delirium

1. DeliriumDelirium
Dr Doha Rasheedy
Lecturer of geriatric medicine
Geriatrics Intensive care unit
Geriatric medicine department
Ain Shams University

2. Delirium
 It is a neuropsychiatric syndrome alsoIt is a neuropsychiatric syndrome also
called acute confusional state or acutecalled acute confusional state or acute
brain failure that is common among thebrain failure that is common among the
medically ill and often is misdiagnosed asmedically ill and often is misdiagnosed as
a psychiatric illness which can result ina psychiatric illness which can result in
delay of appropriate medical intervention.delay of appropriate medical intervention.
There is significantly mortality associatedThere is significantly mortality associated
with delirium so identifying it is crucialwith delirium so identifying it is crucial

3.  Delirium, defined as an acute alteration in
attention and cognition, is a common,
serious, and potentially preventable
source of morbidity and mortality for older
persons. The incidence of delirium
increases with age, cognitive impairment,
frailty, illness severity, comorbidity, and
other risk factors.

4. DIAGNOSING DELIRIUMDIAGNOSING DELIRIUM
 Underecognition is a major problemUnderecognition is a major problem
 DSM-IVDSM-IV criteria precise but difficult tocriteria precise but difficult to
applyapply
 Confusion Assessment Method (CAM)Confusion Assessment Method (CAM)
– clinically more usefulclinically more useful
– >95% sensitivity and specificity>95% sensitivity and specificity

5. DSM-IVDSM-IV DIAGNOSTIC CRITERIADIAGNOSTIC CRITERIA
 Disturbance of consciousness with reduced ability toDisturbance of consciousness with reduced ability to
focus, sustain, or shift attentionfocus, sustain, or shift attention
 Change in cognition (e.g., memory deficit, disorientation,Change in cognition (e.g., memory deficit, disorientation,
language disturbance) or a perceptual disturbance notlanguage disturbance) or a perceptual disturbance not
better accounted for by existing dementiabetter accounted for by existing dementia
 Development over a short time (hours to days) andDevelopment over a short time (hours to days) and
fluctuation during the dayfluctuation during the day
 Evidence from history, physical, or labs that disturbanceEvidence from history, physical, or labs that disturbance
is direct physiologic consequence of a medical conditionis direct physiologic consequence of a medical condition

6. CONFUSION ASSESSMENTCONFUSION ASSESSMENT
METHODMETHOD
Requires features 1 and 2 and either 3
or 4:
 1. Acute change in mental status and1. Acute change in mental status and
fluctuating coursefluctuating course
 2. Inattention2. Inattention
 3. Disorganized thinking3. Disorganized thinking
 4. Altered level of consciousness4. Altered level of consciousness

7. Clinical characteristicsClinical characteristics
 Develops acutely (hours to days)Develops acutely (hours to days)
 Characterized by fluctuating level ofCharacterized by fluctuating level of
consciousnessconsciousness
 Reduced ability to maintain attentionReduced ability to maintain attention
 Agitation or hypersomnolenceAgitation or hypersomnolence
 Extreme emotional labilityExtreme emotional lability
 Cognitive deficits can occurCognitive deficits can occur

8. Clinical characteristics: cognitiveClinical characteristics: cognitive
deficitsdeficits
 Language difficulties: word finding difficulties,Language difficulties: word finding difficulties,
dysgraphiadysgraphia
 Speech disturbances: slurred, mumbling,Speech disturbances: slurred, mumbling,
incoherent or disorganizedincoherent or disorganized
 Memory dysfunction: marked short-term memoryMemory dysfunction: marked short-term memory
impairment, disorientation to person, place, time.impairment, disorientation to person, place, time.
 Perceptions: misinterpretations, illusions,Perceptions: misinterpretations, illusions,
delusions and/or visual (more common) ordelusions and/or visual (more common) or
auditory hallucinationsauditory hallucinations
 Constructional ability: can’t copy a pentagonConstructional ability: can’t copy a pentagon

9. Sleep-wake disturbanceSleep-wake disturbance
 Fragmented throughout 24-hour periodFragmented throughout 24-hour period
 Reversal of normal cycleReversal of normal cycle

10. Affective LabilityAffective Lability
 Mood may fluctuate widely in a very shortMood may fluctuate widely in a very short
period of time (minutes/hours)period of time (minutes/hours)
 Anxiety/panic/fear/angerAnxiety/panic/fear/anger
 Apathy/sadness - commonly mistaken forApathy/sadness - commonly mistaken for
depressiondepression
 Euphoria (esp. if steroid-induced)Euphoria (esp. if steroid-induced)

11. Subtypes of DeliriumSubtypes of Delirium
 Hyperactive or agitated deliriumHyperactive or agitated delirium
 Hypoactive deliriumHypoactive delirium
 MixedMixed

12. Types of deliriumTypes of delirium
 Hyperactive or hyperalertHyperactive or hyperalert
– the patient is hyperactive, combative andthe patient is hyperactive, combative and
uncooperative.uncooperative.
– May appear to be responding to internalMay appear to be responding to internal
stimulistimuli
– Frequently these patients come to ourFrequently these patients come to our
attention because they are difficult to care for.attention because they are difficult to care for.

