Delirium

Amer Rawajfeh. MD. JB.Psych

Pyschiatrist
National Center for Mental Health
Ministry of Health
 Delirium
• Delirium is defined by the acute onset of
fluctuating cognitive impairment and a
disturbance of consciousness. Delirium is a
syndrome, not a disease.
• Delirium has a sudden onset (hours or days),
a brief and fluctuating course, and rapid
improvement when the causative factor is
identified and eliminated.
 Delirium
• Delirium is underrecognized by health care
workers.
• Physicians must recognize delirium to identify
and treat the underlying cause and to avert
the development of delirium-related
complications such as accidental injury
because of the patient's clouded
consciousness.
 Delirium by Other Names
Intensive care unit psychosis
Acute confusional state
Acute brain failure
Encephalitis
Encephalopathy
Toxic metabolic state
Central nervous system toxicity
Sundowning
Cerebral insufficiency
Organic brain syndrome
 Delirium
Delirium is characterized by an acute decline in
both the level of consciousness and cognition
with particular impairment in attention that
develop over a short time. A life threatening,
yet potentially reversible disorder of the
central nervous system (CNS),delirium often
involves perceptual disturbances,
Abnormalities of mood, behavior and
psychomotor activity, and sleep cycle
impairment.
• clinical features are often present and may be
prominent. They can include disorganization of thought
processes (ranging from mild tangentiality to frank
incoherence), perceptual disturbances such as illusions
and hallucinations, psychomotor hyperactivity and
hypoactivity, disruption of the sleep wake cycle (often
manifested as fragmented sleep at night, with or
without daytime drowsiness), mood alterations (from
subtle irritability to obvious dysphoria, anxiety, or even
euphoria), and other manifestations of altered
neurological function (autonomic hyperactivity or
instability, and dysarthria).
 Epidemiology
• Delirium is a common disorder, with most incidence
and prevalence rates reported in elderly adults.
• prevalence :0.4 percent for people 18 years of age and
older, and 1 % of elderly persons age 55 years or older
,(13 % in the age 85 years and older group in the
community).
• Among elderly emergency department patients, 5 to
10 percent have been reported to have delirium. At
the time of admission to medical wards, between 15
and 21 % of older patients meet criteria for delirium.
 Epidemiology

• Most Common in:

• Elderly patients
• ICU patients 70%-87%
• Cardiac surgery inpetant 16%-34%
• Post-OP surgery patients 10%-15%
• Terminally ill Cancer patients 23%-
28%
 Risk factors:
• Advanced age.
• polypharmacy
• Preexisting cognitive impairment or depression.
• history of delirium.
• Alcohol use.
• Severe or terminal illness.
• Impaired mobility.
• Hearing or vision impairment.
• Malnutrition.
• Male gender.
 Causes:
• According to DSM-5 we have five categories:
• Substance intoxication delirium
(alcohol,cocaine,narcotics,digoxin,h2-blocker)
• Substance withdrawal delirium
(alcohol , BZD)
• Medication-induced delirium
(Anticholinergic, steroids ,TCA, BZD)
• Delirium due to another medical condition
• (CVA, mass lesion, infections, metabolic
causes)
• Delirium due to multiple etiologies
 Types of delirium:
• There are three types of delirium based on psychomotor activity:
1. Mixed type:
.Psychomotor activity may remain stable at baseline or fluctuate
rapidly
between hyperactivity and hypoactivity.
. Most common type.
2. Hypoactive (“quiet”) type:
.Decreased psychomotor activity, ranging from drowsiness to lethargy
to stupor.
. More likely to go undetected.
. More common in the elderly.
3. Hyperactive type (“ICU psychosis”):
. Manifests with agitation, mood lability, and uncooperativeness.
. Less common, but more easily identified due to its disruptiveness
. More common in drug withdrawal or toxicity
 Diagnosis
DSM-5 Criteria for Delirium
1. Disturbance in attention and awareness.
2. Disturbance in an additional cognitive domain.
3. Develops acutely over hours to days, represents
a change from baseline, and tends to fluctuate.
4. Not better accounted for by another
neurocognitive disorder.
5. Not occurring during a coma.
6. Evidence from history, physical, or labs that the
disturbance is a direct consequence of another
medical condition, substance
intoxication/withdrawal,exposure to toxin
• Once delirium is diagnosed , blood glucose, pulse-
oximetry, ABGs, and ECG are done at bedside.
• Labs obtained in delirium workup include, CBC
with differential, urinalysis, and urine culture.
• Urine drug screen, a blood alcohol level,
therapeutic drug levels (e.g., antiepileptics,
digoxin, lithium), a hepatic panel, thyroid
hormone levels, or a chest x-ray may also be
needed depending on the clinical presentation.
• Head imaging (head CT or MRI brain), EEG, and
lumbar puncture should be performed if focal
neurological deficits are present or a cause of
delirium cannot be identified with the initial
workup.
 Treatment
• Identify and treat the underlying cause
• Maintain nutrition ,hydration ,electrolyte
balance, and monitor vitals
• D2 antagonists (Haloperidol is the
preferred agent) are indicated for
treatment of agitation
• Benzodiazepine are avoided unless
treating delirium due to alcohol or
benzodiazepine withdrawal
Thank you