Delirium

1. Delirium Lea C. Watson, MD, MPH Robert Wood Johnson Clinical Scholar UNC Department of Psychiatry

2. 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.”

3. 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. 4 major causes • Underlying medical condition • Substance intoxication • Substance withdrawal • Combination of any or all of these

5. Patients at highest risk • Elderly • >80 years • demented • multiple meds • Post-cardiac surgery • Burns • Drug withdrawal • AIDS

6. Prevalence • Hospitalized medically ill 10-30% • Hospitalized elderly 10-40% • Postoperative patients up to 50% • Near-death terminal patients up to 80%

7. Clinical features Prodrome Fluctuating course Attentional deficits Arousal /psychomotor disturbance Impaired cognition Sleep-wake disturbance Altered perceptions Affective disturbances

8. Prodrome • Restlessness • Anxiety • Sleep disturbance

9. 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

10. Attentional deficits • Easily distracted by the environment • May be able to focus initially, but will not be able to sustain or shift attention

11. Arousal/psychomotor disturbance • Hyperactive (agitated, hyperalert) • Hypoactive (lethargic, hypoalert) • Mixed

12. Impaired cognition • Memory Deficits • Language Disturbance • Disorganized thinking • Disorientation • Time of day, date, place, situation, others, self

13. Sleep-wake disturbance • Fragmented throughout 24-hour period • Reversal of normal cycle

14. Altered perceptions • Illusions • Hallucinations - Visual (most common) - Auditory - Tactile, Gustatory, Olfactory • Delusions

15. Affective disturbance • Anxiety / fear • Depression • Irritability • Apathy • Euphoria • Lability

16. Duration • Typically, symptoms resolve in 10-12 days - may last up to 2 months • Dependent on underlying problem and management

17. 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

18. 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

19. 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 Causes: “I WATCH DEATH”

20. “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

21. “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

22. “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

23. Alcohol Amphetamines Cannabis Cocaine Hallucinogens Inhalants Opiates Phencyclidine (PCP) Sedatives Hypnotics Drugs of abuse

24. Causes • 44% estimated to have 2 or more etiologies

25. 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?

26. 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

27. Workup • Electrolytes • CBC • EKG • CXR • EEG- not usually necessary

28. 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)

29. 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)

30. Workup • Consider: - Heavy metals - Lupus workup - Urinary porphyrins

31. 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

32. 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

33. 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

34. Management • Environmental interventions - “Timelessness” - Sensory impairment (vision, hearing) - Orientation cues - Family members - Frequent reorientation - Nightlights

35. 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)

36. 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

37. Management • Benzodiazepines - Treatment of choice for delirium due to benzodiazepine or alcohol withdrawal

38. Management • Benzodiazepines - May worsen confusion in delirium - Behavioral disinhibition, amnesia, ataxia, respiratory depression - Contraindicated in delirium due to hepatic encephalopathy

39. 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

40. 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