DELIRIUM

WHAT IS IN THIS PRESENTATION:

Why do we need to know about delirium?

What is delirium?

D/D with respect to psychiatry

How to prevent delirium?

Diagnosis and assessment

Treatment

WHY DO WE NEED TO KNOW ABOUT DELIRIUM?

WHY DO WE NEED TO KNOW ABOUT DELIRIUM?

Delirium is common

Delirium is associated with increased complications

Delirium is often unrecognized

Delirium is preventable

WHAT IS DELIRIUM?

WHAT IS DELIRIUM?

• Acute confusional state

• Constellation of symptoms

• Widespread disruption of higher cortical function

• Acute onset and fluctuating course

• Three core domains:

- cognitive with disproportionate impairment of attention

- circadian disturbance (sleep wake cycle, motor alterations)

- disturbances of higher level of thinking(comprehension, language, thinking process)

CORE FEATURES & ASSOCIATED FEATURES

Core features:• Features that are almost invariably present• Disturbances of - attention - memory - orientation - language - thought process - sleep-wake cycle

Meagher et

al 2007 BJP

CORE FEATURES & ASSOCIATED FEATURES

Associated features:

• Features that are more variable in presentation

• Psychotic symptoms• Affective disturbances• Different motoric profiles

Meagher et al 2007 BJP

IMPAIRMENT OF CONSCIOUSNESS Universal, fluctuating

Barely perceptible dulling of awareness to profound coma

Worsen at night, with fatigue, decreased environmental stimuli

Failure to be selective -----------distractible

Failure to mobilize & sustain attention -------impaired attention

Inability to shift attention------------perseveration

Minor degree---vague malaise, feelings of uncertainity, difficulties in judging passage of time, focusing attention, neglect of appearance, episode of incontinence

Severe degree----too slow in responding, loses thread in conversation, attention to outside events hard to arouse and sustain, drowsy

RECENT WORKS

• Disorder of global cognition

• Prominent disturbance of attention

• Disorientation is least frequent core symptom

• Cognition & language are not as fluctuant as previously described

• Subsyndromal , resolving , persisting delirium

Meagher et al BJP 2012 & BJP 2007

PREDISPOSING OR VULNERABILITY FACTORS

Demographics Older age Male genderCognitive status Dementia Cognitive impairment History of delirium DepressionFunctional status Functional dependence Immobility Poor activity level History of fallsSensory impairment Vision impairment Hearing impairment

Decreased Intake Dehydration MalnutritionDrugs Multiple psychoactive drugs High number of drugs Alcohol abuseMedical Comorbidity High severity of illness High level of comorbidity Chronic renal or hepatic disease Previous stroke Neurologic disease Metabolic derangements Fracture or trauma Terminal illness HIV infection

Inouye SK. NEJM 2006;354:1157-65

PRECIPITATING FACTORS OR INSULTS

Drugs Sedative hypnotics Narcotics Anticholinergic drugs Polypharmacy Alcohol or drug withdrawalPrimary neurological diseases Stroke, particularly nondominant hemispheric Intracranial bleed Meningitis/encephalitisEnvironmental Intensive care unit admission

Physical restraint useBladder catheter useHigh number of proceduresPainEmotional stress

Prolonged sleep deprivation

Intercurrent illnesses Infections Iatrogenic complications Severe acute illness Hypoxia Shock Fever/hypothermia Anemia Dehydration Poor nutritional status Low serum albumin Metabolic derangements (e.g., electrolytes, glucose, acid-base)Surgery Orthopedic surgery

Cardiac surgeryDuration of cardiopulmonary bypassNon-cardiac surgery

Inouye SK. NEJM 2006;354:1157-65

URGENT RECOGNITION: Wernicke’s Hypoxia Hypoglycemia Hypertensive encephalopathy Intracerebral hemorrhage Meningitis/encephalitis Poisoning/medications

ETIOLOGIES -“ I WATCH DEATH “

• I = Infection

• W = Withdrawal• A = Acute Metabolic• T = Trauma• C = CNS Pathology• H = Hypoxia