13.  Hypoactive or hypoalertHypoactive or hypoalert
– Pt appears to be napping on and offPt appears to be napping on and off
throughout the daythroughout the day
– Unable to sustain attention when awakened,Unable to sustain attention when awakened,
quickly falling back asleepquickly falling back asleep
– Misses meals, medications, appointmentsMisses meals, medications, appointments
– Does not ask for care or attentionDoes not ask for care or attention
– This type is easy to miss because caring forThis type is easy to miss because caring for
these patients is not problematic to staffthese patients is not problematic to staff

14.  MixedMixed
– a combination of both types just describeda combination of both types just described
 The most common types are hypoactiveThe most common types are hypoactive
and mixed accounting for approximatelyand mixed accounting for approximately
80% of delirium cases80% of delirium cases

15. Differential DiagnosisDifferential Diagnosis
 DementiaDementia
 Psychotic DisordersPsychotic Disorders
 DepressionDepression

16. Differentiating between deliriumDifferentiating between delirium
and a psychiatric disorderand a psychiatric disorder
 Clouded consciousness or decreasedClouded consciousness or decreased
level of alertnesslevel of alertness
 DisorientationDisorientation
 Acuity of onset and course- serial mentalAcuity of onset and course- serial mental
status exams can help demonstrate thisstatus exams can help demonstrate this
 Age >40 without prior psych historyAge >40 without prior psych history
 Presence of risk factors for delirium,Presence of risk factors for delirium,
recent medical illness or treatmentrecent medical illness or treatment

17. Delirium versus DementiaDelirium versus Dementia
 DeliriumDelirium
– Rapid onsetRapid onset
– Primary defect inPrimary defect in
attentionattention
– Fluctuates during theFluctuates during the
course of a daycourse of a day
– Visual hallucinationsVisual hallucinations
commoncommon
– Often cannot attend toOften cannot attend to
MMSE or clock drawMMSE or clock draw
 DementiaDementia
– Insidious onsetInsidious onset
– Primary defect in shortPrimary defect in short
term memoryterm memory
– Attention often normalAttention often normal
– Does not fluctuateDoes not fluctuate
during dayduring day
– Visual hallucinationsVisual hallucinations
less commonless common
– Can attend to MMSECan attend to MMSE
or clock draw, butor clock draw, but
cannot perform wellcannot perform well

18. Mood disorders vs DeliriumMood disorders vs Delirium
 Mood disorders manifest persistent ratherMood disorders manifest persistent rather
than labile mood with more gradual onsetthan labile mood with more gradual onset
 In mania the patient can be very agitatedIn mania the patient can be very agitated
however cognitive performance is nothowever cognitive performance is not
usually as impairedusually as impaired
 Flight of ideas usually have some threadFlight of ideas usually have some thread
of coherence unlike simple distractibilityof coherence unlike simple distractibility
 Disorientation is unusual in maniaDisorientation is unusual in mania

19. Risk Factors for DeliriumRisk Factors for Delirium
Patient characteristicsPatient characteristics
 Hospitalized elderlyHospitalized elderly
 Multiple medical conditionsMultiple medical conditions
 Multiple medicationsMultiple medications
 Terminally illTerminally ill
 Sensory (hearing or visual)Sensory (hearing or visual)
deprivationdeprivation
 Sleep deprivedSleep deprived
Medical conditionsMedical conditions
 DementiaDementia
 Postsurgical status (Cardiac ,Postsurgical status (Cardiac ,
Hip ,Transplant )Hip ,Transplant )
 BurnsBurns
 Abrupt discontinuation ofAbrupt discontinuation of
alcohol or drugsalcohol or drugs
 MalnourishmentMalnourishment
 Chronic hepatic diseaseChronic hepatic disease
 DialysisDialysis
 Parkinson's diseaseParkinson's disease
 HIV infectionHIV infection
 Poststroke statusPoststroke status

20. The pathophysiology of deliriumThe pathophysiology of delirium
 Many hypotheses exist including:Many hypotheses exist including:
 Neurotransmitter abnormalitiesNeurotransmitter abnormalities
 Inflammatory response with increased cytokinesInflammatory response with increased cytokines
 Changes in the blood-brain barrier permeabilityChanges in the blood-brain barrier permeability
 Widespread reduction of cerebral oxidativeWidespread reduction of cerebral oxidative
metabolismmetabolism
 Increased activity of the hypothalamic-pituitaryIncreased activity of the hypothalamic-pituitary
adrenal axisadrenal axis

