Very helpful for all medical students and doctors. MBBS student, Resident doctor

1. DELIRIUM
DR VIREN SOLANKI
SECOND YEAR RESIDENT
PSYCHIATRY, BMC.

3. DELIRIUM
.

4. 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

5. 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.

6. 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

8. OTHER TERMS FOR DELIRIUM
• Intensive care unit psychosis
• Acute Brain failure
• Acute confusional state
• Toxic metabolic state
• Sun downing
• Central nervous system toxicity
• Encephalitis

9. 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%

12. 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

13. 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.

14. 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.

15. 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

16. NEUROTRANSMITTER IMBALANCE

17. 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 .

20. NEUROTRANSMITTER IMBALANCE
• DOPAMINE
- excess
- dopamine antagonist effective
• GLUTAMATE
- act on NMDA receptor , excess
- exito -toxicity
• GABA
- delirium secondary to alcohol & BZD withdrawal

21. 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.

22. HOW DOSE IT MANIFEST ?

23. HOW DOSE IT MANIFEST ?
• Inattention
• Disturbance of consciousness
• Disturbance of Orientation & memory
• Perceptual disturbance
• Fluctuation
• Disruption of sleep wakefulness
• Disorder of thought and language

24. INATTENTION
• Forgets instructions.
• Repeatedly asks the same questions.
• Gives different replies to same questions.
• Distraction to seeming irrelevant stimuli.

25. DISTURBANCE OF CONSCIOUSNESS
• Falling asleep during interview.
• Conflicting reports about awake mental state
of the patient provided by various caregivers.

26. 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

27. PERCEPTUAL DISTURBANCE
• Both hallucinations and illusion are seen.
• Visual hallucination more common , which
indicate organic etiology.
• Tactile and auditory hallucinations can be
seen.

28. DISORDERS OF THOUGHT
• Abnormalities in form and content of thinking
are prominent.
• Thinking may become bizarre or illogical.
• Delusion of persecution are common.

29. TYPES OF DELIRIUM

30. 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.

31. 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.

32. EXAMINATION IN THE PATIENT WITH
DELIRIUM
• Physical examination.
• Assess hydration , nutritional status.
• Evidence of sepsis.
• Consider differential diagnosis.
• Confirm the Diagnosis.
• Rate the severity of delirium.
• Rate the subtype of delirium.

33. 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
pressure
hypotension Shock , hypothyroidism , addison’s disease
hypertension Encephalopathy , intracranial mass
4 respiration tachypnea Diabetes ,metabolic acidosis , fever , cardiac
failure
shallow Alcohol or other substance intoxication

34. Cont….
parameter finding Clinical implication
5 neck Nuchal
rigidity
Meningitis , subarachnoid hemorrhage
6 eyes papiliede
ma
Tumor, hypertensive encephalopathy
Papillary
dilatation
Anxiety , autonomic over activity ( like delirium
tremens)
7 tongue laceration Evidence of GTCS
8 thyroid enlarge Hypothyroidism

36. HOW TO DIAGNOSE ?

51. 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.

52. 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.

53. 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.

54. BENZODIAZEPINES
• It may Increase agitation.
• Best reserve for Delirium secondary to
alcohol/Benzodiazepines withdrawal.
• Relatively contraindicated in delirium due to
organic etiology.

55. 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.

56. 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.

57. 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