• D = Deficiencies (especially vitamin)

• E = Endocrinopathies• A = Acute Vascular• T = Toxins• H = Heavy metals

Flacker JM. J Gerontol Biol Sci 1999;54:B239-46

DIFFERENTIAL DIAGNOSIS IN PSYCHIATRY

DIFF DELIRIUM & PSYCHIATRIC DISORDER

• Clouded consciousness or decreased level of alertness

• Disorientation

• Acuity of onset and course- serial mental status exams can help demonstrate this

• Age >40 without prior psych history

• Presence of risk factors for delirium, recent medical illness or treatment

DELIRIUM V/S SCHIZOPHRENIA

• Onset of schizophrenia is rarely after 50.

• Auditory hallucinations are much more common than visual hallucinations

• Memory is grossly intact and disorientation is rare

• Speech is not dysarthric

• No wide fluctuations over the course of a day

• Thought content and abnormal perceptions are related

• In delirium, thought and perception are influenced by immediate environment

MOOD DISORDER V/S DELIRIUM

• Mood disorders manifest persistent rather than labile mood with more gradual onset

• In mania the patient can be very agitated however cognitive performance is not usually as impaired

• Flight of ideas usually have some thread of coherence unlike simple distractibility

• Disorientation is unusual in mania

DELIRIUM V/S DEMENTIA

Delirium Dementia

Impaired memory +++ +++

Impaired thinking +++ +++

Clouding of consciousness +++ -

Major attention deficit +++ +

Fluctuation of course/day +++ +

Disorientation +++ ++

Vivid perceptual dbn ++ +

Incoherent speech ++ +

Disrupt sleep/wake cycle ++ +

Nocturnal exacerbation ++ +

Acute/subacute onset ++ -

Impaired judgement ++ +++

DELIRIUM IS PREVENTABLE

PREVENTING DELIRIUM

• Yale delirium prevention trial

• Designed to counteract iatrogenic influences leading to delirium in the hospital

• Multicomponent intervention strategy targeted at 6 delirium risk factors

SIGNIFICANCE OF DELIRIUM PREVENTION TRIAL

• First demonstration of delirium as a preventable medical condition

• Targeted multicomponent strategy works• Significant reduction in risk of delirium and total

delirium days, without significant effect on delirium severity or recurrence

• Primary prevention of delirium likely to be most effective treatment strategy

• Effectiveness and cost-effectiveness of the program has been demonstrated in multiple studies

YALE DELIRIUM PREVENTION PROGRAM

• Cognitive impairment

• Sleep deprivation

• Immobilization

• Vision impairment

• Hearing impairment

• Dehydration

• Reality orientation

• Sleep enhancement protocol

• Early mobilization

• Vision aids, adaptive eqp.

• Amplifying devices, adaptive eqp

• Early recognition & Rx

Risk factor Intervention

DIAGNOSIS AND ASSESSMENT

DIAGNOSIS AND ASSESSMENT

• Delirium is a clinical diagnosis

• History and physical examination

• Mental Status Exam

• Rating Scales-consider on admission

ASSESSMENT INSTRUMENTS

To identify delirium:• Delirium rating scale – revised 98 ( DRS – R98)• Confusion assessment method (CAM)• Delirium symptom interview (DSI)• Confusion assessment method for ICU (CAM-ICU)• Intensive care delirium screening checklist (ICDSC)

To assess symptom severity:• Delirium detection scale (DDS)• Memorial delirium assessment scale (MDAS)

To test neuropsychological function:• Cognitive test for delirium (CTD)

DIAGNOSIS AND ASSESSMENT

Lab tests cannot diagnose delirium but may support dx CBC, CMP, UA, urine tox, TSH, B12, ammonia CXR, EKG, LP if indicated Neuroimaging

EEG Generalized slowing in delirium, nonspecific Triphasic waves in hepatic encephalopathy Low voltage fast activity in EtOH or BZD w/d

