Delirium

Most perferable medicaiton to use?

Lorazepam (Ativan) - short acting and has no active metabolites- both IM and IV forms

Should patients with delirium be left alone?

NO- Some patients with delirium also may become suicidal or homicidal - Therefore, they should not be left unattended or alone

Delirium always should be suspected when...

An acute or subacute deterioration in behavior, cognition, or function occurs, especially in patients who are elderly, demented, or depressed.

Medication-induced delirium

Anticholinergics (*Benadryl*, tricyclic antidepressants), Narcotics (*meperidine*), Sedative hypnotics (benzodiazepines), Histamine-2 (H2) blockers (*cimetidine*), Corticosteroids (*steroid psychosis*), Centrally acting antihypertensives (*methyldopa* (used in preg), reserpine), Anti-Parkinson drugs (*levodopa*)

Patients with delirium who are hypoactive

Are withdrawn, less active, and sleepy

Strongest most consistent risk factors

*Demenita* - Underlying dementia is observed in 25-50% of patients - The presence of dementia increases the risk of delirium 2-3 times

Haloperidol (Haldol)-SE

*Monitor for extrapyramidal symptoms* (reduce dose if these occur); avoid anticholinergics; severe neurotoxicity manifesting as rigidity or inability to walk or talk may occur in patients with *thyrotoxicosis* also receiving antipsychotics; if IV/IM, watch for hypotension; caution in diagnosed CNS depression or cardiac disease; if history of seizures, benefits must outweigh risks; *significant increase in body temperature* may indicate intolerance to antipsychotics (discontinue if it occurs) *(only talked about bold)*

Overall- All the causes of Delirium- AEIOU TIPS

- A = Alcohol ( Drugs & Toxins) - E = Endocrine, Exocrine, Electrolyte - I = Insulin (glycemia) - O = Opiates, OD, Operation - U = Uremia - T = Trauma, Temperature - I = Infection - P = Psychiatric disorder - S = Seizure , Stroke, Shock, Space occupying lesion

Physical Exam with Delirium

- A careful and complete physical examination including a mental status examination is necessary. - Testing vital signs such as temperature, pulse, blood pressure, and respiration is mandatory. (they may be hypoxic, have a fever with sepsis- vital signs are important- they can give you reason)

Infectious causes of Delirium

- CNS infections such as meningitis - Encephalitis - HIV-related brain infections - Septicemia - Pneumonia - Urinary tract infections*

Other tests for Delirium

- Chest X-ray - pneumonia, pneumonthroax? - Lumbar Puncture- meningitis? - Pulse oximetry- are they hypoxic? - Electrocardiogram- do they have an arrhythmia?

Structural Changes that can cause Delirium

- Closed head injury or cerebral hemorrhage - Cerebrovascular accidents, such as cerebral infarction, subarachnoid hemorrhage, and hypertensive encephalopathy - Primary or metastatic brain tumors - Brain abscess

Signs of Delirium

- Clouding of consciousness - Difficulty maintaining or shifting attention - Disorientation - Delusions - Hallucinations - Fluctuating levels of consciousness

Age with Delirium

- Delirium can occur at any age, but it occurs more commonly in patients who are elderly and have compromised mental status - Delirium can occur in a person with dementia is important

Dementia vs Delirium *

- Delirium has increase or decreased psychomotor changes where dementia has often normal psychomotor changes - Delirium duration is days to week and dementia is months to years (delirium- usually reversible)

Differential of Delirium

- Dementia - Depression - Mania - Acute schizophrenic reaction - Sundowning- Part of old age (patients who are elderly are expected to become confused in the hospital- their input is not as good- mind starts playing tricks)

DSM 4 Criteria

- Disturbance of consciousness occurs, with reduced ability to focus, sustain, or shift attention. - Change in cognition occurs that is not better accounted for by a preexisting, established, or evolving dementia. - The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day. - Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause (he didn't read this)

Neurological Symptoms of Delirium

- Dysphasia - Dysarthria - Tremor - Asterixis in hepatic encephalopathy and uremia - Motor abnormalities

Environmental Modifications: Family and Sensory deficits

- Family members and staff should explain proceedings at every opportunity, reinforce orientation, and reassure the patient. - Sensory deficits should be corrected, if necessary, with eyeglasses and hearing aids (give them what they need) - NEVER LEAVE THE PERSON ALONE

Metabolic causes of Delirum

- Fluid and electrolyte abnormalities, acid-base disturbances, and hypoxia - Hypoglycemia - Hepatic or renal failure - Vitamin deficiency states (especially thiamine and cyanocobalamin) - *dont forget about vitamins* - Endocrinopathies associated with the thyroid and parathyroid (also liver and renal failure)

What type of delirium does what?

