delirium

Question 1

Delirium epidemiology?

Answer 1

half of hospitalized elderly patients have delirium.
90% of patients with preexisting NCD (dementia) will develop superimposed delirium.
Delirium increases the risk of later developing major NCD

Question 2

delirium risk factors?

Answer 2

1. old age
2. prior hx of delirium
3. serious or terminal illness
4. multiple medical comorbidities
5. preexisting cognitive impairment

Question 3

delirium precipitating factors?

Answer 3

1. polypharmacy
2. alcohol use or withdrawal
3. infection
4. dehydration, malnutrition, sleep depravation
5. organ failure
6. mechanical ventilation

Question 4

common causes of medication-induced delirium?

Answer 4

benzodiazepines
nonbenzodiazepine hypnotics
anticholinergics
TCA
opioids
corticosteroids

Question 5

delirium symptoms?
types?

Answer 5

primarily a disorder of attention and awareness (disorientation) that develops acutely over hours or days and fluctuates during the day (worse at night). Can also develop deficits in recent memory, language, and visual disturbances (visual hallucinations or illusions) as well as disruption in circadian rhythm.

3 types:
1. purely hypoactive (low psychomotor activity, drowsy, lethargy, stupor. most likely to go undetected esp in elderly
2. purely hyperactive (irritable, noncooperative, most common in drug induced delirium)
3. mixed

Question 6

Delirium DSM-5?

Answer 6

1. disturbance in attention and awareness
2. disturbance in additional cognitive domain
3. develops acutely over hours to days, represents a change from baseline, and fluctuates during the day
4. not better accounted for by another neurocognitive disorder or occurring during coma
5. clinical evidence that the disturbance is a direct consequence of another medical condition, substance intoxication/withdrawal, exposure to toxin, or multiple etiologies

Question 7

clinical work to identify underlying cause?

Answer 7

1. quick initial tests: finger-stick glucose, ECG, pulse-oximetry, ABG
2. delirium workup: basic metabolic panel, CBC with differential, serum Mg, urinalysis and urine culture
3. AS NEEDED: chest xray, urine/serum drug screen, alcohol blood levels, therapeutic drug levels, liver enzymes, thyroid profile, vit. B12
4. if no cause can be identified, no improvements despite known cause, head trauma hx, or new onset focal neurologic deficits: head CT/MRI, EEG, lumbar puncture

Question 8

delirium tx?

Answer 8

medical emergency
1. treat underlying cause
2. encourage family members to visit to help supervise and orient patient
3. reorient with time, place, person and open windows, place calendars and clocks
4. use haloperidol (antipsychotics) for agitation BUT not in parkinson patients
5. avoid benzos as they may cause paradoxical disinhibition (unless in alcohol or benzo withdrawal)
6. avoid restraints