TREATMENT

TREATING PATIENTS WITH DELIRIUM

Treat underlying causes Don’t stop looking after finding one potential

cause

• Anticipate in high risk states

• Diagnosis & treatment should occur concurrently

• Regular evaluation of progress is important

• Best managed in hospital setting

TREATING PATIENTS WITH DELIRIUM

• Supportive and environmental measures - support and orientation

- unambiguous environment

- maintaining competence

• Drug treatment - antipsychotics

- benzodiazepines

- emerging therapies

• Managing patients after discharge

PROVIDING SUPPORT AND ORIENTATION Communicate clearly and concisely; give repeated

verbal reminders of the day, time, location, and identity of key individuals, such as members of the treatment team and relatives

Provide clear signposts to patient's location including a clock, calendar, chart with the day's schedule

Have familiar objects consistency in staff Use television or radio for relaxation and to help the

patient maintain contact with the outside world Involve family and caregivers to encourage feelings of

security and orientation

PROVIDING AN UNAMBIGUOUS ENVIRONMENT

Simplify care area by removing unnecessary objects; allow adequate space

between beds Consider using single rooms to aid rest and avoid

extremes of sensory experience Avoid using medical jargon in patient's presence

because it may encourage paranoia Ensure that lighting is adequate; provide a 40 60 W

night light to reduce misperceptions Control sources of excess noise (such as staff,

equipment, visitors); aim for < 45 decibels in the day and < 20 decibels at night

Keep room temperature between 21.1°C to 23.8°C

MAINTAINING COMPETENCE Identify and correct sensory impairments

Encourage self care and participation in treatment

Treatments to allow maximum periods of uninterrupted sleep

Maintain activity levels:

-ambulatory patients should walk three times each day;

-non ambulatory patients should undergo a full range of movements for 15 minutes three times each day

DRUG TREATMENT

• Benefits v/s adverse effects

• Use of psychotropic drugs: - complicates ongoing assesment of MSE

- impair patient’s ability to understand or co-operate

- greater incidence of falls

• Prescribing often influenced by: - pressure from relatives

- time constraints

-diff in coomunication between medical & nursing staff

ANTIPSYCHOTICS

• Hyperactive and hypoactive delirium

• Improve cognition

• Rapid onset

• Improvement evident in hours or days

• Superior to benzodiazepines

ANTIPSYCHOTICS

• Chlorpromazine , Haloperidol, Droperidol – similar efficacy

• Atypicals – further research needed

• Haloperidol is preferred:

- fewer active metabolites

- limited anticholinergic side effects

- less sedative & hypotensive effects

- administered by different routes

- EPS *reported incidence is low

*iv administration – EPS less likely

BENZODIAZEPINES

• Can protect or pose risk

• Delirium associated with seizure, withdrawal from alcohol or sedatives

• Adjunct if antipsychotics are not tolerated

• Lorazepam is preferred

- rapid onset

- short duration of action

- low risk of accumulation

- no major active metabolites

- predictable bioavailability if given i.m.

EMERGING THERAPIES

• Physostigmine – anticholinergic delirium

(hypoxia, hypoglycaemia, drug related, trauma)

• Nicotine replacement treatment – protective?

• Pimozide –potent calcium antagonist

- delirium ass with hypercalcemia

• Trazadone & Mianserin ( 5HT 2 antagonist)

• Light therapy

OUTCOME OF DELIRIUM

40%

25%

35%

Recovery Permanent Cognitive Impairment Mortality

MANAGING AFTER DISCHARGE• Many patients dicharged before full resolution

• Delirium may persists for weeks or even months

• Risk of new diagnosis of dementia increased at least threefold

• Problems in attention may persist

• Prevent further episodes

- address risk factors

- correct sensory impairments

• Look for psychological sequalae

- depression

- PTSD

• Follow up - must

THANK YOU

“Knowing is not enough;we must apply.

Willing is not enough;we must do.”

- Goethe