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DELIRIUM
Prepared By-Dr Jag Mohan Prajapati(M.D.)
Senior Resident
Department of Psychiatry, ABVGMC,
Vidisha
DEFINITION
• Acute decline in level of consciousness with
particular impairment in attention.(Ref-Kaplan)
• Life threatening, yet potentially reversible
disorder.
• The term delirium derives itself from the Latin
word delirare, which means to deviate and was
originally described by Celcius.
• Commonest organic mental disorder.
• Coded as F05 in ICD10 and 6D70 in ICD11.
OTHER NAMES OF DELIRIUM
• Acute confusional state.
• Acute brain failure.
• ICU psychosis.
• Organic psychosis.
• Organic brain syndrome.
• Cerebral insufficiency.
EPIDEMIOLOGY
• 1% in >55 years.
• 13% in >85 years.
• 80% of all terminally ill.
• 10% of general hospital population..
• Institutionalized elderly>ICU>Post op
PATHOPHYSIOLOGY
• Neuroanatomical area involved-dorsal
tegmental pathway(regulates attention and
arousal)
• Decreased acetyl choline/ loss of cholinergic
neurons.
PREDISPOSING FACTORS
BRAIN DAMAGE
(E.G.
DEMENTIA)
EXTREMES OF
AGE
CHRONIC
MEDICAL
ILLNESSES
DRUG
DEPENDENCE
ON
PSYCHOTROPIC
DRUGS
GENERALIZED
OR FOCAL
CEREBRAL
LESION
PAST HISTORY
OF DELIRIUM
PRECIPITATING FACTORS
INFECTION MALNUTRITION
DEHYDRATION
(ELECTROLYTE
DISTURBANCES)
SURGERY HEAD INJURY DRUGS
CHANGE IN
ENVIRONMENT
(ICU ,
RESTRAINTS).
CAUSES OF DELIRIUM
MEDICAL
ACUTE INFECTIONS(e.g. Septicemia, Pneumonia etc.)
METABOLIC(Hepatic Encephalopathy, uremic encephalopathy, Hypoxia, Cardiac
Failure, Cardiac arrest, Hypoglycemia)
Endocrine (Hypo and hyperthyroidism, hypo and hyperparathyroidism, Hypo and
Hyper pituitarism)
Electrolyte disturbances (Hyponatremia)
SURGICAL
HEAD INJURY,
POLYTRAUMA,
ICU,
POST OP RECOVERY.
NUTRITIONAL DEFICIENCY
THIAMINE,
NIACIN
DRUGS
INTOXICATION,
WITHDRAWAL(ALCOHOL,SEDATIVE).
ANTICHOLINERGICS(ATROPINE,DHATURA).
TCA,ANTIPARKINSONS.
CLINICAL FEATURES
1 IMPAIRMENT IN CONSCIOUSNESS(HALLMARK)
-DISORIENTATION TO T/P/P (ALTERED SENSORIUM)
-CLOUDING OF CONSCIOUSNESS
-ACUTE ONSENT
-FLUCTUATING COURSE
-MORE WORSE IN EVENING
2 ATTENTION IMPAIRMENT
-REDUCED ABILITY TO FOCUS,SUSTAIN,SHIFT ATTENTION.
3 MEMORY
-IMMEDIATE AND RECENT MEMORY ABSENT
-REMOTE MEMORY PRESENT
-NEW LEARNING ABSENT
4 PSYCHOMOTOR ACTIVITY: CAN BE HYPERACTIVE OR
HYPOACTIVE
-INCREASED REACTION TIME
-FLOW OF SPEECH CAN BE INCREASED OR DECREASED
-ENHANCED STARTLE REACTION
5 THINKING AND REASONING
-THOUGHT PROCESS IS DISORGANIZED
-MILD TANGENTIALITY TO FRANK INCOHERENCE
-FLEETING (NOT FIXED) PARANOID DELUSIONS
6 PERCEPTION
-TRANSIENT VISUAL HALLUCINATIONS
-TACTILE HALLUCINATION IN ALTERED SENSORIUM
7 EMOTIONS
-IRRITABILITY,DYSPHORIA,EUPHORIA,APATHY,LABILITY
8 OTHERS
-ALTERATION IN SLEEP WAKE CYCLE(CIRCADIAN RHYTHM
DISTURBANCES)
-AUTONOMIC HYPERACTIVITY(TACHYCARDIA, INCREASED BP)
9 MOTOR SYMPTOMS
-ASTERIXIS(FLAPPING TREMORS)
-TONE AND REFLEX ABNORMALITY
-TREMORS
-CORPHOLOGIA/FLOCILLATION(PICKING BEHAVIOUR)
-OCCUPATIONAL DELIRIUM-BEHAVIOUR AS IF IN THEIR WORKPLACE
WHILE BEING IN THE HOSPITAL BED.
10 OTHER NEUROLOGICAL SYMPTOMS
-NYSTAGMUS,INCOORDINATION,URINARY INCONTINENCE.
