13 - Delirium Flashcards
What else is delirium known as?
DELIRIUM IS ALSO KNOWN AS…. • Acute confusional state • Acute mental status change • Altered mental status • Organic brain syndrome • Reversible dementia • Toxic or metabolic encephalopathy
Can be confusing… Just say delirium
What is delirium?
An acute change in mental status **
There are many diagnostic criteria, but all you need to know is this
What is the incidence of delirium?
• 1/3 of inpatients aged 70+ on general medical units, half of whom are delirious on admission • In ICU: more than 75% • At end of life: up to 85%
When you see a change in mental status, it is important to get to the bottom of it ***
What morbidities are associated with delirium?
• Recent meta-analysis: 3000 pts followed for
almost 2 years showed increased risk:
- 2-fold for death
- 2.4-fold for institutionalization
- 12.5-fold for new dementia
• Persistence of delirium → poor long-term
outcomes
When your nurse calls you and tell you there has been a change in who the patient is, take them seriously ***
What are some of the characteristics of delirium?
1. Acute change in mental status and fluctuating course 2. Inattention 3. Disorganized thinking 4. Altered level of consciousness
Even if you expect this (surgery), it deserves some attention
Describe the spectrum of delirium
• Hyperactive or agitated delirium — 25% of all
cases
• Mixed
• Hypoactive delirium — ≥50% of all cases, but
less often recognized and appropriately
treated, and poorer prognosis
HYPOactive is actually more common - a newly lethargic patient is also a change in mental status
What could cause delirium?
Cholinergic deficiency
- Can be exacerbated by medication
- Avoids meds that block acetycholine
What else could cause delirium?
Inflammation
• Especially important in postoperative, cancer, and
infected patients
• Inflammation can break down blood-brain barrier,
allowing toxic medications and cytokines access to
CNS
• Neuroinflammation may damage neurons, lead to
long-term cognitive effects
What are the risk factors involved in delirium?
• Delirium “caused” by “sum” of predisposing and
precipitating factors
• The greater the burden of predisposing factors,
the fewer precipitating factors required to cause
delirium
What are the predisposing factors?
- Advanced age
- Dementia
- Functional impairment in ADLs
- Medical comorbidity
- History of alcohol abuse
- Male sex (maybe)
- Sensory impairment (↓ vision, ↓ hearing)
What puts patients at high risk to develop delirium?
Already having dementia
What are the precipitating factors for delirium?
PRECIPITATING FACTORS • Acute cardiac events • Acute pulmonary events • Bed rest • Drug withdrawal (sedatives, alcohol) • Fecal impaction • Fluid or electrolyte disturbances • Indwelling devices • Infections (esp. respiratory, urinary) • Medications • Restraints • Severe anemia • Uncontrolled pain • Urinary retention
What else can you use as a list of possibilities for delirium?
Use the DEMENTIAS mneumonic
What are pre-op risk factors for delirium?
• Age over 70 • Cognitive impairment • Physical functional impairment • History of alcohol abuse • Abnormal serum chemistries • Intrathoracic and aortic aneurysm surgery
What is important in the history for delirium patients?
History
• Focus on time course of cognitive changes, esp.
their association with other symptoms or events
• Medication review, including OTC drugs, alcohol
What is important in the physical exam for delirium patients?
Physical examination • Vital signs • Oxygen saturation • General medical evaluation • Neurologic and mental status examination
What are the general principles of management for delirium patients?
MANAGEMENT:
GENERAL PRINCIPLES
• Requires interdisciplinary effort by MDs, nurses,
family, others
• Multifactorial approach is most successful
because multiple factors contribute to delirium
• Failure to diagnose and manage delirium →
costly, life-threatening complications; loss of
function
What are the keys to effective management of delirium patients?
- Identify and treat reversible contributors
- Maintain behavioral control
- Anticipate and prevent complications
- Restore function
What drugs should you reduce or eliminate in your patient with delirium?
Any medication that can affect the CNS • Alcohol • Anticholinergics • Anticonvulsants • Antidepressants (anticholinergic only) • Antihistamines (anticholinergic only) • Antiparkinsonian agents • Antipsychotics • Barbiturates • Benzodiazepines • Chloral hydrate • H2-blocking agents • Non-benzodiazepine sedatives • Opioid analgesics (esp. meperidine)
What are the non-pharmacological treatment strategies for dementia patients?
• Use orienting stimuli (clocks, calendar, radio)
• Provide adequate socialization
• Use eyeglasses and hearing aids appropriately
• Mobilize patient as soon as possible
• Ensure adequate intake of nutrition and fluids, by hand
feeding if necessary
• Educate and support the patient and family
How do you manage the behavioral problems in dementia patients?
• Provide “social” restraints: consider a sitter or
allow family to stay in room
• Avoid physical or pharmacologic restraints
• If absolutely necessary for agitation in delirium,
medications can be considered
➢ High potency antipsychotics such as Haloperidol (offlabel)
are treatment of choice in low doses
➢ Contraindicated in Parkinson disease, Lewy-body
dementia or history of neuroleptic malignant syndrome
What is the best management for dementia pateints?
- Prevention
- Start out with nonpharmacologic approach
- Limit or avoid psychoactive and other high-risk
medications
What are the delirium guidelines?
• Assess risk factors on admission
• Implement preventive interventions
• Screen for incident delirium
• To manage delirium, treat underlying causes, provide
a suitable environment, manage distress with
behavioral methods, use antipsychotics only
if needed
Test Question: what is the definition of of delirium?
- An acute mental status change
- Disorganized thinking
- Change in attention
The answer is ALL OF THE ABOVE
Test Question: how common is delirium?
- Very common
- A very serious complication of stressors
Test Question: what causes delirium?
A sum of predisposing and precipitating factors
