Delirium

Give the onset, course, level of alertness, and prognosis for dementia.

Dementia Onset: long Course: stable Level of alertness: stable Prognosis: irreversible

Delirium carries a poor prognosis. What is the mortality rate after 1 year?

Mortality 1 year after diagnosis is estimated to be up to 40%.

What scale can be used in gauging the severity of alcohol withdrawal and determining the dose of benzodiazepines needed?

The Revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale

Define attention.

The ability to maintain focus on a particular stimulus or activity.

What helps to guide the treatment approach for a patient with delirium?

The level of psychomotor activity exhibited by the patient.

The concept of the "ICU triad," consists of what?

pain, agitation, and delirium The triad emphasizes the interrelationship among these conditions. The treatment of one affects the others.

What can be used to evaluate for delirium?

The Confusion Assessment Method (CAM)

Delirium is a medical and psychiatric emergency, often described as what?

"acute brain failure" It should viewed as akin to failure of other organ systems (ie, heart failure, respiratory failure, or renal failure).

What are risk factors for delirium?

- dementia, - elderly age, - medical illness, - polypharmacy, - recent surgery. Several causes of delirium may be present simultaneously.

What are associated symptoms of delirium?

- memory deficits, - visuospatial dysfunction, - perceptual disturbances, such as visual hallucinations. These can result in behavioral problems which interfere with management, such as: - agitation, - wandering, - pulling out intravenous lines, catheters, etc.

Thoroughly review the medication list as a preventive measure. What are common iatrogenic causes of delirium?

- sedative-hypnotics (ie, benzodiazepines), - anticholinergics, - H2-receptor antagonists, - corticosteroids, - narcotics, - antibiotics (especially fluoroquinolones). Discontinue or switch medications if this is an option.

Question 4: In the previous case, which of the following features most distinguishes delirium from early dementia? A Decreased attention B Disorientation C Cognitive deficits D Behavioral disturbances

A Decreased attention Both delirium and dementia can result in behavioral disturbances, cognitive deficits, and poor orientation. However, in all cases of delirium there is an alteration (reduction) in the level of attention. In early dementia, attention and concentration are typically maintained.

What is the next step in treating a pt with suspected delirium?

A cause of the delirium should be sought by: - reviewing the patient's medical record, - performing a focused history and physical examination, - obtaining clinically guided laboratory and imaging studies.

Define sundowning.

A phenomenon characterized by worsening of neurocognitive symptoms during the late afternoon or evening hours, usually in elderly and/or cognitively impaired individuals.

Name the possible precipitants of delirium.

Acute intermittent porphyria (a group of disorders that cause buildup of certain chemicals related to heme production) Cardiovascular diseases: Arrhythmias, congestive heart failure, myocardial infarction Central nervous system disorders: Brain trauma, epilepsy, neoplasm, cerebral vascular accident, subdural hematoma, vasculitis Drugs of abuse (in intoxication or withdrawal): Alcohol, barbiturates, benzodiazepines, narcotics Electrolyte imbalances Endocrine disorders: Adrenal insufficiency, hypoglycemia, parathyroid dysfunction Hepatic encephalopathy Infections: UTI, pneumonia, sepsis, meningitis, encephalitis Medications: Anticholinergics, anticonvulsants, antihypertensive agents, antiparkinsonian agents, H2 blockers, digitalis, corticosteroids, narcotics, benzodiazepines Pulmonary disorders: Hypercarbia, hypoxemia Sleep deprivation Uremia Vasculitis Vitamin deficiencies: B12, folic acid, thiamine

Question 3: A 71-year-old woman with a history of early Alzheimer disease is brought to the hospital by her family because "she is just not acting like her normal self" since waking up this morning. She takes no medications. On mental status examination, she is lethargic, easily distractible, and oriented only to person. At baseline, she is oriented to person and place, but has difficulty recalling the date and time. Physical examination and diagnostic workup are suggestive of an uncomplicated urinary tract infection (UTI). What is the most important component of treating this patient's delirium? A Begin oral antipsychotic therapy. B Treat her UTI with antibiotics. C Start her on an oral benzodiazepine. D Start maintenance intravenous fluids and place a Foley catheter.