21. Causes
 D rugs (particularly narcotics and anticholinergics), withdrawal
esp.EtOH and benzodiazepines
 E ndocrine (hypo and hyperglycemia,hypercalcemia, hypo,
hyperthyroidism)
 L ow oxygen – hypoxia
 I nfections (particularly UTIs and pneumonia)
 R etention- urinary
 I nflammatory arthritis (eg. gout),neurological (eg. meningitis);
I ntoxication
 U nderperfused – CHF, CVA, Acute MI
 M etabolic – sodium, pottasium,azotemia, liver failure
 S tool – fecal impaction

22. Etiology: DrugsEtiology: Drugs
 Anticholinergics (furosemide, digoxin,Anticholinergics (furosemide, digoxin,
theophylline, cimetidine, prednisolone,theophylline, cimetidine, prednisolone,
TCA’s, captopril)TCA’s, captopril)
 Analgesics (morphine, codeine..)Analgesics (morphine, codeine..)
 SteroidsSteroids
 Antiparkinson (anticholinergic andAntiparkinson (anticholinergic and
dopaminergic)dopaminergic)
 Sedatives (benzodiazepines, barbiturates)Sedatives (benzodiazepines, barbiturates)
 AnticonvulsantsAnticonvulsants

23. Etiology: Drugs continuedEtiology: Drugs continued
 AntihistaminesAntihistamines
 Antiarrhythmics (digitalis)Antiarrhythmics (digitalis)
 AntihypertensivesAntihypertensives
 AntidepressantsAntidepressants
 Antimicrobials (penicillin, cephalosporins,Antimicrobials (penicillin, cephalosporins,
quinolones)quinolones)
 SympathomimeticsSympathomimetics

24. EVALUATION: HISTORY &EVALUATION: HISTORY &
PHYSICALPHYSICAL
 HistoryHistory
– Focus on time course of cognitive changes,Focus on time course of cognitive changes,
esp. their association with other symptoms oresp. their association with other symptoms or
eventsevents
– Medication review, including OTC drugs,Medication review, including OTC drugs,
alcoholalcohol
 Physical examinationPhysical examination
– Vital signsVital signs
– Oxygen saturationOxygen saturation
– General medical evaluationGeneral medical evaluation
– Neurologic and mental status examinationNeurologic and mental status examination

25. LABORATORY TESTINGLABORATORY TESTING
Based on history and physicalBased on history and physical
– Include CBC, electrolytes, renal function testsInclude CBC, electrolytes, renal function tests
– Also helpful: UA , LFTs, serum drug levels, arterialAlso helpful: UA , LFTs, serum drug levels, arterial
blood gases, chest x-ray, ECG, culturesblood gases, chest x-ray, ECG, cultures
– Cerebral imaging rarely helpful, except with headCerebral imaging rarely helpful, except with head
trauma or new focal neurologic findingstrauma or new focal neurologic findings
– EEG and CSF rarely yield helpful results, except withEEG and CSF rarely yield helpful results, except with
associated seizure activity or signs of meningitisassociated seizure activity or signs of meningitis

26. MANAGEMENTMANAGEMENT
 PrioritiesPriorities
– Pay attention to life-threatening disorders.Pay attention to life-threatening disorders.
– Rule out life-threatening illness.Rule out life-threatening illness.
– Stop all suspected medications.Stop all suspected medications.
– Monitor vital signsMonitor vital signs
 Interdisciplinary treatmentInterdisciplinary treatment
– Elimination or correction of the underlying causeElimination or correction of the underlying cause
– Symptomatic and supportive measuresSymptomatic and supportive measures
– Avoid the complications of delirium by:Avoid the complications of delirium by:
- removing indwelling devices ASAPremoving indwelling devices ASAP
- preventing or treating constipation and urinary retentionpreventing or treating constipation and urinary retention
- encouraging proper sleep hygiene, avoiding sedativesencouraging proper sleep hygiene, avoiding sedatives
 Optimize medication regimenOptimize medication regimen

27. Supportive measuresSupportive measures
 Safe environmentSafe environment
– Protection from physical harm butProtection from physical harm but Avoid physical restraintAvoid physical restraint
– Low beds, guard rails and careful supervisionLow beds, guard rails and careful supervision
 Maintaining fluid and electrolyte balance , AdequateMaintaining fluid and electrolyte balance , Adequate
nutritionnutrition
 Prevent aspiration , decubitus ulcersPrevent aspiration , decubitus ulcers
 Predictable, orienting environment :easy-to-read calendarsPredictable, orienting environment :easy-to-read calendars
and clocksand clocks
 Presence of family members can be helpful , frequentPresence of family members can be helpful , frequent
interaction , Frequent verbal orientationinteraction , Frequent verbal orientation
 Support for confusion or hallucinations , encouraged toSupport for confusion or hallucinations , encouraged to
express fears and discomfortsexpress fears and discomforts
 Adequate lighting and reasonable noise levelAdequate lighting and reasonable noise level
 Devices available - eye glasses and hearing aidsDevices available - eye glasses and hearing aids

