10-29-07 Delirium
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Delirium
Evaluation of Delirium
• Mental Status Exam – will show changes in consciousness, orientation, attention, mood & affect
• Neurologic Exam – assess medications & time of onset of delirium, also neuron physical
• Labs – blood chemistries (hypoglycemic?), blood count (infection?), drug levels, ABG, urinalysis, CXR
• Follow-up Labs – electroencephalogram (seizures?), CT scan, lumbar puncture
Epidemiology of Delirium
• Hospitalized Patients – occurs in 10-30% of all hospitalized medical/surgical patients!
• High-Risk Pop – include elderly, post-heart surgery, burn, prior psychiatric, drug withdrawal, AIDS
Delirium
• Delirium – “acute brain failure”, transient, reversible cerebral dysfunction, acute onset, very fluctuating
• Clinical Features – prodromal, fluctuation, inattentive, sleep/wake, memory, orientation, perception, phys:
o Prodromal symptoms – restless, anxious, irritable
o Fluctuating Course – changes can occur on the order of minutes
o Neurologic – motor abnormalities, altered EEG findings – fast low voltage activity
o Attention Deficit – can’t pay attention or focus
o Altered Arousal – hyperactive/hypoactive, constantly changing
o Sleep-wake Disturbance – circadian rhythm altered
o Impaired Memory – immediate & recent memory often lost
o Cognitive & Speech – can be disorganized & impaired
o Orientation – unaware of person, place, time
o Perceptions – can have delusions (fixed false belief), visual hallucination, auditory/tactile illusion
o Emotional – anxiety, panic, fear, anger, sadness, depression, apathy, euphoria (steroid)
Delirium Diff. Dx, vs. Dementia
• Differential Diagnosis – includes delirum, psychosis, and dementia
o Psychosis (schizophrenia, mania) – will not fluctuate, have normal EEG, no 1st pres. elderly
o Dementia – more gradual & stable than delirium
• Delirum vs. Dementia – differ in many ways:
o Onset/Duration – delirium more acute; dementia chronic
o Course – delirium more fluctuating; dementia stable
o Alertness – delirium has wider range; dementia has normal alertness
o Attention – delirium easily distracted, dementia has normal attention
o Orientation – both impaired
o Memory – delirium has short-term memory loss; dementia has global memory loss
o Thought – delirium affects thought process (disorganized); dementia affects content (poverty)
o Perception – delirium has many illusions/hallucinations, dementia rarely has perceptual problems
Causes of Delirum
• Unknown Cause – pathophysiology of delirum is largely unclear
• Wide Range – a wide range of factors can contribute to the onset of delirium
• Cholinergic Deficit – best hypothesis ( patients with delirium anxiety often have anticholinergic activity
o Anticholinergics – antihistamines, tricyclic antidepressants
o Cardiac – anti-arrhythmia drugs can cause
• Hypoxia/Hypoglycemia – other possible causes
• Course – recovery/progression ( dementia ( death or chronic delirious state
• Morbidity and mortality – high rates of complications even vs dementia
Delirium Treatment
• Treat Underlying Cause – usually a dangerous underlying cause of delirium (sepsis, drug withdrawal)
• Safety – danger of patient hurting oneself/others ( get sitters, restraints
• Monitoring – keep close watch on vital signs, labs
• Meds – minimize all medications given (many psychoactive, e.g. pain meds), manage w/ benzodiazepines
• Social Support – comfort patient & family, assure that disease is reversible
• Environmental – have well-lit facilities with windows, helps orient patient
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