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 cant
seem to sit still. Last night after his surgery
he was fine, reading the paper and talking to
his familytoday I dont even think he
knows where he is can you come see
him?
Med student says:
sounds like DELIRIUM- good thing you
called- Ill 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 (dont 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 seecommon 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 patients life