DELIRIUM

DR VIREN SOLANKI
SECOND YEAR RESIDENT
PSYCHIATRY, BMC.
 DELIRIUM
.
 INTRODUCTION
• Delirium as defined by DSM-5 is characterized by an
ACUTE decline in both the level of awareness and
cognition with particular impairment in ATTENTION.
• Often involves perceptual disturbance, abnormal
psychomotor activity, sleep cycle impairment.
• Life threatning , medical emergency, high mortality
rate.
• Potentially reversible brain dysfunction
 INTRODUCTION
• Psychiatric manifestations are purely of
organic etiology.
• Most common consultation liation conditition.
• Often under- recognized.
• Often under- treated.
• Cause burden on health care system.
 BURDEN OF DELIRIUM
• Increased MORTALITY
• Increased length of care
• Increased nursing care
• Increased risk of cognitive & functional decline
• Prevention of early rehabilitation
• Increase distress to care givers
 OTHER TERMS FOR DELIRIUM
• Intensive care unit psychosis
• Acute Brain failure
• Acute confusional state
• Toxic metabolic state
• Sun downing
• Central nervous system toxicity
• Encephalitis
 HOW COMMON IT IS ?
POPULATION PREVALENCE RANGE (%)

Institutionalized elderly 44%

Orthopedic surgery patient 33%

Terminally ill cancer patient 23-28%

Cardiac surgery patient 16-34%

Critical care unit patient 16%

Emergrncy deoartment 7-10%

 PREDESPOSING FACTORS FOR
DELIRIUM
• Age 65 and older
• Male sex
• Dementia
• History of delirium
• Hearing & vision impairment
• History of fall
• Low level of activity
• Dehydration
• Alcohol abuse
• Co existing medical conditition
 PRECIPITATING FACTORS FOR
DELIRIUM
• DRUGS- sedative hypnotics , Narcotics ,
anticholinergic drugs, poly pharmacy,
Alcohol or drug withdrawal.
• PRIMARY NEUROLOGICAL DISEASES- stroke,
intracranial bleeding , meningitis or
encephalitis.
• INTERCURRENT ILLNESSES- infection , sepsis
dehydration, shock , hypoxia , poor nutritional
status , metabolic derangement.
 PRECIPITATING FACTORS FOR
DELIRIUM
• SURGERY- orthopedic surgery , Cardiac surgery
, prolong cardio pulmonary bypass.
• ENVIRONMENTAL - prolong sleep deprivation,
use of physical restraints , use of bladder
catheter , pain , emotional stress , use of
multiple procedures.
 WHY DOSE DELIRIUM OCCUR ?
• Pathophysiology is not clearly understood yet.
• Impaired oxygen supply associated with all
delirium.
• Common hypothesis to describe delirium:
1) Neurotransmitter imbalance hypothesis
2) Neuro-inflammatory hypothesis
3) Substance withdrawal induced delirium
NEUROTRANSMITTER IMBALANCE
NEUROTRANSMITTER IMBALANCE
• ACETYLCHOLINE DEFICIENCY
- core neurotransmitter involved in delirium.
- ACH is necessary for REM sleep, attention,
arousal, memory.
- loss of cholinergic neuron are strongly
associated with delirium.
- some clinical scenario .
NEUROTRANSMITTER IMBALANCE
• DOPAMINE
- excess
- dopamine antagonist effective
• GLUTAMATE
- act on NMDA receptor , excess
- exito -toxicity
• GABA
- delirium secondary to alcohol & BZD withdrawal
 NEUROINFLAMMATION HYPOTHESIS

• CYTOKINES:
- IL-1, IL-2, TNF and INTERFERON may
contribute to delirium.
- they may change permeability of blood –
brain barrier.
- cytokines interact with neurotransmitter
level.
HOW DOSE IT MANIFEST ?
 HOW DOSE IT MANIFEST ?
• Inattention
• Disturbance of consciousness
• Disturbance of Orientation & memory
• Perceptual disturbance
• Fluctuation
• Disruption of sleep wakefulness
• Disorder of thought and language
 INATTENTION
• Forgets instructions.
• Repeatedly asks the same questions.
• Gives different replies to same questions.
• Distraction to seeming irrelevant stimuli.
 DISTURBANCE OF CONSCIOUSNESS

• Falling asleep during interview.

• Conflicting reports about awake mental state
of the patient provided by various caregivers.
 DISORDERS OF ORIENTATION&MEMORY

• Not aware about time , place , person &self.

