Delirium Edited

Delirium
GROUP 2
By:
Orach walter
Kakaire Rasool
Namukwaya Shamira
Samira Shide
Opiyo Ivan
Objectives
• Definition
• Epidemiology
• Risk factors
• Etiology
• Clinical manifestations
• Types
• Diagnosis
• ICU psychosis
• Investigations
• Management
Delirium
• Characterized by an acute fluctuating syndrome of
encephalopathy causing disturbed consciousness,
attention, cognition, and perception.
• Has sudden onset, a brief and fluctuating course and
rapid improvement when the causative factor is
eliminated.
• Life threatening yet potentially reversible disorder of
the CNS
• Often involves perceptual disturbances, abnormal
psychomotor activity, and sleep cycle impairment.
Epidemiology
• The prevalence in the general population (across all
healthcare settings) is about 0.4%.
• The prevalence in the community is thought to be
between 1–2% but may be as high as 14% in people
aged over 85 years.
• The prevalence among people aged 65 years and over
living in long-term care is 10–40%.
Epidemiology
• Delirium is thought to affect up to 50% of older
people (over 65 years) in hospital, 30% of older
people (over 65 years) in emergency departments,
complicate 17–61% of major surgical procedures, and
occur in 70–87% of Intensive Care Unit admissions.
• One review found that the prevalence of persistent
delirium (continuing until or after discharge) in
hospital patients (aged over 50 years) was 44.7%. The
combined proportions of persistent delirium at 1, 3,
and 6 months after discharge from hospital were
32.8%, 25.6%, and 21%.
Epidemiology …
• 70 to 87% of patients in ICU
• 60% of patients in nursing homes or post acute
care settings
• 21% of patients with severe burns
• 30 to 40 % of patients with AIDS while
hospitalized
• 80% of terminally ill patients
Risk factors
 Polypharmacy, including fractures, low albumin,
use of psychotic dehydration
medications ( esp BZDs  Impaired mobility
and anticholinergics)  Hearing or vision
 Advanced age > 65yrs impairment
 Preexisting congnitive  Malnutrition
impairment or depression  Male gender
 Prior hx of delirium  Stress
 Substance misuse – eg,  Extreme sensory
alcohol experience – i.e,
 Severe or terminal illness hypothermia or
 Multiple medical hyperthermia
comorbidities – eg, AIDS,
Etiology
Almost any medical condition can cause delirium
(see examples in Table 8-1).
The DSM-5 recognizes five broad categories:
• Substance intoxication delirium
• Substance withdrawal delirium
• Medication-induced delirium
• Delirium due to another medical condition
• Delirium due to multiple etiologies
Drugs-induced delirium
Common medication- induced delirium:
• Tricyclic antidepressants
• Anticholinergics
• Benzodiazepines
• Nonbenzodiazepine hypnotics
• Corticosteroids
• H2 blockers
• Meperidine
Causes / Ddx cont…
• Infectious (encephalitis, meningitis, UTI, pneumonia)
• Withdrawal (alcohol, barbiturates, benzodiazepines)
• Acute metabolic disorder (electrolyte imbalance, hepatic or
renal failure)
• Trauma (head injury, postoperative)
• CNS pathology (stroke, hemorrhage, tumor, seizure
disorder, Parkinson’s)
• Hypoxia (anemia, cardiac failure, pulmonary embolus)
• Deficiencies (vitamin B 12 , folic acid, thiamine)
• Endocrinopathies (thyroid, glucose, parathyroid, adrenal)
• Acute vascular (shock, vasculitis, hypertensive
encephalopathy)
• Toxins, substance use, medication (alcohol, anesthetics,
anticholinergics, narcotics)
• Heavy metals (arsenic, lead, mercury)
Clinical manifestations
• Disorientation: Usually to time or place, rarely
to person.
• Changes in speech: Slow, pressured, rambling,
or disorganized.
• Perceptual disturbances: Misinterpretations,
illusions, or hallucinations.
• Sleep disturbances: Sun downing with daytime
drowsiness and night-time insomnia and
confusion.
Clinical Scenarios of Delirium on Exam
Types of delirium.
There are three types of delirium based on psychomotor activity.
1. Mixed type
 Psychomotor activity may remain stable at baseline or fluctuate rapidly
between hyperactivity and hypoactivity.
 Most common type.
2. Hypoactive (“quiet”) type

 Decreased psychomotor activity, ranging from drowsiness to lethargy to
stupor, apathy
 More likely to go undetected and could be confused with depression.
 More common in the elderly.
3. Hyperactive type (“ICU psychosis”)

