Delirium (When things really do go bump in the night!

)
Dr sadia yasir

ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY

Psychiatrists Providing Collaborative Care Bridging Physical and Mental Health
 Objectives

 List DSM-5 criteria for delirium

 Identify signs and symptoms of delirium
 Identify risk factors for delirium
 Recognize common precipitating causes of delirium
 Describe differences between delirium and other similar disorders
 Describe the assessment and treatment for patients with delirium

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 Sequence of presentation

 DSM-5 Criteria
 Synonyms and terminology
 Prevalence
 Recognition
 Risk Factors
 Clinical features
 Pathophysiology
 A CASE PRESENTATION
 Etiology
 Assessment
 Treatment
 Prevention

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 DSM 5 Criteria - Delirium
• Disturbance in attention and awareness
• Develops over short period; fluctuates
• Additional disturbance in cognition
• Not accounted for by other neurocognitive disorders
• Caused by a general medical condition
• Can be multiple etiologies

American Psychiatric Association: Diagnostic and Statistical

Manual of Mental Disorders, 5th Edition. Arlington, VA,
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American Psychiatric Association, 2013. 4
 DSM 5 Criteria
• Classification of delirium
– Delirium due to another medical condition
– Substance intoxication delirium
– Substance withdrawal delirium
– Delirium due to multiple etiologies
– Medication induced delirium

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 DSM 5 Criteria

 Further Specifiers
– Time
 Acute : Hours/Days
 Persistent: Weeks/Months
– Level of activity
 Hyperactive
 Hypoactive
 Mixed level of activity

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 Synonyms for Delirium

• Acute confusional state

• Encephalopathy
• Acute brain failure
• ICU psychosis
• Altered mental status
• Acute reversible psychosis
• Reversible dementia
• Acute mental status change
• Organic brain syndrome
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 Prevalence of Delirium
Prevalence %

Severe burn

Nursing home

Terminally ill patients

Post repair of fractured hip

Post CABG

Post op patients

AIDS

ICU elderly

Hospitalzed cancer

Hospitalized elderly

Hospitalized medically ill

ER

0 10 20 30 40 50 60 70 80 90

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 Recognition of Delirium

• Delirium is commonly unrecognized

– ER physicians miss 87-83% of cases (Han, Wilson & Ely, 2013)
– Hospital admission 14-24% (overall prevalence 1-2%) (Fong, Tulebaev & Inouye, 2011)
– Nurses recognize delirium more frequently than physicians, 45% v. 20%
• Delirium should always be considered when there is an acute or
subacute deterioration in behavior, cognition or function
• 30-40% of delirium cases are preventable (Hshieh, et. Al, 2015)

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 Consequences of Delirium

• Increased Mortality
– Almost 25% more chances of death with delirium in hospitalized patients (Curyto et. al, 2007)
– Adjusted risk of death – twice as compared to non-delirious controls (Inouye et. al, 1998)

• Increased Morbidity
– Poor functional recovery
– Possible future cognitive decline
– Increased risk of complications
– Increased nursing home placement
– Increased costs and LOS
– Depression, PTSD

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 Risk Factors for Delirium
(Partial List)
• Elderly
– Impaired acetylcholine neurotransmission
– Vascular changes
– Pharmacokinetic changes
• CNS disorders
– Major neurocognitive disorders represents one of the greatest risk factors
• Multiple medications (including starting more than 3-5 new meds)
• Burn patients
• Low serum albumin
• Drug and Alcohol Abuse

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 Clinical Features of Delirium

• Temporal course
– Abrupt or acute onset
• Within days
– Fluctuation in symptom severity
• Waxing and waning
• Worse at night
• May result in diagnostic uncertainty

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 Clinical Features

• Diffuse cognitive impairment

– Attentional deficits
• Reduced ability to focus, sustain or shift attention
• “Clouding of consciousness”
– Memory impairment
• Long and short term
– Disorientation
• Commonly to time and place
• Rarely to person
– Executive dysfunction

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 Clinical Features

• Thought disturbances
– Disorganized
• Language disturbances
– Word finding problems
– Dysgraphia
– Dysarthria
– Dysnomia
• Perceptual disturbances
– Misperceptions
– Hallucinations (Visual >> Auditory)
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 Clinical Features

• Psychomotor abnormalities
– Hyper, hypo or mixed
• Sleep-wake cycle disturbance
– Insomnia
– Frequent napping or drowsiness during the day
– Reversal of sleep/wake cycle
• Delusions
– Usually paranoid and not systematized
• Affective lability
• Neurologic abnormalities
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 Differential Diagnosis of Delirium
Delirium Dementia Depression
Onset Abrupt Slow and insidious Variable

Daily Course Fluctuating Usually stable Usually stable

Length Hours to weeks Years Variable
Consciousness Reduced Clear Clear
Alertness Increased or Usually normal Normal
decreased
Activity Increased or Variable Variable
decreased
Attention Impaired Usually normal Usually normal
Orientation Impaired Impaired Normal