PREVENTION OF DELIRIUM
Identification of high risk patients.
Close monitoring for early signs of delirium is warranted among patients who are
at high risk.
Constipation, dehydration and polypharmacy need to be avoided.
Adequate lighting, ventilation and clear communication can help prevent delirium.
Donepezil,melatonin and a melatonin receptor agonist ramelteon has been tried in
the prevention of post-operative delirium with varying results.
Benzodiazepines are better avoided or used with caution, if there is a risk for
delirium, except in cases of alcohol withdrawal.
There exists some evidence to suggest prophylactic use of haloperidol.
Multifactorial intervention programmes like HELP or Hospital Elder Life
Programme includes frequent reorientation, reduced use of psychotropic
drugs, early mobilization, proper nutrition and hydration, sleep rhythm
maintenance and provisions for vision and hearing adaptation.
MANAGEMENT OF DELIRIUM
IDENTIIFY THE CAUSE
HISTORY AND EXAMINATION,DRUG
REVIEW,INVESTIGATIONS
NON
PHARMACOLOGICAL
MANAGEMENT
ARRANGE-APPROPRIATE LIGHTING,FREQUENT
REORIENTATION,FREQUENT VISITS BY CLOSE
FRIENDS AND RELATIVES
MANAGE-
DEHYDRATION,CONSTIPATION,IMMOBILITY,PAI
N,MALNUTRITION,INSOMNIA
AVOID- ANTICHOLINERGIC
MEDICATIONS,SENSORY DEPRIVATION
PHARMACOLOGICAL
MANAGEMENT
ANTIPSYCHOTICS-HALOPERIDOL(1ST
CHOICE),QUETIAPINE
Investigations are needed to find out the causes of delirium.
CBC, electrolytes, urine routine, liver function, renal function, thyroid function are indicated in all
patients with delirium.
Neuroimaging may also be indicated.
EEG in delirium shows generalized slowing of background rhythm, except in delirium tremens.
Some sources claim that EEG in delirium tremens may show fast activity.
The degree of generalized slowing may correlate with the degree of delirium. However ,EEG
findings are often clouded by the effect of prescribed drugs including benzodiazepines.
Treatment should include both symptomatic and cause target approach.
Pharmacological and non Pharmacological methods can be used.
Correction of underlying cause is very important.
Physical support to prevent accidents, moderately lit room, and frequent orientation to time ,place
,a friend or relative in room are all useful.
One on one nursing care may be required in severe cases.
Pharmacotherapy for psychotic symptoms and insomnia, like haloperidol i.m. or droperidol i.v.
along with lorazepam can be given.
It is better to avoid long acting benzodiazepines unless the underlying cause warrants it, like
alcohol.
Delirium generally resolves within a week of treating the cause, and maximum duration as per
ICD10 is 6months.without treatment ,however progression to stupor, coma or death can occur.
Lethal condition with up to 10% mortality rates.
CONFUSION ASSESSMENT METHOD(CAM)
FEATURE 1 ACUTE ONSET OR
FLUCTUATING COURSE
FEATURE 2 INATTENTION
FEATURE 3 DISORGANIZED
THINKING
FEATURE 4 ALTERED LEVEL OF
CONSCIOUSNESS
Diagnosis of delirium by CAM requires the presence
of features 1 & 2 and either 3 or 4
PERSISTENT DELIRIUM
Though classically considered a transient or episodic condition, delirium may
be persistent in some cases at least.
PerD or persistent delirium is a term used to describe those patients meeting
the criterion of delirium even after twelve months of duration.
Those with non-progressive delirium meeting some but not all criterion of
delirium is called subsyndromal delirium.
EXCITED DELIRIUM AND BELLS MANIA
Excited delirium is a type of agitated delirium in which the person may
exhibit superhuman like powers.
In
addition,agitation,restlessness,anxiety,hallucinations,tachycardia,diaphoresis
and bizarre behaviour are also noted, making the overall presentation similar
to delirium tremens.
It often occurs with substance abuse like that of cocaine.
Bells mania was a term originally used by Luther Bell to describe a condition
similar to excited delirium.
ENCEPHALOPATHY
It is a loosely defined term, often used interchangeably with delirium.
There does not exist any consensus regarding the definition of
encephalopathy.
It can be used to denote either a disease or a clinical finding.
In practice, the term encephalopathy is used to denote any condition that
affects the functioning of brain.
Many times, the underlying cause is used as a preceding term while describing
encephalopathy.
Hence, hepatic encephalopathy is a term used to denote encephalopathy
secondary to liver dysfunction.
Other common causes include hypoxia,hypertension,uraemia,HIV, wernicke’s,
septic, traumatic and toxic.
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
DELIRIUM BY DR JAGMOHAN PRAJAPATI.......
HYPOACTIVE DELIRIUM
Delirium can present either as hyperactive delirium and hypoactive
delirium. In hyperactive delirium the patient is generally aroused,
hyper vigilant, agitated, aggressive, and may experience
hallucinations and delusions. This hyperactive form is the typical and
expected form of presentation of delirium. Hypoactive delirium, on
the other hand, presents with decreased reactivity, motor and speech
retardation, and facial inexpression.