 Manifests with agitation, mood lability, and uncooperativeness.
 Less common, but more easily identified due to its disruptiveness.
 More common in drug withdrawal or toxicity.
DSM 5 criteria
A. A disturbance in attention (i.e. reduced ability to
direct, focus, sustain, and shift attention) and
awareness (reduced orientation to the environment).
B. The disturbance develops over a short period of time
(usually hours to a few days), represents a change
from baseline attention and awareness, and tends to
fluctuate in se verity during the course of a day.
C. An additional disturbance in cognition (e.g. memory
deficit, disorientation, language, visuospatial ability,
or perception).
DSM 5 Criteria
D. The disturbances in Criteria A and C are not better
explained by another preexisting, established, or
evolving neurocognitive disorder and do not occur in the
context of a severely reduced level of arousal, such as
coma.
E. There is evidence from the history, physical
examination , or laboratory findings that the disturbance
is a direct physiological consequence of another medical
condition, substance intoxication or withdrawal (i.e., due
to a drug of abuse or to a medication), or exposure to a
toxin, or is due to multiple etiologies.
ICU psychosis
• ICU psychosis is a form of delirium, or acute
brain failure.
• Organic factors including dehydration, hypoxia
(low blood oxygen), heart failure (inadequate
cardiac output), infection and drugs can cause
or contribute to delirium.
ICU psychosis …
• Among the factors which are believed to play into ICU
psychosis are:
1. Sensory deprivation (being put in a room often without
windows, away from family, friends and all that is familiar),
2. Sensory overload (being tethered to noisy machines day
and night),
3. Pain (which may not be adequately controlled in an ICU),
4. Sleep deprivation,
5. Disruption of the normal day-night rhythm, or simply
6. The loss of control over their lives that patients often feel in
an ICU.
Investigations
• Are done to rule out possible causes depending on
the specific patient
– Full hx, include collateral hx and cognition testing eg,
MMSE
– Full examination- look for sources of infection, in ears
and throat; look for rashes, lymphadenopathy and check
for constipation.
– Urine culture and sensitivity
– Urine drug screen
– Blood tests (e.g., VDRL, heavy metal screen, B12 and
folate levels, antinuclear antibody [ANA], ammonia
level, HIV, erythrocyte sedimentation rate [ESR])
cont’d
• Blood cultures and indicated serology
• Serum levels of medications (e.g., digoxin,
theophylline, phenobarbital, cyclosporine)
• Lumbar puncture
• Brain computerized tomography (CT) or
magnetic resonance imaging (MRI)
• Electroencephalogram (EEG)
Management of delirium
Supportive mgt
• Hospitalization is essential: Delirium is a medical emergency.
• Vigorously investigate and treat any underlying medical
condition.
• To limit confusion and foster trust, try to ensure that the patient
is nursed by the same staff consistently.
• Merely the physical presence of a reassuring person is often
enough to calm a distressed patient.
• Maximize visual acuity (e.g. glasses, appropriately lit
environment) and hearing ability (e.g. hearing aid, quiet
environment) to avoid misinterpretation of stimuli.
• Encourage a friend or family member to remain with the patient
to help comfort and orientate them.
Management of delirium
• Clocks, calendars and familiar objects may be helpful with
orientation.
• Avoid medication unless the patient is causing a risk to
themselves or others.
Environmental mgt
• Avoid sensory extremes (over or under stimulation)
• Adequate space and sleep
• Avoid specialty jargon
• Control room lighting, excess noise, room temperature
degrees
• Use health advocates (interpreters) if needed
• Maintain walking in ambulant patients
Medical management
• Using drugs to treat delirium can lead to adverse effects and
worsening of delirium; therefore, careful consideration is required.
• Antipsychotics have beneficial effects in selected patients,
particularly those who are aggressive and do not respond to verbal
and non-verbal de-escalation techniques.
• Typical antipsychotics, especially low dose haloperidol, are
generally effective in treating delirious symptoms, in part due to
their sedative qualities, but perhaps also due to their effects on the
dopamine–acetylcholine balance.
• Avoid using benzodiazepines to treat delirium that is not due to
alcohol or benzodiazepine withdrawal. these medications often
worsen delirium by causing paradoxical disinhibition or
oversedation.
prognosis
• Delirium has a fluctuating course and recovery
can be rapid or take weeks to months.
Persistent delirium occurs more often in older
hospitalized patients, and is associated with
adverse outcomes
• Physical function can be impaired for 30 days
or more after discharge in people who have
developed delirium in hospital.
Thank you for listening
Reference
• First aid in psychiatry.
• https://patient.info/doctor/delirium-pro

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Delirium

2. Hypoactive (“quiet”) type

3. Hyperactive type (“ICU psychosis”)

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