- In delirium resulting from alcohol/sedative withdrawal, increased EEG fast-wave activity occurs. - In patients with hepatic encephalopathy, diffuse EEG slowing occurs. (so not really helpful)

Mortality/Morbidity of delirium

- In patients who are admitted with delirium- mortality= 10-26% - Patients who develop during hospitalization- mortality = 22-76%- and high rates of death during the months following discharge*

Complications of Delirium

- Malnutrition, fluid and electrolyte abnormalities, hypoxia - Aspiration pneumonia - Pressure ulcers - Weakness, decreased mobility, and decreased function - Falls and combative behavior leading to injuries and fractures - Wandering and getting lost

Mechanism of Delirium

- Not fully understood - Wide variety of structural or physiological insults - The main hypothesis is reversible impairment of cerebral oxidative metabolism and multiple neurotransmitter abnormalities

How do you prevent it?

- Patients who are at high risk for delirium should be monitored closely as outpatients, during hospitalization, and throughout surgical procedures (patients should be educated, don't take a lot of medication cold-medications given by pharmacists) - Providers should become familiar with prescribing practices for patients who are elderly, keeping dosages low and avoiding medications that cause delirium. - Monitoring the patient's mental status as a vital sign helps diagnose delirium early. (stay hydrated, ask about natural products)

Neuroimaging

- Perform CT scan of the head. - Magnetic resonance imaging (MRI) of the head may be helpful in the diagnosis of stroke, hemorrhage, and structural lesions (looking for a bleed)

Environmental Modifications - more

- Physical restraints should be avoided (use chemical) - Delirious patients may pull out intravenous lines, climb out of bed, and may not be compliant. - Perceptual problems lead to agitation, fear, combative behavior, and wandering. Severely delirious patients benefit from constant observation (sitters), which may be cost effective for these patients and help avoid the use of physical restraints. - These patients should never be left alone or unattended.

Operation-Related Delirium

- Preoperative (dementia, polypharmacy, drug withdrawal, fluid and electrolyte imbalance- you stop them from eating) - Intraoperative (meperidine, long-acting benzodiazepines, anticholinergics such as atropine; however, medications such as glycopyrrolate can be used because, in contrast to atropine, they do not cross the blood brain barrier) - Postoperative (hypoxia, hypotension- and not perfusing) - Drugs are a common risk factor for delirium, and drug-induced delirium is commonly seen in medical practice, especially in hospital settings. - The risk of anticholinergic toxicity is greater in elderly persons, and the risk of inducing delirium by medications is high in frail, elderly persons and in those with dementia.

Environmental Modifications

- Reorientation techniques or memory cues such as a calendar, clocks, and family photos may be helpful. (wouldn't help someone with dementia) - The environment should be stable, quiet, and well-lighted. Support from a *familiar nurse* and family should be encouraged.

Prognosis

- Resolution of symptoms may take longer in patients with poor premorbid cognitive function, incorrect or incomplete diagnosis of contributing factors, and structural brain diseases treated with large doses of psychoactive medications prior to the onset of acute medical illness. - For some patients, the cognitive effects of delirium may resolve slowly or not at all. (the longer you take to fix the worse it will get)

Hypoperfusion States causes of Delirium

- Shock - Congestive heart failure - Cardiac arrhythmias - Anemias (not getting blood to their head- afib decreases your pumping power by 10%)

Toxic Causes of Delirium

- Substance intoxication - Alcohol, heroin, cannabis, PCP, and LSD - Substance withdrawal from alcohol, opioids, and benzodiazepines

Medical Care: Fluid and Nutrition

- These should be given carefully because the patient may be unwilling or physically unable to maintain a balanced intake (don't overload- but don't want them dehydrated) - For the patient suspected of having alcohol toxicity or alcohol withdrawal, therapy should include multivitamins, especially *thiamine*

5 important risk factors for Delirium in the hospital

- Use of physical restraints (chemical restrains are ok) - Malnutrition - Use of a bladder catheter (infection- urocepsis) - Any iatrogenic event (illness) - Use of 3 or more medications (sometimes on wrong meds, more poeple they see more meds can be prescribed, maybe even same by accident)

Haloperidol (Haldol)

A butyrophenone high-potency antipsychotic. - One of most effective antipsychotics for delirium. - High-potency antipsychotic medications also cause less sedation than phenothiazines and reduce risks of exacerbating delirium - PO/IM

Risperidone (Risperdal)

A newer antipsychotic with fewer extrapyramidal adverse effects than Haldol. - Binds to dopamine D2-receptor with 20 times lower affinity than for 5-HT2-receptor. - Improves negative symptoms of psychoses and reduces incidence of adverse extrapyramidal effects. (PO)- lower doses w older renal or hepatic failure predisposed to hypotension

How is delirium defined?