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 Pathophysiology of Delirium: Acetylcholine
• Acetylcholine
– The cholinergic system is involved in:
• Attention
• Arousal
• Memory
– Decreased cholinergic activity produces deficits in:
• Information processing
• Arousal
• Attention and ability to focus
– Various metabolic insults, thiamine deficiency and anti-cholinergic medications all can produce
delirium through a decrease in cholinergic activity

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 Pathophysiology of Delirium: Dopamine

• Dopamine
– An excess of dopamine may be a source of the agitation, delusions and psychosis
in delirious patients
– There is an inverse relationship between dopamine and acetylcholine levels
– Dopaminergic agents may induce delirium
– Dopamine antagonists are an effective treatment for delirium

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 Etiology of Delirium

• Identification of underlying cause is paramount to treatment

• Common causes
– General medical conditions
– Medications
– Substance intoxication
– Substance withdrawal
– Multiple etiologies

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 Etiology of Delirium
• Intoxication with drugs
– Many drugs implicated, especially anticholinergic agents, NSAIDs, antiparkinsonism agents,
antimicrobials, steroids, opiates, sedative-hypnotics, and illicit drugs
• Withdrawal syndromes
– Alcohol, sedative-hypnotics, and barbiturates
• Metabolic causes
– Hepatic, renal or pulmonary insufficiency
– Endocrinopathies such as hypothyroidism, hyperthyroidism, hypopituitarism or hypoglycemia
– Disorders of fluid and electrolyte balance

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 Etiology of Delirium
• Infections
– Sepsis, meningitis, pneumonia, syphilis and urinary tract infection
• Head trauma
– Subdural hematoma, closed head injury/concussion
• Epilepsy
• Neoplastic disease
– CNS metastasis or limbic encephalopathy
• Vascular disorders
– Cerebrovascular (stroke)
– Cardiovascular (acute MI, ACS, Hypertensive Emergency)

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 Life Threatening Causes of Delirium
(Caplan and Stern, 2008)
 W: Wernicke's encephalopathy; withdrawal (alcohol or BZDs)
 H: Hypoglycemia; hypoxia; hypoperfusion of CNS; hypertensive crisis, hyper or
hypothermia
 I: Infections; intracranial processes
 M: Metabolic derangements; Meningitis/encephalitis
 P: Poisons
 S: Seizures (status epilepticus)

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 Assessment of Delirium

• Recognition
• Consider screening tool for ancillary staff (e.g. brief cognitive assessment)
• History
– Establish course of mental status changes
• Talk to family or caregivers
• Recent medication change(s)
• Symptoms of medical illness
• Review medical record
• Review anesthesia record if post-op
– Onset of delirium is best clue to causality

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 Assessment of Delirium

• Physical and neurologic examination

– Vitals and focused physical exam
• Mental status
– Observe for behavioral signs
• Cognitive tests
– Folstein Mini Mental State Exam
– Clock drawing task
– Digit span
– Months backwards

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 Assessment of Delirium

• Basic laboratory test • Additional tests

– Blood chemistries – ECG
– Complete blood count – EEG
– Hepatic function panel – Cardiac enzymes
– TSH – HIV
– B12 and folate – Chest X-ray
– RPR – ANA, RF, CRP
– ABG – Lumbar puncture
– Serum drug levels – Blood cultures
– Urinalysis and collection for culture – Heavy metals
– CT or MRI

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 Assessment of Delirium
• Electroencephalogram
– Helpful to confirm the diagnosis
– Usually generalized slowing
– Low voltage fast activity in alcohol or sedative-hypnotic withdrawal
– Picture: Delirium Detection Using EEG
• Structural Neuroimaging
– Focal neurologic signs
– History or concern of head trauma
– No clear cause of delirium found

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 Treatment of Delirium

• Two important aspects

–Identify and reverse the reason(s) for the delirium
–Managing behaviors
– Sitter
– Restraints (Not appropriate)
– Reduce psychiatric or behavioral symptoms of delirium
• Non pharmacologic treatment
• Pharmacologic treatment

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 Treatment of Delirium

• Non-pharmacologic Interventions
– Aims
• Cognitively non-demanding
• Limit the risk of harm to self and/or others
– Types
• Avoid interruption of sleep
• Room close to nursing station
• Sitter, feeding assistance and encouragement during meals
• Clocks and calendar and orientation board
• Adequate lighting
• Sensory aids, cleaning of ear wax

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 Treatment of Delirium

• Major classes of medications utilized

– Antipsychotics
• Typical
• Atypical
– Cholinesterase inhibitors
– Benzodiazepines

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 Predisposing Factors to Delirium (targets for prevention efforts)

 Cognitive impairment or disorientation

 Dehydration or constipation
 Hypoxia
 Immobility or limited mobility
 Infection
 Multiple medications
 Pain
 Poor nutrition
 Sensory impairment
 Sleep disturbance

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 Take Home Points
• Delirium is acute alteration in cognitive functioning with fluctuations in
attention span and other symptoms
• Delirium is a serious, though under-recognized condition
• Frailty increases risk of delirium
• Management involves maximization of medical condition while
minimization of polypharmacy
• Prevention, detection and education are key

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 REFERENCES
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added

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