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Mind & Being Links
Delerium
- causes and risk factors
- signs, symptoms, and diagnosis
- pathophysiology
- treatments
- consequences and course
- the patient
- health care team
- community involvement
- resources and references
Delirium is a disturbance in consciousness, along with a change in cognition, due to a general medical condition.
Causes and Risk Factors
- infection and medications are most common
Medications:
- alcohol: intoxication, withdrawal, WK
- antidepressants: SSRIs, TCA
- anticholinergics: atropine, benztropine, scopolamine
- sedatives, narcotics, anesthetics, anticholinergics, anticonvulsants, dopinergic agents, steroids, insulin, glyburide,, NSAIDs
Infection:
- UTI, pneumonia
- encephalitis, meningitis
- abscess, sepsis
Organ failure
- shock
- congestive heart failure
- hepatic failure
- azotemia
- hypothyroidism
- hypoxia, hypercapnia
- hypertensive encephalopathy
- hypothermia
Acute metabolic disorder:
- ketoacidosis
- hypo, hyperglycemia
- hypomagnesemia
- hypercalcemia
- parathyroid
- adrenal
Other
- Withdrawal: alcohol, benzodiazepines
- Trauma: head injury, postoperative
- CNS pathology: stroke, hemorrhage, tumour, seizures, Parkinson's, vasculitis
- Hypoxia: anemia, cardiac failure, pulmonary embolus
- Deficiencies: vitamin B12, folic acid, thiamine
- Heavy metals: arsenic, lead, mercury
Risk factors for developng delirium include:
- hospitalization (incidence 10-40%)
- nursing home residents (incidence 60%)
- childhood (febrile illness)
- old age, especially in men
- severe illness: cancer, AIDS
- pre-existing cognitive impairment
- recent anesthesia
- substance abuse
Signs, Symptoms, and Diagnosis
Disturbance in consciousness can include reduced clarity of awareness of the environment, with reduced ability to focus, sustain, or shift attention. These disturbances develop over a short time (usually hours to days) and tend to fluctuate over the course of a day. This is in contrast to dementia, which shows an irreversible decline over time.
Upon history, physical exam, or lab findings, direct physiological causes can be found.
- Tab 1
- Tab 2
- Lab investigations
- diagnostic imaging
Mental Status Assessment
Change in cognition can involve a memory deficit, disorientation, or language disturbance. Perceptual disturbances, such as illusions or hallucinations, can also occur. Agitation is unfortunately quite common.
Common symptoms include:
- wandering attention
- distractibility
- disorientation (usually time and place)
- misinterpretations, illusions, hallucinations
- speech/language disturbances (dysarthria, dysnomia, dysgraphia)
- affective symptoms: anxiety, fear, depression, irritability, anger, euphoria, apathy
- shifts in psychomotor activity: groping, picking at clothes, attempts to get out of bed when unsafe, sudden movements, sluggishness, lethargy
Lab Investigations
- CBC + diff
- electrolytes
- calcium (hypercalcemia)
- phosphate
- magnesium
- glucose
- ESR
- liver enzymes
- RFTs
- TSH
- vitamin B12, folate, thiamine
- albumin
- urine C&S, R&M
as indicated:
- toxicology/heavy metal screen
- VDRL, HIV, blood cultures
diagnostic imaging
As indicated:
- ECG
- CXR
- CT head
Do imaging if there is a focal neurological deficit, acute change in status, anticoagulant use, acute incontinence, gait abnormality, or history of cancer.
Pathophysiology
Treatments
Identify and treat underlying cause immediately. Stop all non-essential medications, and maintain nutrition, hydration, and electrolyte balance.
Good sleep is important; attempt without medicine if possible.
The environment should be quiet and well-lit.
Optimize communication; make sure patients have their glasses and hearing aids.
Have family members present for reassurance, touch, and re-orientation.
A calendar and clock can help with orientation.
Keep people stimulated; curent events, word games, etc
early mobiliation
symptomatic: neuroleptics (NOT benzodiazepines)
- use when patient is agitated, combative, and can't be consoled
- are not needed with hypoactive delerium
haldol (0.5-1.0 mg BID/TID)
- excess sedation
- QT prolongation
- extrapyramidal symptoms
- avoid in if Parkinson's disease and alcohol withdrawal (decreased seizure threshold)
atypical antipsychotics (if used carefully); use as little as possible
Consequences and Course
2x mortality, 7x if not detected (Siddiqi, 2006)
Up to 50% mortality rate one year after an episode of delirium.
Up to 76% mortality rates in hospitalized pts
The Patient
Health Care Team
Community Involvement
References
Siddiqui. 2006 Age Aging
Inouye 2006. NEJM. 354:1157-65.
Preventing Delerium (NEJM, 1999)