Delirium

Question 1

What is delirium?

Answer 1

• Acute onset of confusion/disorientation, excitement, incoherent speech and agitation
• Often confused with psychosis, mood disorder or dementia
• The disturbances in attention and cognition are NOT better explained by a pre-existing or establish neurocognitive disorder.
• Patients with dementia CAN develop delirium and this is associated with poor outcomes and increased mortality.
• KEY FEATURE: attentional and cognitive disturbances usually develop over a short period of time (hours to days) and fluctuate during the course of the day.
• Usually evidence is present from H&P, Recent medical condition, medication adverse reaction of cause of delirium.
• In delirium, cognitive decline is rapid, as opposed to dementia, which is gradual and progressive.

Question 2

What are the 3 types of delirium?

Answer 2

1. Hypoactive delirium

• Commonly observed in ICU or hospitalized older adult ( up to 30% of ICU patients)
• Usually manifested by lethargy, psychomotor retardation, and decreased arousal levels

2. Hyperactive delirium

• Typically characterized by hyperarousal, psychomotor agitation and hypervigilance
• LEAST common form

3. Mixed delirium

• Patients vacillate between periods of hypo- and hyperactivity

Question 3

What are some risk factors for delirium?

Answer 3

• Age: young children and those older than 60 years
• Preexisting brain damage or dementia
• History of alcoholism
• Diabetes
• Malnutrition
• Cancer

Question 4

What are the subjective findings associated with delirium?

Answer 4

• Onset is acute, worsening at night
• Impaired memory, thinking and judgement
• Inattention, disorientation, confusion
• Frequently associated with:
  
  • Incoherent speech,
  • Fear or acute anxiety
  • Disrupted sleep
  • Perception disturbances
  • Carphologia- ‘lint’ picking behavior, grasping at imaginary objects, such as bed linens, clothes, etc.

Question 5

What medications are used to treat delirium?

Answer 5

If non-pharmacologic management fails to reduce anxiety and agitation, then the provider may proceed with pharmacologic management:

1. Lorazepam (Ativan)
2. Olanzapine (Zyprexa) 2.5 mg for patient with dementia, po (rapidly dissolving) or IM
3. Haloperidol (Haldol)
   * Subsequent doses should be given every 1-2 hours until patient is calm

4. Benzodiazepines MAY WORSEN delirium, especially in the elderly

5. If patient is lucid, may give oral Quetiapine (Seroquel), olanzapine (Zyprexa), risperidone (Risperdal), or haloperidol (Haldol)
   * Always give the lowest possible effective dose if patient is elderly or has diagnosed dementia.

Question 6

How do you manage a patient with delirium?

Answer 6

• Treat the underlying medical cause!
• Perform a differential diagnosis and obtain additional diagnostic tests
• Discontinue any unnecessary medications (see required reading for listing of potentially deliriogenic medications)
  
  • Consult a pharmacist if necessary
• Discontinue any unnecessary catheters/monitors or intravenous lines
• Prescribe and administer non-pharmacologic delirium interventions
  
  • Early mobilization
  • Promoting adequate sleep
  • Use of non-pharmacologic pain management techniques
  • Cognitive reorienting
  • Providing appropriate adaptations for sensory impairments
  • Promoting adequate oxygenation
  • Managing nutrition and hydration
  • Preventing constipation
  • Prescribe additional medications only if needed
  • Ensure proper follow-up care is provided
• Patients should be constantly supervised until agitation clears
• Medical, neurologic and psychiatric consultations