This document provides an overview of delirium. It begins by outlining what topics will be covered, including the definition of delirium, differential diagnosis, prevention, diagnosis/assessment, and treatment. Delirium is defined as an acute confusional state involving cognitive and circadian impairments. Risk factors are discussed, as well as how delirium is preventable using a multicomponent strategy targeting risk factors. Diagnosis involves a mental status exam and scales. Treatment focuses on supporting the patient, managing the environment, treating the underlying cause, and occasionally using antipsychotics or benzodiazepines. Outcomes include full recovery in 40% of cases and permanent cognitive impairment or mortality in the remaining cases.

1. DELIRIUM

2. WHAT IS IN THIS PRESENTATION:
 Why do we need to know about delirium?
 What is delirium?
 D/D with respect to psychiatry
 How to prevent delirium?
 Diagnosis and assessment
 Treatment

3. WHY DO WE NEED TO KNOW ABOUT
DELIRIUM?

4. WHY DO WE NEED TO KNOW ABOUT DELIRIUM?
 Delirium is common
 Delirium is associated with increased complications
 Delirium is often unrecognized
 Delirium is preventable

5. WHAT IS DELIRIUM?

6. WHAT IS DELIRIUM?
• Acute confusional state
• Constellation of symptoms
• Widespread disruption of higher cortical function
• Acute onset and fluctuating course
• Three core domains:
- cognitive with disproportionate impairment of attention
- circadian disturbance (sleep wake cycle, motor alterations)
- disturbances of higher level of thinking(comprehension, language,
thinking process)

7. CORE FEATURES & ASSOCIATED FEATURES
Core features:
• Features that are almost invariably present
• Disturbances of - attention
- memory
- orientation
- language
- thought process
- sleep-wake cycle
Meagher et al 2007 BJP

8. CORE FEATURES & ASSOCIATED FEATURES
Associated features:
• Features that are more variable in presentation
• Psychotic symptoms
• Affective disturbances
• Different motoric profiles
Meagher et al 2007 BJP

9. IMPAIRMENT OF CONSCIOUSNESS
 Universal, fluctuating
 Barely perceptible dulling of awareness to profound coma
 Worsen at night, with fatigue, decreased environmental stimuli
 Failure to be selective -----------distractible
 Failure to mobilize & sustain attention -------impaired attention
 Inability to shift attention------------perseveration
 Minor degree---vague malaise, feelings of uncertainity, difficulties in
judging passage of time, focusing attention, neglect of appearance,
episode of incontinence
 Severe degree----too slow in responding, loses thread in conversation,
attention to outside events hard to arouse and sustain, drowsy

10. RECENT WORKS
• Disorder of global cognition
• Prominent disturbance of attention
• Disorientation is least frequent core symptom
• Cognition & language are not as fluctuant as previously
described
• Subsyndromal , resolving , persisting delirium
Meagher et al BJP 2012 & BJP 2007

11. PREDISPOSING OR VULNERABILITY FACTORS
Demographics
Older age
Male gender
Cognitive status
Dementia
Cognitive impairment
History of delirium
Depression
Functional status
Functional dependence
Immobility
Poor activity level
History of falls
Sensory impairment
Vision impairment
Hearing impairment
Decreased Intake
Dehydration
Malnutrition
Drugs
Multiple psychoactive drugs
High number of drugs
Alcohol abuse
Medical Comorbidity
High severity of illness
High level of comorbidity
Chronic renal or hepatic disease
Previous stroke
Neurologic disease
Metabolic derangements
Fracture or trauma
Terminal illness
HIV infection
Inouye SK. NEJM 2006;354:1157-65

12. PRECIPITATING FACTORS OR INSULTS
Drugs
Sedative hypnotics
Narcotics
Anticholinergic drugs
Polypharmacy
Alcohol or drug withdrawal
Primary neurological diseases
Stroke, particularly nondominant hemispheric
Intracranial bleed
Meningitis/encephalitis
Environmental
Intensive care unit admission
Physical restraint use
Bladder catheter use
High number of procedures
Pain
Emotional stress
Prolonged sleep deprivation
Intercurrent illnesses
Infections
Iatrogenic complications
Severe acute illness
Hypoxia
Shock
Fever/hypothermia
Anemia
Dehydration
Poor nutritional status
Low serum albumin
Metabolic derangements (e.g., electrolytes,
glucose, acid-base)
Surgery
Orthopedic surgery
Cardiac surgery
Duration of cardiopulmonary bypass
Non-cardiac surgery
Inouye SK. NEJM 2006;354:1157-65