A transient, usually reversible, cause of cerebral dysfunction and manifests clinically with a wide range of neuropsychiatric abnormalities

Delirium

Acute confusional state is transient global disorder to cognition - The condition is a *medical emergency* associated with increased morbidity and mortality rates - Early diagnosis and resolution of symptoms are correlated with the most favorable outcomes. Therefore, it must be treated as a medical emergency

Impaired attention assessment

Can be assessed with bedside tests that require sustained attention to a task that has not been memorized, such as reciting the days of the week or months of the year backwards, counting backwards from 20, or doing serial subtraction (as long as they dont have to memorize something they do okay)

Risperidone (Risperdal)-SE

Can cause orthostatic *hypotension, seizures, hyperprolactinemia*, and *body temperature regulation abnormalities*; has potential for proarrhythmic effects by *prolonging QT interval*; >2 mg/d may increase adverse extrapyramidal effects in elderly patients

Cyanocobalamin (B12)

Can give with B12 deficiency (like with a bipass) - Problem can be absorption -> so need to remember that - Give a lot at a time 1,000 mcg IM, sub q- if its a bipass

Lorazepam (Ativan)- side effects

Caution in limited pulmonary reserve, patients who are elderly, and very ill patients; can cause hypoxic cardiac arrest; caution also needed in patients with myasthenia gravis, organic brain syndrome, or Parkinson disease - Don't use with respiratory depression

Lab studies

Complete blood cell count with differential Electrolytes, Glucose, *Renal and liver function* tests, Thyroid function studies, Urine analysis , Urine and blood *drug screen* -include alcohol Thiamine and vitamin B-12 levels, Tests for bacteriological and viral etiologies, Sedimentation rate (inflammation, infection) (earlier the better!!)

Clinical Hallmarks of delirium

Decreased attention span and a waxing and waning type of confusion (latin for off track)

Patients who are elderly

Delirium often is the presenting symptom of an underlying illness.

How to treat Delirium

Find underlying cause- 16% of the time you cant find the underlying cause

Thiamine (B1)

For alcohol withdrawal and in cases of Wernicke encephalopathy.

Patients with delirium who are hyperactive

Have an increased state of arousal, psychomotor abnormalities, and hypervigilance

Some examples of herbal products that have anticholinergic effects

Henbane, jimson weed, and mandrake

Causes of Delirium

Hypoxia, Hypoglycemia, Hyperthermia, Anticholinergic delirium, Alcohol or sedative withdrawal, Infections *(UTI)*, Metabolic abnormalities (diabetics) Structural lesions of the brain , Postoperative states, Miscellaneous causes, such as sensory deprivation, sleep deprivation, fecal impaction, urinary retention, and change of environment (dementia with delirium) Postictal state, Unfamiliar environment

Delirium in hospitalized patients

In patients who are elderly and patients in the postoperative period, delirium may result in a prolonged hospital stay, increased complications, increased cost, and long-term disability

Number one cause of Delirium

In persons who are elderly, *medication* at therapeutic doses and levels can cause delirium - Because GFR goes down, hepatic clearance goes down, normal does can affect elderly different

Mixed delirium

Individuals display daytime sedation with nocturnal agitation and behavioral problems

Diganosis of Delirum

Is clinical - No single test is successful. - Obtaining a thorough history is essential (get from those around this)

Obtaining a drug history

Is imperative- patients may be taking over-the-counter cold and sleep medications, which are frequent causes of delirium (cold med with benadryl) - Drugs can be the sole cause of delirium - Be aware of medications with significant anticholenergic effect - Any recent addition of a new medication or increase in dose should be verified

Is delirium a disease?

No- a syndrome with multiple causes that result in a similar constellation of symptoms

Hyperactive delirium

Observed in patients in a state of alcohol withdrawal or intoxication with to phencyclidine (PCP), amphetamine, and lysergic acid diethylamide (LSD).

Hypoactive delirium

Observed in patients in states of hepatic encephalopathy and hypercapnia

What should be the goal?

PREVENTION A multicomponent intervention study that targeted cognitive impairment, sleep deprivation, immobility, visual impairment, hearing impairment, and dehydration showed significant reduction in the number and duration of episodes of delirium in older patients who were hospitalized

Physical Signs of Delirium

Patients have difficulty sustaining attention, problems in orientation and short-term memory, poor insight, and impaired judgment. - Key elements here are *fluctuating levels of consciousness*

Delirium symptoms hallucinations

Patients may have visual hallucinations or persecutory delusions as well as grandiose delusions

Electroencephalogram- What is observed?

Slowing of the posterior dominant rhythm and increased generalized slow-wave activity are observed on electroencephalogram (EEG) recordings - (The type of patterns observed includes triphasic waves in toxicity or metabolic derangement, continuous discharges in nonconvulsive status epilepticus, and localized delta activity in focal lesions)- didnt say this

Medication History

The use of complementary medicine is increasing in North America. While these products are considered to be "natural," they may contain ingredients or contaminants that can contribute to delirium - Both the cause and symptoms of delirium should be treated.

Lorazepam (Ativan)

When patient needs to be sedated for longer than 24 h, this medication is excellent. - Commonly used prophylactically to prevent delirium tremens