend
Trazadonesedating antidepressant
Lorazepam
Haloperidol
Physostigmine
Donexepril
Drug therapy
All drugs have side effects
Use only if delirium interfereing with therapy
Stopped taking notes during drug discussion
CNS aidsKNOW THESE SLIDES
Thought to invade the brain shortly after systemic infxn
Early on indiv are not immunocomp and they can contain the infection until later
Produces a subcortical dementia (central white matter, basal ganglia, thalamus and
brain stem)
Get mental slowing, forgetfulness, apathy