13. Risk Factors
Predisposing
Precipitating
Comorbidities
·Diabetes
·MI
·Etc…
Perioperative
Drugs
·Anesthetics
· Opioids
· Benzodiazepines
·Etc…

14. URGENT RECOGNITION:
 Wernicke’s
 Hypoxia
 Hypoglycemia
 Hypertensive encephalopathy
 Intracerebral hemorrhage
 Meningitis/encephalitis
 Poisoning/medications

15. ETIOLOGIES -“ I WATCH DEATH “
• I = Infection
• W = Withdrawal
• A = Acute Metabolic
• T = Trauma
• C = CNS Pathology
• H = Hypoxia
• D = Deficiencies
(especially vitamin)
• E = Endocrinopathies
• A = Acute Vascular
• T = Toxins
• H = Heavy metals

16. Flacker JM. J Gerontol Biol Sci 1999;54:B239-46

17. DIFFERENTIAL DIAGNOSIS IN
PSYCHIATRY

18. DIFF DELIRIUM & PSYCHIATRIC DISORDER
• Clouded consciousness or decreased level of alertness
• Disorientation
• Acuity of onset and course- serial mental status exams can
help demonstrate this
• Age >40 without prior psych history
• Presence of risk factors for delirium, recent medical illness or
treatment

19. DELIRIUM V/S SCHIZOPHRENIA
• Onset of schizophrenia is rarely after 50.
• Auditory hallucinations are much more common than visual
hallucinations
• Memory is grossly intact and disorientation is rare
• Speech is not dysarthric
• No wide fluctuations over the course of a day
• Thought content and abnormal perceptions are related
• In delirium, thought and perception are influenced by
immediate environment

20. MOOD DISORDER V/S DELIRIUM
• Mood disorders manifest persistent rather than labile mood
with more gradual onset
• In mania the patient can be very agitated however cognitive
performance is not usually as impaired
• Flight of ideas usually have some thread of coherence unlike
simple distractibility
• Disorientation is unusual in mania

21. DELIRIUM V/S DEMENTIA
Delirium Dementia
Impaired memory +++ +++
Impaired thinking +++ +++
Clouding of consciousness +++ -
Major attention deficit +++ +
Fluctuation of course/day +++ +
Disorientation +++ ++
Vivid perceptual dbn ++ +
Incoherent speech ++ +
Disrupt sleep/wake cycle ++ +
Nocturnal exacerbation ++ +
Acute/subacute onset ++ -
Impaired judgement ++ +++

22. DELIRIUM IS PREVENTABLE

23. PREVENTING DELIRIUM
• Yale delirium prevention trial
• Designed to counteract iatrogenic influences leading to
delirium in the hospital
• Multicomponent intervention strategy targeted at 6 delirium
risk factors

24. SIGNIFICANCE OF DELIRIUM PREVENTION TRIAL
• First demonstration of delirium as a preventable medical
condition
• Targeted multicomponent strategy works
• Significant reduction in risk of delirium and total delirium days,
without significant effect on delirium severity or recurrence
• Primary prevention of delirium likely to be most effective
treatment strategy
• Effectiveness and cost-effectiveness of the program has been
demonstrated in multiple studies

25. YALE DELIRIUM PREVENTION PROGRAM
• Cognitive impairment
• Sleep deprivation
• Immobilization
• Vision impairment
• Hearing impairment
• Dehydration
• Reality orientation
• Sleep enhancement
protocol
• Early mobilization
• Vision aids, adaptive eqp.
• Amplifying devices,
adaptive eqp
• Early recognition & Rx
Risk factor Intervention

26. DIAGNOSIS AND ASSESSMENT

27. DIAGNOSIS AND ASSESSMENT
• Delirium is a clinical diagnosis
• History and physical examination
• Mental Status Exam
• Rating Scales-consider on admission

28. ASSESSMENT INSTRUMENTS
To identify delirium:
• Delirium rating scale – revised 98 ( DRS – R98)
• Confusion assessment method (CAM)
• Delirium symptom interview (DSI)
• Confusion assessment method for ICU (CAM-ICU)
• Intensive care delirium screening checklist (ICDSC)
To assess symptom severity:
• Delirium detection scale (DDS)
• Memorial delirium assessment scale (MDAS)
To test neuropsychological function:
• Cognitive test for delirium (CTD)

