presentation

1. Delirium 2.0
Diagnosis and Management
Dr. Drew Chenelly

2. What is Delirium?
A condition of severe confusion brought on
by a rapid change in brain function which is
reversible under most circumstances and is
usually caused by a treatable physical illness.
acute confusional state…metabolic encephalopathy…toxic psychosis

3. Who develops Delirium?
 33% of institutionalized elderly.
 60% of Pts. Admitted to a hospital from LTC.
 80% of individuals with terminal illness.
 Risk factors : 1) dementia 2) depression
3) cardiovascular disease 4) polypharmacy
5) sensory impairment 6) severe or numerous
chronic illnesses 7) immobility 8) malnutrition 9) ETOH
abuse 10) medical procedures and surgery.
The greater the age the greater the risk
 30% to 60% of cases go undiagnosed.

4. Delirium Signs and Symptoms1
 Sudden change in mental status.
 Fluctuating course, worse at night.
 Disordered attention and arousal.
 Gross disorientation.
 Visual illusions or hallucinations.
 Disrupted sleep-wake cycle.
 Emotional disturbance: lability, anger, fear, apprehension,
bewilderment, euphoria, tears, anxiety, apathy.

5. Delirium Signs and Symptoms2
 Delusions and bizarre behavior: disrobing in
public, urinating in inappropriate places, talking to
nonexistent people.
 Fragmented or disordered stream of thought:
incoherent, irrelevant, perseverative, rambling speech.
 Dazed facial expression.
 Motor signs are possible: tremor, myoclonus, ataxia.
 May use screening tools: DRS, CAM, NEECHAM…
see handouts
 Can be subtle…does not always present with agitation.

6. CAM Demonstration

7. Delirium Signs and Symptoms3
psychomotor subtypes:
 Hyperactive: (15%) loud, rambunctious,
disruptive.
 Hypoactive: (20%) quietly confused, may sit
without moving, eating or drinking.
 Mixed: (50%) features of both hyper & hypo.
 Normal consciousness: (15%) display all
features of delirium without an obvious
change in arousal.

9. Delirious Patients

10. Mechanisms of Delirium
 Impairment of the thalamus and reticular activating
system of the brain stem.
 Failure of cholinergic, dopaminergic and serotonergic
transmission.
 Neuronal membrane dysfunction.
 Widespread reduction of cerebral metabolism.
 EEG shows generalized slowing of cortical activity.

11. Delirium Causes1
Usually multifactoral and at times the cause cannot be determined.
METABOLIC (25%):
 Thiamine, B12, Folate
 Hyponatremia
 Hypernatremia
 Hyperkalemia
 Hypercalcemia
 Hyperglycemia
 Hypoglycemia
Thyroid Disorder
Adrenal Disorder
Renal Disorder
Hepatic Disorder
Hypoxia
Hypercapnia

12. Delirium Causes2
 Anticholinergics
 Anticonvulsants
 Antiparkinsons
 Sedative/hypnotics
 Corticosteroids
 Narcotics
 Antihypertensives
 Antiarrhythmics
 Psychotropics
 Antibiotics
 H2 blockers
 NSAIDs
 Digoxin
 Dilantin
 Sinemet
 Morphine
 Prednisone
 Valium
 Ciprofloxacin
 Elavil
 Cogentin
 Ranitidine
TOXIC: mostly drugs (20%) see handouts
solvents…insecticides…plants…heavy metals

13. Delirium Causes3
 Infection (30%): UTI, pneumonia, meningitis, encephalitis.
 Seizures
 Stroke
 CHF
 Head Trauma
 Tumor
 ETOH and drug abuse
 Sleep deprivation
 Cancer within the brain or paraneoplastic
 Serotonin Syndrome
 NMS
 SIADH
 MI
 COPD
 Change of environment

14. Finding The Cause
 History & Physical
 Review medications
 Check vital signs
 CBC
 Electrolytes
 Glucose
 BUN & Creatinine
 Liver function
 Thyroid function
 B12 & Folate
 Urinalysis
 Chest X-ray
 O2 saturation
Brain imaging, blood gases,
drug screens and other tests as
indicated See handouts

15. Pharmacological Interventions
antidopaminergicmost desirable
 Haloperidol 0.5mg IM up to 2mg per day.
 Risperidone 0.5mg PO bid up to 4mg qd.
 Zyprexa 5mg qhs PO up to 20mg qd.
 Seroquel 50mg bid PO up to 600mg qd.
Avoid benzodiazepines and sleeping medications

16. Environmental Interventions
 Keep exposure to stimulation to an absolute
minimum.
 Avoid the use of physical restraint.
 Allow physical activity whenever possible.
 Ask family members to increase visits sitting quietly
with resident.
 Create a soothing, familiar environment in room with
soft music and dim lighting.
 Frequent, brief, reassuring contacts by staff…move
and speak slowly.
 Encourage rest and attend to physical comfort.

17. Staff Response

18. General Considerations
 Average duration with treatment is one week but in the
frail elderly can take several weeks to resolve.
 Can delirium appear before any other signs of illness?
 Delirium = worse prognosis for underlying disease.
 Mortality rates for pts with delirium = 10% to 33%.
 Each episode may lead to decline in functional ability.
 Beware of the default dementia or psychiatric diagnoses.