B Treat her UTI with antibiotics. The most important component of delirium treatment is to detect and treat the precipitating factor(s). In this case, the patient's dementia predisposes her to delirium, while the acute onset of the UTI precipitated her change in mental status. Of note, all antibiotics have the potential to contribute to the worsening of delirium, so a change in medication may be necessary if the patient needs a prolonged course. Use of antipsychotics has been associated with increased mortality in the elderly. Thus, these agents should be reserved for situations in which the patient's behaviors put herself or others at risk for harm. Benzodiazepines are not appropriate, as they may cause excessive sedation, disinhibition, or paradoxical excitation. While maintenance intravenous fluids or a Foley catheter may be necessary in certain cases, these items may restrict patient mobility, thereby exacerbating delirium and increasing risk of falls.

What medication class should be avoided, unless treating alcohol or sedative-hypnotic withdrawal?

Benzodiazepines

Question 2: In the previous case, what class of medication would be an appropriate first-line treatment for delirium tremens? A First-generation antipsychotic B Second-generation antipsychotic C Benzodiazepine D Barbiturate

C Benzodiazepine Delirium tremens (DTs) is one of the only forms of delirium for which benzodiazepines are useful. Oral benzodiazepines can be used early in alcohol withdrawal to reduce agitation and prevent progression to seizures or DT. Once a person has developed DT, medication must be given by intravenous route. Sedation with phenobarbital (a barbiturate) or propofol may be necessary for refractory DT and requires intubation. Antipsychotics are generally not used in DT, as they can lower the patient's seizure threshold.

Question 1: A 32-year-old man with a 12-beer per day drinking history for the last year presents to the emergency department with headache, stomach upset, and tremulousness after deciding to quit drinking cold turkey earlier that day. On examination, he is afebrile with normal vital signs. He is alert and oriented to person, place, time, and situation. The man appears diaphoretic and anxious. If this patient were to progress to delirium tremens, how many hours would this be expected take? A 6 to 12 hours after his last drink B 12 to 24 hours after his last drink C 24 to 48 hours after his last drink D 48 to 96 hours after his last drink

D 48 to 96 hours after his last drink This patient is experiencing early symptoms of alcohol withdrawal which typically begin within the first 6 to 12 hours following the last drink. Alcoholic hallucinosis, characterized by visual, tactile, and auditory hallucinations without disturbances in attention or awareness, occurs within 12 to 24 hours and lasts up to 48 hours. Delirium tremens rarely occurs before the 48-hour mark and may not appear until up to 96 hours from the last drink.

Question 5: During morning pre-rounds, a medical student finds her 72-year-old male patient unresponsive to verbal stimuli. The patient groans to sternal rub but does not otherwise respond. What is the best descriptor for this patient's level of attention and awareness? A Mild delirium B Moderate delirium C Severe delirium D Coma

D Coma Coma is defined by unresponsiveness to verbal stimuli and precludes a diagnosis of delirium. Delirium can be conceptualized on a continuum, lying between normal attentiveness/awareness and coma.

Give the onset, course, level of alertness, and prognosis for delirium.

Delirium Onset: short Course: fluctuating Level of alertness: hypoactive, hyperactive, mixed Prognosis: reversible

What are the 4 diagnostic criteria for delirium?

Diagnostic criteria for delirium: - Disturbance in baseline attention and awareness. - The disturbance develops over a short period of time (hours to days), and fluctuates in severity over the course of the day. - A disturbance in cognition such as memory deficit, language, visuospatial ability, or perception is present. - The disturbances are not better explained by a neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma.

Explain the evaluations that should be included for a pt presenting with delirium.

Evaluation of delirium should include an assessment of potential contributing factors. History and physical examination findings should guide further workup. Bedside testing, such as pulse-oximetry, electrocardiography, fingerstick glucose testing, arterial blood gas analysis, and bladder scan may reveal hypoxemia, hypercapnia, hypo/hyperglycemia, or urinary retention.

What is the cornerstone of treatment for delirium?

Identification and correction of the underlying abnormality. This approach ideally results in reversal of the delirious state, typically over the course of 1 week. However, patients may show subtle signs of delirium for months afterwards.

What lab and radiograph tests should be considered?

Laboratory and radiographic studies to consider includ: - a comprehensive metabolic panel with ammonia, - complete blood count with leukocyte differential, - B12 and folate levels, - urinalysis, - urine drug screen, - blood and urine cultures, - cerebrospinal fluid (CSF) analysis and culture, - chest radiography. Electroencephalography (EEG) has poor sensitivity and specificity for delirium, but may help in ruling out nonconvulsive epilepsy.

