Delirium

Question 1

Define delirium

Answer 1

Acute confusional state

Question 2

What does delirium effect?

Answer 2

Affects global cognitive function

Including memory, orientation, language, perception and visuospatial skills (all domains of cognitive function)

Question 3

What are some other features of delirium?

Answer 3

Other features:
Psychomotor disturbance
Altered sleep-wake cycle
Emotional lability –> outbursts of crying, laughing, angry quickly

Question 4

Describe the DSM-5 criteria of Delirium

Answer 4

Acute onset

Disturbance in attention, awareness, and cognition

Fluctuates in severity

Attributable to an underlying cause (Can occur secondary to infections but can be many causes)

Question 5

Describe the prevalence of delirium

Answer 5

Delirium affects ~11-42% of medical inpatients

Especially common among older adults

1/3 of medical inpatients > or = to70 years of age

Question 6

Describe delirium and surgery

Answer 6

Most common surgical complication

15-25% after elective surgery

50% after major, non-elective surgery

Question 7

Describe the sigificance of delirium?

Answer 7

Poor prognostic indicator

Delirium is associated with1:
2 x ↑ risk of death
2.5 x↑ risk of discharge to higher level of care
12.5 x ↑ risk of developing dementia

↑ length of hospitalization (5-10 days)

Sustained functional decline 6 months after admission2

Question 8

Describe the interplay between dementia and delirium

Answer 8

Do not know if delirium episode changes something permanently that predisposes them to dementia or reveals underlying mechanism that increases one’s predisposition to dementia

Question 9

Describe the risk factors for Delirium

Answer 9

underlying vulnerability + stressors

Question 10

Describe the prevalence of delirium stratified by age group

Answer 10

Delirium risk is higher in older adults

Question 11

Describe the drugs that are risk factors for delirium

Answer 11

Muscle Relaxants –> Cyclobenzaprine, Baclofen, Methocarbamol
CBZ, Phenyton –> Higher serum concnetrations
Gabapentin/Pregab —> Not used for anticonvulsnats; high prevalence in pain –> Same effecrs

Corticosteorids – > 40 mg for a COPD exacerbation –> higher doses of CS’s
Psychoactive NSAID’s –>Indomethacin
Digoxin –> Higher doss and serum concetn

Question 12

IS delirium often recognized? Why or why not?

Answer 12

Only 12-35% of delirium cases are recognized1

Underrecognized and under-diagnosed

Question 13

What is the most useful bedside method for assessing a suggestive diagnosis of delirium? How is it scored?

Answer 13

Question 14

Describe the subtypes of delirium

Answer 14

Might have one or switch between two

Question 15

Which subtype of delirium is most likely to be recognized?

Answer 15

Hyperactive more likely to be recognized –> Doing something –> Getting out of bed, hitting nurses
–> More likely to be diagnosed with delirium

Hypodelirium –> Less diagnosed –> Hard to arouse them or not coherent –> Laying in bed, sedated

Question 16

Describe a study looking at the prognosis of delirium?
Duration?
Outcomes?

Answer 16

o Causes: 58% due to infection, 36% due to metabolic, 18% drug-induced
o Duration: mean of 16 days, but ranges 2-96 days
o Outcomes: 48% mortality (70% with infection),12% persisted, 33% resolved

Question 17

Is it appropriate to diagnose someone with dementia after a period of delirium?

Answer 17

Not appropriate to assess someone or diagnose dementia after a period of delirium

Can last a long time (2-96 days)

Question 18

Describe the differences between delirium and dementia

Answer 18

Question 19

Describe the strategies for delirium prevention

Answer 19

Stopping meds/substace withdrawal delirium –> Nicotine replacement therapy –> Get outside to smoke

Question 20

Describe the management of delirium

Answer 20

Thorough medical evaluation for underlying cause –> Not ruling out medications just cause you diagnosed a UTI

Medications –> least important –> Minor role to play in tx of delirium

Question 21

In geriatrics, what is the severity of delirium?

Answer 21

Delirium should be considered a Medical Emergency in geriatrics

URGENT CARE

Worse outcomes longer it continues untreated

Question 22

What are some underlying causes of delirium?

Answer 22

 Readily reversible causes (e.g., hypoxia, hypo/hyperglycemia, hyponatremia, hyperkalemia)
 Infection
 Neurologic (stroke)
 Medication induced adverse effects, overdose, supratherapeutic levels
 Toxicology (alcohol or substance use/withdrawal)
 Metabolic
 Cardiopulmonary
 Environmental factors (lack of sleep, unfamiliar environment, lack of hearing/vision aids)
 Other: pain, urinary retention, constipation

Question 23

Pharmacological Therapy is only indicated when:

Answer 23

Question 24

Are anti-psychotics an on label indication for delirium?

Answer 24

Off-label

Question 25

Which medications are used for delirium?

Answer 25

Haloperidol: Conventional – Theoretical advantage of being in an injectable form

Haloperidol: Reasonable for a day or 2 of usage

Safety –> Higher risk of EPS in adults with continuous use over a long period of time

If using AP for more than 5 days: Switch haloperidol to atypical AP

Cannot not appropriately stop Benzo –> Tirate dose down –> precipitate higher likelihood of return and worsen delirium (longer o recovr)

Question 26

Haloperidol Usage for Delirium

Answer 26

Conventional drug of choice

Available in oral and parenteral formulations

If longer treatment duration is required, switch to atypical to ↓ risk for EPS

Question 27

Are atypical anti-psychotics used for delirium? Comparisons?

Answer 27

Atypical Antipsychotics (olanzapine, quetiapine, risperidone)

↓ risk for EPS but ↑ risk for orthostatic hypotension

Olanzapine is the most anticholinergic

Quetiapine agent of choice for individuals with Parkinson’s disease or Lewy Body Dementia

Quetiapine has the elast DA blocking –> Parkinson’s dx lack of DA neurons in the brain

Quetiapine least DA blocking effect –> Clozapine can also be used but ade make use limited in acute setting

Question 28

Describe the differences in antipsychotics

Answer 28

Question 29

Warnings of atypical antipsychotics

Answer 29

Atypical antipsychotics have a black-box warning for use in individuals with dementia

↑ risk of mortality (~1.6x)

Not seen in studies of short-term use for delirium (3-7 days