Delirium

Question 1

Como fazer o diagnóstico de delirium?

Answer 1

Using the CAM, a diagnosis of delirium is made if there is (1) an acute onset and fluctuating course and (2) inattention accompanied by either (3) disorganized thinking or (4) an altered level of consciousness. These scales are based on criteria from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) or the WorldHealth Organization’s International Classification of Diseases (ICD). Unfortunately, these scales do not identify the full spectrum of patients with delirium. All patients who are acutely confused should be presumed delirious regardless of their presentation due to the wide variety of possible clinical features.

Question 2

Quais os dados mais importantes na história de um delirium?

Answer 2

The three most important pieces of history are the patient’s baseline cognitive function, the time course of the present illness, and current medications.
Patients with a more hypoactive, apathetic presentation with psychomotor slowing may be identified as being different from baseline only through conversations with family members. A number of validated instruments have been shown to diagnose cognitive dysfunction accurately by using a collateral source, including the modified Blessed Dementia Rating Scale and the Clinical Dementia Rating (CDR).
Other important elements of the history include screening for symptoms of organ failure or systemic infection, which often contributes to delirium in the elderly. A history of illicit drug use, alcoholism, or toxin exposure is common in younger delirious patients. Finally, asking the patient and collateral source about other symptoms that may accompany delirium, such as depression and hallucinations, may help identify potential therapeutic targets.

Question 3

O que buscar no exame físico do delirium?

Answer 3

The general physical examination in a delirious patient should include a careful screening for signs of infection such as fever, tachypnea, pulmonary consolidation, heart murmur, and stiff neck.
The appearance of the skin can be helpful, showing jaundice in hepatic encephalopathy, cyanosis in hypoxemia, or needle tracks in patients using intravenous drugs.
Tangential speech, a fragmentary flow of ideas, or inability to follow complex commands often signifies an attentional problem. There are formal neuropsychological tests to assess attention, but a simple bedside test of digit span forward is quick and fairly sensitive. In this task, patients are asked to repeat successively longer random strings of digits beginning with two digits in a row. Average adults can repeat a string of five to seven digits before faltering; a digit span of four or less usually indicates an attentional deficit unless hearing or language barriers are present.
The remainder of the screening neurologic examination should focus on identifying new focal neurologic deficits.

Question 4

Qual deve ser a investigação metabólica inicial do delirium?

Answer 4

Complete blood count Electrolyte panel including calcium, magnesium, phosphorus 
Liver function tests, including albumin 
Renal function tests 
Urinalysis and culture  
Chest radiograph  
Blood cultures Electrocardiogram 
Arterial blood gas 
Serum and/or urine toxicology screen (perform earlier in young persons)

Question 5

Qual deve ser a investigação estrutural no delirium? (Exame neurologico alterado OU nao esclarecimento da causa metabólica)

Answer 5

Brain imaging with MRI with diffusion and gadolinium (preferred) or CT

Suspected CNS infection: lumbar puncture after brain imaging

Suspected seizure-related etiology: electroencephalogram (EEG) (if high suspicion, should be performed immediately)

Question 6

Qual a investigação metabólica avançada de delirium que nao foi esclarecido na investigação inicial?

Answer 6

• Vitamin levels: B12, folate, thiamine
• Endocrinologic laboratories: thyroid-stimulating hormone (TSH) and free T4; cortisol
• Serum ammonia
• Sedimentation rate
• Autoimmune serologies: antinuclear antibodies (ANA), complement levels; p-ANCA, c-ANCA
• Infectious serologies: rapid plasmin reagin (RPR); fungal and viral serologies if high suspicion; HIV antibody

Question 7

Como deve ser o manejo do delirium?

Answer 7

Management of delirium begins with treatment of the (1) underlying inciting factor (e.g., patients with systemic infections should be given appropriate antibiotics, and underlying electrolyte disturbances judiciously corrected).

(2) Relatively simple methods of supportive care can be highly effective in treating patients with delirium. Reorientation by the nursing staff and family combined with visible clocks, calendars, and outside-facing windows can reduce confusion. Sensory isolation should be prevented by providing glasses and hearing aids to patients who need them. Sundowning can be addressed to a large extent through vigilance to appropriate sleep-wake cycles. During the day, a well-lit room should be accompanied by activities or exercises to prevent napping. At night, a quiet, dark environment with limited interruptions by staff can assure proper rest. These sleep-wake cycle interventions are especially important in the ICU setting as the usual constant 24-h activity commonly provokes delirium. Attempting to mimic the home environment as much as possible also has been shown to help treat and even prevent delirium. Visits from friends and family throughout the day minimize the anxiety associated with the constant flow of new faces of staff and physicians. Allowing hospitalized patients to have access to home bedding, clothing, and nightstand objects makes the hospital environment less foreign and therefore less confusing. Simple standard nursing practices such as maintaining proper nutrition and volume status as well as managing incontinence and skin breakdown also help alleviate discomfort and resulting confusion
ent of the underlying inciting factor (e.g., patients with systemic infections should be given appropriate antibiotics, and underlying electrolyte disturbances judiciously corrected).

(3)Chemical restraints should be avoided, but when necessary, very low dose typical or atypical antipsychotic medications administered on an as-needed basis are effective. The recent association of antipsychotic use in the elderly with increased mortality rates underscores the importance of using these medications judiciously and only as a last resort