Mixed delirium may present how?

One may have a normal level of psychomotor activity, but have altered awareness and alertness. Alternatively, mixed delirium may present with rapid fluctuation of activity level.

What are the medications of choice for treatment of non-neuropathic pain?

Opiates However, opiates can worsen delirium if dosed too high. Meperidine and codeine should in particular be avoided.

Define awareness.

Orientation to situation and surroundings.

A mnemonic for common contributing factors to the development of delirium in those with preexisting cognitive impairment includes...

PInCH ME: Pain, Infection, Constipation, Hydration status, Medications, Environment

What are other diseases in the differential diagnosis for delirium?

Psychotic disorders such as schizophrenia and acute mania. However, individuals with delirium display a fluctuating level of consciousness, and patients with schizophrenia and mania usually maintain an alert level of consciousness. Delirious patients often have VISUAL hallucinations, but primary psychotic disorders more frequently manifest as AUDITORY hallucinations and delusions.

What special cautions should be taken when treating (giving medication) to patients with delirium?

Special caution should be exercised when treating patients with known baseline QTc prolongation, patients receiving other QTc prolonging agents, and individuals with a history of torsades de pointes. Benzodiazepines should be avoided, unless treating alcohol or sedative-hypnotic withdrawal.

Environmental modification is another significant aspect of the treatment approach. Hospitalization can be very distressing and disorienting. How can the environment be modified?

The presence of family members, items from home (ie, pictures), and reminders of location, date, and time help maintain patient orientation. Efforts should be made to reduce excess noise, dim the lights at night, and cluster care activities to minimize disruption to the patient's sleep-wake cycle. Minimize "tethers," such as IV lines, urinary catheters, telemetry wires, and restraints. Restraints may be indicated, however, if the patient poses a risk to himself or others.

True or false: Antipsychotics may be used judiciously for agitation, but are associated with increased mortality in the elderly.

True

True or false: Any disease process, illicit substance, toxin, or medication that affects the central nervous system can cause delirium.

True

True or false: Benzodiazepines are the treatment of choice for delirium associated with alcohol or sedative-hypnotic withdrawal.

True

True or false: Delirium represents a psychiatric emergency and carries a poor prognosis.

True

True or false: Intensive care settings and/or major surgical procedures are risk factors for delirium, especially for geriatric patients.

True

True or false: It is important to note that hypoactive delirium may go unnoticed due to its less disruptive nature.

True

True or false: Medications are a common cause of delirium.

True

True or false: The hallmark of delirium is a fluctuation in the level of attention and awareness.

True

True or false: The most important aspect of delirium treatment is detection and correction of the underlying condition.

True

True or false: The occurrence of symptoms during delirium is an exclusion criterion for many psychiatric disorders.

True

True or false: Major neurocognitive disorder, (specifically dementia), increases the risk of developing delirium, but delirium cannot be diagnosed if the condition is better explained by dementia.

True This can be clinically challenging because both delirium and dementia can exhibit very similar symptoms (eg, memory impairment, cognitive disturbances, and behavioral problems). Several characteristics help distinguish between the two.

What is the hallmark of delirium?

a fluctuation in the level of attention and awareness

Hyperactive delirium is characterized by what?

a high level of psychomotor activity that may be accompanied by mood lability, agitation, and refusal to cooperate with care.

Maintain what to avoid precipitating delirium?

adequate pain control

If behavioral interventions do not adequately manage agitation, pharmacologic intervention may be necessary. Judicious use of what class of medication can be implemented for delirium not caused by alcohol or benzodiazepine withdrawal?

antipsychotics The decision to use antipsychotics should not be taken lightly, as these medications have been linked to an increased risk of mortality in the elderly.

Primary psychotic disorders more frequently manifest what type of hallucination?

auditory

Hypoactive delirium manifests as what?

decreased psychomotor activity that may be associated with sluggishness, lethargy, or stupor.

If possible, use what instead of a benzodiazepine for sedation of critically ill individuals?

dexmedetomidine

EEG findings suggestive of delirium include what finding?

increased generalized slow-wave activity, which may also be seen in dementia. Delirium associated with alcohol withdrawal is associated with increased fast waves on EEG.

What opiates in particular should be avoided?

meperidine codeine

Early recognition and treatment are essential to prevent progression to what 3 things?

stupor, coma, or death

Delirious patients often have what type of hallucination?

visual