Delirium CBM and Oxford Flashcards
Delirium diagnosis
DSM5
1. Disturbance in attention
- Develops over short period of time, change from baseline. Fluctuates.
3. Must also have one disturbance of:
- memory deficit
- disorientation
- language
- visuospatial ability
- perception
4. Not better explained by neurocognitive disorder.
- Evidence it is caused by medical condition.
Confusion Assessment Method Deliriuj diagnosis
- acute onset
- fluctuating course
- inattention
- and one of:
- disorganized thinking
- altered LOC
List clinical subtypes of delirium
- Hyperactice
- Hypoactive
- Mixed
Most common hypoactive and mixed in pall care
List reasons why making the diagnosis of delirium is challenging
- ambiguous terms
- failure to regularly screen for it
- fluctuation in symptoms
- hypoactive hard to recognize
- dementia may contribute
- depression
- mania/psychosis/anxiety/akasthisa
List risks if delirium is missed
- increased morbidty
- using benzo can increase delirium - mistreatment
- opioids for “pain” that is delirium = OIN
History in delirium
- collateral history
- onset
- fluctuation?
- formal cognitive assessment
Physical exam in Delirium
- vital signs
- OIN
- hallucinations
- hyperalgesia
- allodynia
- neuro exam
- focal or unilateral signs
- CN
- asterixis
- myoclonus
- babinksi
- gait
- frontal primitive reflexes
- specific causes of delirium : infection, dehydration
Formal cognitive assessment in delirium : tools
Screening:
- RASS-PAL
- CAM
- BOMC
Diagnosis:
- DSM5
- CAM
Monitoring
- RASS-PAl
Etiology of Delirium in Advanced Cancer
- Intracranial disease
- brain tumour
- LMD
- seizure/post ictal
- Medications
- benzos
- opioids
- tcs
- SSRI
- antipsychotics
- anticholingerics
- antihistamines
- steroids
- cipro ???
- Organ Failure
- Infection
- Heme
- anemia
- DIC
- Metabolic
- Dehydration
- hypercalcemia
- hyponatremia
- hypoglycemia
- hyperglycemia
- Paraneoplastic
- encephalitis
- Withdrawal
- opioids
- benzos
- ETOH
List risk factors for delirium in cancer
- malnutrition, low albumin
- advanced age > 70
- pre-existing cog impairment
- prior delirium
- polypharmacy
- urinary retention, constipation
Pathogenesis
- acute brain failure
- impaired cerebral oxidative metabolism
- multiple neurotransmitter abnormalites
-
High DOPAMINERGIC tone
- dopamine increase in mesolimbic tract
- agitation and delusions
-
Low CHOLINGERIC TONE
- hippocampus and basal forebrain
- Disorientation, hallucinations, memory impairment
-
High DOPAMINERGIC tone
How do opioids increase risk for delirium?
- Morphine metabolites
- M3G
- Hydromorphone metabolite
- H3G
List impacts that delirium can have on patients and families
- palliative emergency
- distressing
- loss of capacity
- loss of meaningful communication
- difficulty assessing pain
- frustration
List common deliriogenic drugs in palliative care
- Anticholingerics (scopolamine, diphenhydramine)
- TCAs
- Anti inflammatories
- Benzos
- Diuretics
- GI meds (ranitidine)
- Opioids
Prognosis of delirium in pall care
- reversibility up to 50%
- terminal delirium very poor prognosis
*
Investigations for delirium
- CBC
- lytes
- urea/Cr
- Calcium
- albumin
- Mg
- glucose
- liver enzymes
- B12/folate
- TSH
- CRP
- ECG
- Urine and culture
- Cxray
- blood cultures
- brain CT/MR
- LP
Life threatening Causes of Delirium
WHHHIMP
- Wernicke’s
- Hypoxia
- Hyper/hypoglycemia
- Hypertensive Encephalopathy
- Intracerebral hemorrhage
- Meningitis /encephalitis
- Poisoning
Differential Diagnosis Delirium (general)
I WATCH DEATH
Infection
Withdrawal - etoh, opioids,
Acute metabolic - hyperCa++, Na, liver, renal failure
Trauma
CNS pathology - stroke, tumour, mets, post ictal
Hypoxia - CHF, anemia
Deficiencies - thiamine, B12, niacian, folate
Endocrine - Hypoglycemia
Acute Vascular - hypertension, hypotension
Toxins - drugs
Heavy Metal
Differential DIMES
DIMES
- Drugs
- Infections
- Metabolic
- Environmenta
- Structural/Seizures/Systemic illness
General approach to delirium management
- address goals of care
- decide to work up and treat reversible causes if relevant
- educate patient and family
- non pharmacologic interventions
- medications for symptoms
- reduce polypharmacy
List non pharmacological Tx for delirium
- frequent orientation of patient
- oral hydration
- hearing aids/glasses
- attention to light /window
- sleep hygiene
- consistent caregivers
- daily routine
- limit immobilization
- limit restraints
Approach to behavioural disturbances
- remove things that aggravate it
- treat medical/physical issues first (pain, hunger, thirst)
- Don’t argue
- reassure
- distract to something pleasant
Antipsychotics in delirium
- Haldol first line
- 0.5mg-1mg po/sc/iv q30 min until agitation settled
- maintenance dosing od to bid
- slowly taper over 5 days
Methotrimeprazine
- 6.25-12.5 mg sc q4h (max 100 mg/day)
Quetiapine
- 12.5-25 mg po or bid/tid
Olanzapine
- 2.5 mg bid
Risperdone
- 0.25-0.5 mg po bid
General side effects of most antipsychotics
- NMS
- Qtc prolongation
- >450 CAUTION
- > 25% increase in Qtc after starting–> stop
- EPS
- Black box warning on many
Extrapyramidal Symptoms
- Dystonia (abnormal spasms, muscle contractions)
- Akathisia (restlessness)
- Parkinsonism (rigidity, tremor, bradykinesia)
- Tardive dyskinesia (irregular, jerky movements)
Dopamine deficiency from dopamine antagonism from antipsychotics, anti-emetics, SSRIs.
Common medications that cause EPS
- Typical antipsychotics
- haldol
- chlorpromazine
- prochlorperazine
- Methotrimeprazine
- Atypical antipsychotics
- Risperdone - worst offender
- Quetiapine - low risk
- Olanzapine - low risk
- Anti emetics
- Metoclopramide
- Antidepressants:
- SSRIs
- SNRIS
- NDRIS
How to treat delirium in Lewy Body Dementia
- AVOID FIRST GEN ANTIPSYCHOTICS
- causes irreversible parkinsonism
- impaired consciousness
- death?
- If really needed, use atypicals cautiously
- Risperdone preferred