29. DIAGNOSIS AND ASSESSMENT
 Lab tests cannot diagnose delirium but may support
dx
 CBC, CMP, UA, urine tox, TSH, B12, ammonia
 CXR, EKG, LP if indicated
 Neuroimaging
 EEG
 Generalized slowing in delirium, nonspecific
 Triphasic waves in hepatic encephalopathy
 Low voltage fast activity in EtOH or BZD w/d

30. TREATMENT

31. TREATING PATIENTS WITH DELIRIUM
Treat underlying causes
 Don’t stop looking after finding one potential cause
• Anticipate in high risk states
• Diagnosis & treatment should occur concurrently
• Regular evaluation of progress is important
• Best managed in hospital setting

32. TREATING PATIENTS WITH DELIRIUM
• Supportive and environmental measures
- support and orientation
- unambiguous environment
- maintaining competence
• Drug treatment
- antipsychotics
- benzodiazepines
- emerging therapies
• Managing patients after discharge

33. PROVIDING SUPPORT AND ORIENTATION
 Communicate clearly and concisely; give repeated verbal
reminders of the day, time, location, and identity of key
individuals, such as members of the treatment team and
relatives
 Provide clear signposts to patient's location including a clock,
calendar, chart with the day's schedule
 Have familiar objects
 consistency in staff
 Use television or radio for relaxation and to help the patient
maintain contact with the outside world
 Involve family and caregivers to encourage feelings of security
and orientation

34. PROVIDING AN UNAMBIGUOUS ENVIRONMENT
 Simplify care area by removing unnecessary objects; allow
adequate space
 between beds
 Consider using single rooms to aid rest and avoid extremes of
sensory experience
 Avoid using medical jargon in patient's presence because it
may encourage paranoia
 Ensure that lighting is adequate; provide a 4060 W night light
to reduce misperceptions
 Control sources of excess noise (such as staff, equipment,
visitors); aim for < 45 decibels in the day and < 20 decibels at
night
 Keep room temperature between 21.1°C to 23.8°C

35. MAINTAINING COMPETENCE
 Identify and correct sensory impairments
 Encourage self care and participation in treatment
 Treatments to allow maximum periods of uninterrupted sleep
 Maintain activity levels:
-ambulatory patients should walk three times each day;
-nonambulatory patients should undergo a full range of
movements for 15 minutes three times each day

36. DRUG TREATMENT
• Benefits v/s adverse effects
• Use of psychotropic drugs:
- complicates ongoing assesment of MSE
- impair patient’s ability to understand or co-operate
- greater incidence of falls
• Prescribing often influenced by:
- pressure from relatives
- time constraints
-diff in coomunication between medical & nursing staff

37. ANTIPSYCHOTICS
• Hyperactive and hypoactive delirium
• Improve cognition
• Rapid onset
• Improvement evident in hours or days
• Superior to benzodiazepines

38. ANTIPSYCHOTICS
• Chlorpromazine , Haloperidol, Droperidol – similar efficacy
• Atypicals – further research needed
• Haloperidol is preferred:
- fewer active metabolites
- limited anticholinergic side effects
- less sedative & hypotensive effects
- administered by different routes
- EPS *reported incidence is low
*iv administration – EPS less likely

39. BENZODIAZEPINES
• Can protect or pose risk
• Delirium associated with seizure, withdrawal from alcohol or
sedatives
• Adjunct if antipsychotics are not tolerated
• Lorazepam is preferred
- rapid onset
- short duration of action
- low risk of accumulation
- no major active metabolites
- predictable bioavailability if given i.m.

40. EMERGING THERAPIES
• Physostigmine – anticholinergic delirium
(hypoxia, hypoglycaemia, drug related, trauma)
• Nicotine replacement treatment – protective?
• Pimozide –potent calcium antagonist
- delirium ass with hypercalcemia
• Trazadone & Mianserin ( 5HT 2 antagonist)
• Light therapy

41. OUTCOME OF DELIRIUM
40%
25%
35%
Recovery Permanent Cognitive Impairment Mortality

42. MANAGING AFTER DISCHARGE
• Many patients dicharged before full resolution
• Delirium may persists for weeks or even months
• Risk of new diagnosis of dementia increased at least threefold
• Problems in attention may persist
• Prevent further episodes
- address risk factors
- correct sensory impairments
• Look for psychological sequalae
- depression
- PTSD
• Follow up - must

43. THANK YOU
“Knowing is not enough;
we must apply.
Willing is not enough;
we must do.”
- Goethe