13 - Delirium

Question 1

What else is delirium known as?

Answer 1

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

Question 2

What is delirium?

Answer 2

An acute change in mental status **

There are many diagnostic criteria, but all you need to know is this

Question 3

What is the incidence of delirium?

Answer 3

• 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 ***

Question 4

What morbidities are associated with delirium?

Answer 4

• 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 ***

Question 5

What are some of the characteristics of delirium?

Answer 5

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

Question 6

Describe the spectrum of delirium

Answer 6

• 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

Question 7

What could cause delirium?

Answer 7

Cholinergic deficiency

• Can be exacerbated by medication
• Avoids meds that block acetycholine

Question 8

What else could cause delirium?

Answer 8

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

Question 9

What are the risk factors involved in delirium?

Answer 9

• Delirium “caused” by “sum” of predisposing and
precipitating factors
• The greater the burden of predisposing factors,
the fewer precipitating factors required to cause
delirium

Question 10

What are the predisposing factors?

Answer 10

• Advanced age
• Dementia
• Functional impairment in ADLs
• Medical comorbidity
• History of alcohol abuse
• Male sex (maybe)
• Sensory impairment (↓ vision, ↓ hearing)

Question 11

What puts patients at high risk to develop delirium?

Answer 11

Already having dementia

Question 12

What are the precipitating factors for delirium?

Answer 12

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

Question 13

What else can you use as a list of possibilities for delirium?

Answer 13

Use the DEMENTIAS mneumonic

Question 14

What are pre-op risk factors for delirium?

Answer 14

• Age over 70
• Cognitive impairment
• Physical functional
impairment
• History of alcohol abuse
• Abnormal serum
chemistries
• Intrathoracic and aortic
aneurysm surgery

Question 15

What is important in the history for delirium patients?

Answer 15

History
• Focus on time course of cognitive changes, esp.
their association with other symptoms or events
• Medication review, including OTC drugs, alcohol

Question 16

What is important in the physical exam for delirium patients?

Answer 16

Physical examination
• Vital signs
• Oxygen saturation
• General medical evaluation
• Neurologic and mental status examination

Question 17

What are the general principles of management for delirium patients?

Answer 17

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

Question 18

What are the keys to effective management of delirium patients?

Answer 18

• Identify and treat reversible contributors
• Maintain behavioral control
• Anticipate and prevent complications
• Restore function

Question 19

What drugs should you reduce or eliminate in your patient with delirium?

Answer 19

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)

Question 20

What are the non-pharmacological treatment strategies for dementia patients?

Answer 20

• 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

Question 21

How do you manage the behavioral problems in dementia patients?

Answer 21

• 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

Question 22

What is the best management for dementia pateints?

Answer 22

• Prevention
• Start out with nonpharmacologic approach
• Limit or avoid psychoactive and other high-risk
  medications

Question 23

What are the delirium guidelines?

Answer 23

• 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

Question 24

Test Question: what is the definition of of delirium?

Answer 24

• An acute mental status change
• Disorganized thinking
• Change in attention

The answer is ALL OF THE ABOVE

Question 25

Test Question: how common is delirium?

Answer 25

• Very common

- A very serious complication of stressors

Question 26

Test Question: what causes delirium?

Answer 26

A sum of predisposing and precipitating factors