28. Pharmacological therapy for deliriumPharmacological therapy for delirium
 Antipsychotic haloperidolAntipsychotic haloperidol
- 0.5 to 1 mg po twice daily- 0.5 to 1 mg po twice daily
- 0.5- 1 mg IM (repeat in 30-60 min if needed- 0.5- 1 mg IM (repeat in 30-60 min if needed
- assess for akathisia and extrapyramidal effects- assess for akathisia and extrapyramidal effects
- avoid in older persons with parkinsonism- avoid in older persons with parkinsonism
- in ICU, monitor for QT interval prolongation, torsade dein ICU, monitor for QT interval prolongation, torsade de
pointes, neuroleptic malignant syndrome, withdrawalpointes, neuroleptic malignant syndrome, withdrawal
dyskinesiasdyskinesias
 Atypical antipsychoticAtypical antipsychotic
– Risperidone 0.5 mg twice dailyRisperidone 0.5 mg twice daily
– Olanzapine 2.5 to 5 mg once dailyOlanzapine 2.5 to 5 mg once daily
– Quetiapine 5mg once dailyQuetiapine 5mg once daily
 BenzodiazepineBenzodiazepine
– 0.5 to 1mg (add every 4h as needed)0.5 to 1mg (add every 4h as needed)
 AntidepressantAntidepressant
– Trazadone 25 to 150mg at bedtimeTrazadone 25 to 150mg at bedtime

29. DRUGS TO REDUCE OR ELIMINATEDRUGS TO REDUCE OR ELIMINATE
 AlcoholAlcohol
 AntibioticsAntibiotics
 AnticholinergicsAnticholinergics
 AnticonvulsantsAnticonvulsants
 AntidepressantsAntidepressants
 AntihistaminesAntihistamines
 AntiparkinsonianAntiparkinsonian
agentsagents
 AntipsychoticsAntipsychotics
 BarbituratesBarbiturates
 BenzodiazepinesBenzodiazepines
 Chloral hydrateChloral hydrate
 HH22 -blocking agents-blocking agents
 LithiumLithium
 Opioid analgesicsOpioid analgesics
(esp. meperidine)(esp. meperidine)
Almost any medication if time course is
appropriate

30. THE BEST MANAGEMENT ISTHE BEST MANAGEMENT IS
PREVENTIONPREVENTION
 Interventions for cognitive impairment,Interventions for cognitive impairment,
sleep deprivation, immobility, sensorysleep deprivation, immobility, sensory
impairment, dehydrationimpairment, dehydration
 Focus on nonpharmacologic approachesFocus on nonpharmacologic approaches
(e.g., sleep protocol involving warm milk,(e.g., sleep protocol involving warm milk,
back rubs, soothing music)back rubs, soothing music)
 Limit or avoid psychoactive and otherLimit or avoid psychoactive and other
high-riskhigh-risk medicationsmedications

31. Course and PrognosisCourse and Prognosis
 Prodromal symptoms may occur a few days priorProdromal symptoms may occur a few days prior
to full development of symptomsto full development of symptoms
 The symptoms will continue to progress/fluctuateThe symptoms will continue to progress/fluctuate
until underlying cause treateduntil underlying cause treated
 Most of the symptoms of delirium will resolveMost of the symptoms of delirium will resolve
within a week of correction/improvement of thewithin a week of correction/improvement of the
underlying etiology HOWEVER symptoms mayunderlying etiology HOWEVER symptoms may
wax and wane. In some patients it can take weekswax and wane. In some patients it can take weeks
for the symptoms to resolve.for the symptoms to resolve.
 Some patients, particularly older patients, maySome patients, particularly older patients, may
never return to baselinenever return to baseline
 Increased risk for postoperative complications,Increased risk for postoperative complications,
longer postoperative recuperation, longer hospitallonger postoperative recuperation, longer hospital
stays, long-term disabilitystays, long-term disability

32. What we see…common casesWhat we see…common cases
 Homeless male, hx. ETOH abuse, 2 daysHomeless male, hx. ETOH abuse, 2 days
post-oppost-op
 82 year-old women with UTI82 year-old women with UTI
 Burn victim after multiple med changesBurn victim after multiple med changes
 Mildly demented 71 year-old after hipMildly demented 71 year-old after hip
replacementreplacement