Delirium

Michele Ritter, M.D.

Argy February, 2007

Delirium vs. Dementia Dementia:

Slow evolution of multiple cognitive deficits Delirium

DSM-IV: Disturbance of consciousness (ie, reduced clarity of awareness of

the environment) with reduced ability to focus, sustain or shift attention

A change in cognition (such as memory deficity, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for my a pre-existing or evolving dementia

The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day

Ther is evidence from the history, physical examination, or laboratory findings that the disturbance is cause by the direct physiological consequences of a general medical condition.

Includes Substance Intoxication Delirium, and Substance Withdrawal Delirium

Delirium – Case #1

A 75-year old male with a history of coronary artery disease, hypertension and atrial fibrillation is brought to the ER by his wife because of lethargy and confusion. The patient’s wife states that the patient tripped on the cat four days earlier and fell, but “didn’t hurt himself”. Otherwise, he’s had no recent changes in medications, no recent fevers.

Subdural hematoma

CNS abnormalities as cause of Delirium Intracranial hemorrhage

Subdural hematoma Epidural hematoma

Cerebral Vascular Accident Ischemic or hemorrhagic stroke

Seizure Post-ictal confusion

Brain tumors Carcinomatous meningitis

Vasculitis

Delirium – Case # 2

A 20-year old Georgetown student is brought to Georgetown emergency room by his friend because he was found to be confused and lethargic. In the E.R. he is noted to have fever to 103°, nuchal rigidity on exam, and the following rash.

Delirium – Case # 2

CNS Infections as cause of delirium

Meningitis Bacteria: Neisseria meningitides, Strep. pneumoniae,

Haemophilus influenzae, Listeria monocytogenes (in elderly).

Viruses: Enterovirus, Herpes simplex Virus (HSV), Cytomegalovirus

HIV: Crytpococcus Encephalitis

HSV Frequently “wacky” behavior for days to hours before

hospitalization Brain abscess

Infection with toxoplasmosis in HIV

Delirium Case # 3

A 34-year old male with no significant past-medical history presents to Georgetown ER after some lethargy and confusion right after finishing his first marathon. His friends state that he “never” drinks or uses drugs, and that he did a very good job of keeping hydrated with water and gatorade during the marathon.

Electrolyte abnormalities as cause of Delirium Hyponatremia

Polydypsia (w/ free water) SIADH

Hypernatremia Diabetes insipidus

Hypercalcemia Think of cancers: Squamous cell lung cancer,

Multiple myeloma Hypoglycemia Uremia

Systemic Infections as cause of delirium Urinary Tract Infections Pneumonia Intra-abdominal infections Line infections Sepsis

Hypoperfusion to the brain results in decreased mental status.

Delirium Case # 4

An 88-year-old nursing home resident with a history of hypertension, Diabetes mellitus and an indwelling foley secondary to neurogenic bladder, presents to the ER with obtundation. She is noted on exam to have a low temperature at 34.7° C, a blood pressure of 88/40 and very cloudy urine in her foley.

Delirium Case # 5

A 56-year-old male with a history of 2 packs of cigarettes/day for 40 years, and a history of a “clotting disorder” presents to the ER with one day of lethargy and confusion. On exam, the patient is afebrile, normotensive with a HR of 110, respiratory rate of 14 and Oxygen saturation of 92% on RA. In general he is oriented to self only, but does not appear to breathing heavily – in NAD. On lung exam there are decreased breath sounds bilaterally. His left lower extremity is noted to be more swollen than the right.

Respiratory abnormalities as cause of dementia Hypoxia

Asthma Pulmonary Embolism Pulmonary Edema (Congestive Heart Failure)

Hypercapnia COPD patients Narcotic overdose

Delirium Case #6

A 18-year old Georgetown college student is brought in to Georgetown ER by the GUTS emergency medical service. He was found staggering down Prospect St. at 3 am. On exam, patient is afebrile, normotensive, slightly tachycardic, and very beligerant. He has slurred speech, and is oriented to self only. Nausea and vomiting along with fecal incontinence ensues.

Drugs as cause for Delirium

Alcohol D-Lysergic acid diethylamide (LSD) Benzodiazepines Narcotics PCP

Delirium Case # 7

An 88-year old female with a history of osteoporosis is brought to GUH by her granddaughter. The granddaughter states that the patient is usually “totally with it” and lives by herself. They spent the day yesterday picnicking in a field in Northern Virginia, and they had noticed some mosquitos bites afterwards, but that was it. Starting today, the patient was noticed to be acting very “wacky”. She also hadn’t gone to the bathroom all day the granddaughter states.

On exam the patient is afebrile, but tachycardic; Her mucus membranes are very dry, and she has mydrasis.

Delirium Case # 8

A 42-year old female with a history of metastatic breast cancer is admitted to GUH with spinal cord compression. She is seen by neurosurgery, and decision is made to defer surgery but instead have patient undergo radiation therapy. Patient is noted over the next several days to have “wacky” behavior – at times oriented to self and place only.

Medications as cause for delirium

Anti-cholinergics Benadryl Tri-cyclic antidepressants

Muscle relaxants Flexeril, skelaxin

Anti-emetics Phenergan

Steroids “steroid psychosis”

Anesthesia Medications

Final Case

A 79-year old female with a history of hypertension, peripheral vascular disease presents to the hospital with some mild confusion. The patient and her daughter states that since earlier that day, the patient has been forgetting things, and had a few episodes of not knowing where she was. She has had no recent changes in medications, no recent hospitalizations.

Final Case (cont.)

PMH: Hypertension Peripheral Vascular Disease – had a femoral-popliteal

bypass in right leg 3 years ago Allergies: NKDA Outpatient Meds:

Lisinopril – 40 mg po QDay Metoprolol – 25 mg po BID

Social History: Lives with daughter; No history of tobacco or alcohol

use; No other drug use; previously worked as history teacher (retired many years ago)

Final Case (cont.)

Review of systems: Gen: No fever, no weakness, no weight

loss/gain, no headache CV: No chest pain, no palpitations Resp: No cough, no SOB GI: No abdominal pain, no nausea/vomiting,

no diarrhea, no constipation Heme: No easy bleeding, bruising

Final Case (cont.)

Physical Exam: VS: 37.6° C, 112/60, 62, 16, 94% on RA Gen.: Alert, but oriented only to self and

place; at times seems to have trouble giving details of her medical history

CV: RRR, no murmurs auscultated Resp.: LCTA bilaterally Abd: soft, nontender, NABS Ext.: No LE edema

Final Case (cont.)

Labs: WBC: 9.8 Hgb.: 11.2 Hct. 33.8 Plt: 228 Sodium: 132, Potassium: 4.0, Chloride: 100

CO2: 21, BUN 13, Cr. 0.8, Glucose 110 Urinalysis: No protein, glucose, ketones;

Leuk. Est: neg. , no WBCs, no RBCs

Final Case (cont.)

Final Case

Delirium Cases -- Synopsis

CNS Process CNS Infections Infections/Sepsis Electrolye Disturbances

Hyponatremia Hypoglycemia Hypercalcemia

Medications Alcohol/Drugs Hypoxia/Hypercapnia Myocardial Infarction