Delirium

Lea C. Watson, MD, MPH

Robert Wood Johnson Clinical Scholar

UNC Department of Psychiatry

Nurse pages med student:

“..Mr. Smith pulled out his NG tube and can’t seem to sit still. Last night after his surgery he was fine, reading the paper and talking to his family…today I don’t even think he knows where he is… can you come see him?”

Med student says:

“…sounds like DELIRIUM- good thing you called- I’ll be right there.”

Delirium

• A sudden and significant decline in mental functioning not better accounted for by a preexisting or evolving dementia

• Disturbance of consciousness with reduced ability to focus, sustain, and shift attention

4 major causes

• Underlying medical condition

• Substance intoxication

• Substance withdrawal

• Combination of any or all of these

Patients at highest risk

• Elderly– >80 years– demented– multiple meds

• Post-cardiac surgery• Burns• Drug withdrawal• AIDS

Prevalence

• Hospitalized medically ill 10-30%

• Hospitalized elderly 10-40%

• Postoperative patients up to 50%

• Near-death terminal patients up to 80%

Clinical features

Prodrome

Fluctuating course

Attentional deficits

Arousal /psychomotor disturbance

Impaired cognition

Sleep-wake disturbance

Altered perceptions

Affective disturbances

Prodrome

• Restlessness

• Anxiety

• Sleep disturbance

Fluctuating course

• Develops over a short period (hours to days)• Symptoms fluctuate during the course of the

day (SYMPTOMS WAX AND WANE)– Levels of consciousness– Orientation– Agitation– Short-term memory– Hallucinations

Attentional deficits

• Easily distracted by the environment

• May be able to focus initially, but will not be able to sustain or shift attention

Arousal/psychomotor disturbance

• Hyperactive (agitated, hyperalert)

• Hypoactive (lethargic, hypoalert)

• Mixed

Impaired cognition

• Memory Deficits

• Language Disturbance

• Disorganized thinking

• Disorientation– Time of day, date, place, situation, others, self

Sleep-wake disturbance

• Fragmented throughout 24-hour period

• Reversal of normal cycle

Altered perceptions

• Illusions

• Hallucinations

- Visual (most common)

- Auditory

- Tactile, Gustatory, Olfactory

• Delusions

Affective disturbance

• Anxiety / fear

• Depression

• Irritability

• Apathy

• Euphoria

• Lability

Duration

• Typically, symptoms resolve in 10-12 days

- may last up to 2 months

• Dependent on underlying problem and management

Outcome

• May progress to stupor, coma, seizures or death, particularly if untreated

• Increased risk for postoperative complications, longer postoperative recuperation, longer hospital stays, long-term disability

Outcome

• Elderly patients 22-76% chance of dying during that hospitalization

• Several studies suggest that up to 25% of all patients with delirium die within 6 months

Causes: “I WATCH DEATH”

• I nfections

• W ithdrawal

• A cute metabolic

• T rauma

• C NS pathology

• H ypoxia

• D eficiencies

• E ndocrinopathies

• A cute vascular

• T oxins or drugs

• H eavy metals

“I WATCH DEATH”

• Infections: encephalitis, meningitis, sepsis

• Withdrawal: ETOH, sedative-hypnotics, barbiturates

• Acute metabolic: acid-base, electrolytes, liver or renal failure

• Trauma: brain injury, burns

“I WATCH DEATH”

• CNS pathology: hemorrhage, seizures, stroke, tumor (don’t forget metastases)

• Hypoxia: CO poisoning, hypoxia, pulmonary or cardiac failure, anemia

• Deficiencies: thiamine, niacin, B12

• Endocrinopathies: hyper- or hypo- adrenocortisolism, hyper- or hypoglycemia

“I WATCH DEATH”

• Acute vascular: hypertensive encephalopthy and shock

• Toxins or drugs: pesticides, solvents, medications, (many!) drugs of abuse

– anticholinergics, narcotic analgesics, sedatives

• Heavy metals: lead, manganese, mercury

Drugs of abuse

• Alcohol• Amphetamines• Cannabis• Cocaine• Hallucinogens• Inhalants

• Opiates• Phencyclidine (PCP)• Sedatives• Hypnotics

Causes

• 44% estimated to have 2 or more etiologies

Workup

• History

• Interview- also with family, if available

• Physical, cognitive, and neurological exam

• Vital signs, fluid status

• Review of medical record– Anesthesia and medication record review -

temporal correlation?

Mini-mental state exam

• Tests orientation, short-term memory, attention, concentration, constructional ability

• 30 points is perfect score

• < 20 points suggestive of problem

• Not helpful without knowing baseline

Workup

• Electrolytes

• CBC

• EKG

• CXR

• EEG- not usually necessary

Workup

• Arterial blood gas or Oxygen saturation

• Urinalysis +/- Culture and sensitivity

• Urine drug screen

• Blood alcohol

• Serum drug levels (digoxin, theophylline, phenobarbital, cyclosporin, lithium, etc)

Workup

• Arterial blood gas or Oxygen saturation

• Urinalysis +/- Culture and sensitivity

• Urine drug screen

• Blood alcohol

• Serum drug levels (digoxin, theophylline, phenobarbital, cyclosporin, lithium, etc)

Workup

• Consider:

- Heavy metals

- Lupus workup

- Urinary porphyrins

Management

• Identify and treat the underlying etiology• Increase observation and monitoring – vital

signs, fluid intake and output, oxygenation, safety

• Discontinue or minimize dosing of nonessential medications

• Coordinate with other physicians and providers

Management

• Monitor and assure safety of patient and staff- suicidality and violence potential- fall & wandering risk- need for a sitter- remove potentially dangerous items from the environment- restrain when other means not effective

Management

• Assess individual and family psychosocial characteristics

• Establish and maintain an alliance with the family and other clinicians

• Educate the family – temporary and part of a medical condition – not “crazy”

• Provide post-delirium education and processing for patient

Management

• Environmental interventions

- “Timelessness”

- Sensory impairment (vision, hearing)

- Orientation cues

- Family members

- Frequent reorientation

- Nightlights

Management

• Pharmacologic management of agitation

- Low doses of high potency neuroleptics (i.e. haloperidol) – po, im or iv

- Atypical antipsychotics (risperidone)

- Inapsine (more sedating with more rapid onset than haloperidol – im or iv only

– monitor for hypotension)

Management

• Haloperidol and inapsine have been associated with torsade de pointes and sudden death by lengthening the QT interval; avoid or monitor by telemetry if corrected QT interval is greater than 450 msec or greater than 25% from a previous EKG

Management

• Benzodiazepines

- Treatment of choice for delirium due to benzodiazepine or alcohol withdrawal

Management

• Benzodiazepines

- May worsen confusion in delirium

- Behavioral disinhibition, amnesia, ataxia, respiratory depression

- Contraindicated in delirium due to hepatic encephalopathy

What we see…common cases

• Homeless male, hx. ETOH abuse, 2 days post-op

• 82 year-old women with UTI

• Burn victim after multiple med changes

• Mildly demented 71 year-old after hip replacement

Summary

• Delirium is common and is often a harbinger of death- especially in vulnerable populations

• It is a sudden change in mental status, with a fluctuating course, marked by decreased attention

• It is caused by underlying medical problems, drug intoxication/withdrawal, or a combination

• Recognizing delirium and searching for the cause can save the patient’s life