• Misidentified people around.
• Talking as if a home or workplace.
• Talking about dead relatives.
• Forgetting about meals, medicine , visitors ,
etc
 PERCEPTUAL DISTURBANCE
• Both hallucinations and illusion are seen.
• Visual hallucination more common , which
indicate organic etiology.
• Tactile and auditory hallucinations can be
seen.
 DISORDERS OF THOUGHT
• Abnormalities in form and content of thinking
are prominent.
• Thinking may become bizarre or illogical.
• Delusion of persecution are common.
TYPES OF DELIRIUM
 TYPES OF DELIRIUM
• HYPERACTIVE :
- increase psychomotor activity (agitation).
- easily recognized.
- common in drug intoxication and
withdrawal, with adverse effect of anti
cholinergic drugs.
- Hallucination and illusion present.
 TYPES OF DELIRIUM
• HYPOACTIVE DELIRIUM:
- Decrease psychomotor activity (retardation).
- More common than hyperactive delirium in
older patient.
- Often unrecognized.
- Metabolic causes are commonly associated.
• MIXED:
- Fluctuation between both.
 EXAMINATION IN THE PATIENT WITH
DELIRIUM
• Physical examination.
• Laboratory examination.
• Assess hydration , nutritional status.
• Evidence of sepsis.
• Consider differential diagnosis.
• Confirm the Diagnosis.
• Rate the severity of delirium.
• Rate the subtype of delirium.
 PHYSICAL EXAMINATION IN DELIRIUM
PATIENT
SR.NO parameter finding Clinical implication

1 pulse tachycardia Hyperthyroidism , infection , heart failure

bradycardia Hypothyroidism , increase ICP

2 temperature fever Sepsis , infections

3 Blood hypotension Shock , hypothyroidism , addison’s disease

pressure
hypertension Encephalopathy , intracranial mass

4 respiration tachypnea Diabetes ,metabolic acidosis , fever , cardiac

failure
shallow Alcohol or other substance intoxication
 Cont….
parameter finding Clinical implication

5 neck Nuchal Meningitis , subarachnoid hemorrhage

rigidity
6 eyes papiliede Tumor, hypertensive encephalopathy
ma
Papillary Anxiety , autonomic over activity ( like delirium
dilatation tremens)
7 tongue laceration Evidence of GTCS
8 thyroid enlarge Hypothyroidism
 LABORATORY AND STANDARD
STUDIED
• Complete blood count
• RFT , LFT including SGPT and SGOT
• Electrolyte (mainly Na and K )
• Urine examination ( routine and micro)
• Thyroid function test
• ECG
• CHEST X-RAY
 ADDITIONAL TEST WHEN INDICATED

• Blood , urine , and CSF cultures.

• Lumber puncture CSF examination.
• Computed tomography or magnetic resonance
imaging ( for hemorrhage or hematomas ).
 EEG IN THE DELIRIUM
• When diagnosis is in doubt , EEG may be
diagnostic.
• EEG has false-negative rate of 17 % and false-
positive rate of 22 %.
• EEG show diffuse slow voltage or low voltage
activities.
HOW TO DIAGNOSE ?
 MMSE & CLOCK DRAW
• Not designed for delirium.
• Useful from separating “normal” from
“abnormal”.
• Not specific for distinguishing delirium from
dementia.
• May be useful as change from baseline.
BEFORE GOING TO MANAGEMENT LETS
TAKE 2 MINUTE BREAK ……..
 PHARMECOLOGICAL TREATMENT
• Avoid unnecessary use of medicines.
• Only for few patient.
• Anti- psychotics (main stay of treatment).
- not recommended with hypoactive delirium.
• Benzodiazepine ( in alcohol withdrawal only).
• Acetyl cholinesterase inhibitor
(physiostigmine).
• Melatonin.
 TYPICAL ANTIPSYCHOTIC
• HALOPERIDOL:
- Try to only use for severe agitation.
- Lowest anticholinergic activity of all major
neuroleptics .
- High potency.
-Can be use IM/IV.
- 0.5-1 mg initial dose, can be given max 4 mg/day
gradually.
- Taper as soon as possible.
 ATYPICAL ANTIPSYCHOTICS
• All Antipsychotics should be given in low dose.
• Low dose Risperidone starting at .25 mg BID.
• Olanzapine 2.5 mg/d initial dose.
• Quetiapine 12.5 mg/g starting dose.
 BENZODIAZEPINES
• It may Increase agitation.
• Best reserve for Delirium secondary to
alcohol/Benzodiazepines withdrawal.
• Relatively contraindicated in delirium due to
organic etiology.
 ELECTROCONVULSIVE THERAPY
• ECT is also a treatment for delirium when
other approved option failed.
• Use for delirium patients with severe agitation
not respond to pharmacotherapy.
 TREATMENT OF SPECIFIC ETIOLOGIES OF
DELIRIUM
• ANTICHOLINERGIC INTOXICATION:
-Almost always result in delirium.
- cholinesterase inhibitor like physiostigmine is
effective.
• SUBSTANCE INTOXICATION:
- BZD - flumazenil
- opiate – naloxone, naltrexone.
 COURSE &PROGNOSIS
• Onset is usually sudden.
• Usually last less than a week.
• After removing etiological factor , delirium recede in 1 to
4 day .
• Although some symptoms may take up to 2 week to
resolve completely.
• Once it over patient referred it as bad dreams or
nightmares.
• May progress to dementia.
• In older person , it take longer time to resolve.
 HOW DO WE PREVENT IT ?
• Identify high risk patient
• Do cognitive assessment as routine
• Reduce bad bugs
• Maintain adequate analgesia
• Maintain oxygenation
• Try not to move pateints
• Use the same nurse if possible
• Familiar things – pictures from home , cloths