Hyperactivity and hypo activity can co-exist, and is termed mixed
delirium.
Hypoactive delirium is often under diagnosed, and is associated with a poor
outcome, than hyperactive variant.
It also has the potential to be misdiagnosed as depression.
There are studies that suggest that up to 50% of all delirium cases are
hypoactive.
Depressive disorder and dementia are important differentials to hypoactive
delirium.
EEG may be of special use in identifying hypoactive delirium.
General management approaches remain similar to hyperactive variant,
though less agitation control is often needed.
Duration of illness and overall prognosis appears slightly bad, in comparison
with hyperactive variant. This could be partially due the high chances delayed
diagnosis.
TWILIGHT AND ONEROID
TWILIGHT- Acute onset, variable duration interruption in continuity of
consciousness where episodes of abnormal consciousness come as in islands
between normal consciousness.
ONEROID- Waking dream like state with disorientation and hallucinatory
behaviour.
DELIRIUM V/S DEMENTIA
S.NO. FEATURE DELIRIUM DEMENTIA
1 ONSET ACUTE INSIDIOUS
2 COURSE FLUCTUATING PROGRESSIVE
3 DURATION WEEKS TO MONTHS OFTEN PROGRESSIVE AND
IRREVERSIBLE
4 ATTENTION AND
CONCENTRATION
IMPAIRED INTACT UNTIL LATE STAGES
5 ORIENTATION IMPAIRED INTACT UNTIL LATE STAGES
6 MEMORY IMPAIRED IMMEDIATE
MEMORY
INTACT IMMEDIATE
MEMORY
7 PERCEPTION HALLUCINATIONS AND
ILLUSIONS
VARIABLE
8 THOUGHT DELUSIONS COMMON VARIABLE
9 DIURNAL VARIATION PRESENT ABSENT
10 PROGNOSIS OFTEN REVERSIBLE OFTEN IRREVERSIBLE
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DELIRIUM BY DR JAGMOHAN PRAJAPATI.......

  • 1. DELIRIUM Prepared By-Dr Jag Mohan Prajapati(M.D.) Senior Resident Department of Psychiatry, ABVGMC, Vidisha
  • 2. DEFINITION • Acute decline in level of consciousness with particular impairment in attention.(Ref-Kaplan) • Life threatening, yet potentially reversible disorder. • The term delirium derives itself from the Latin word delirare, which means to deviate and was originally described by Celcius. • Commonest organic mental disorder. • Coded as F05 in ICD10 and 6D70 in ICD11.
  • 3. OTHER NAMES OF DELIRIUM • Acute confusional state. • Acute brain failure. • ICU psychosis. • Organic psychosis. • Organic brain syndrome. • Cerebral insufficiency.
  • 4. EPIDEMIOLOGY • 1% in >55 years. • 13% in >85 years. • 80% of all terminally ill. • 10% of general hospital population.. • Institutionalized elderly>ICU>Post op
  • 5. PATHOPHYSIOLOGY • Neuroanatomical area involved-dorsal tegmental pathway(regulates attention and arousal) • Decreased acetyl choline/ loss of cholinergic neurons.
  • 6. PREDISPOSING FACTORS BRAIN DAMAGE (E.G. DEMENTIA) EXTREMES OF AGE CHRONIC MEDICAL ILLNESSES DRUG DEPENDENCE ON PSYCHOTROPIC DRUGS GENERALIZED OR FOCAL CEREBRAL LESION PAST HISTORY OF DELIRIUM
  • 7. PRECIPITATING FACTORS INFECTION MALNUTRITION DEHYDRATION (ELECTROLYTE DISTURBANCES) SURGERY HEAD INJURY DRUGS CHANGE IN ENVIRONMENT (ICU , RESTRAINTS).
  • 8. CAUSES OF DELIRIUM MEDICAL ACUTE INFECTIONS(e.g. Septicemia, Pneumonia etc.) METABOLIC(Hepatic Encephalopathy, uremic encephalopathy, Hypoxia, Cardiac Failure, Cardiac arrest, Hypoglycemia) Endocrine (Hypo and hyperthyroidism, hypo and hyperparathyroidism, Hypo and Hyper pituitarism) Electrolyte disturbances (Hyponatremia) SURGICAL HEAD INJURY, POLYTRAUMA, ICU, POST OP RECOVERY.
  • 10. CLINICAL FEATURES 1 IMPAIRMENT IN CONSCIOUSNESS(HALLMARK) -DISORIENTATION TO T/P/P (ALTERED SENSORIUM) -CLOUDING OF CONSCIOUSNESS -ACUTE ONSENT -FLUCTUATING COURSE -MORE WORSE IN EVENING 2 ATTENTION IMPAIRMENT -REDUCED ABILITY TO FOCUS,SUSTAIN,SHIFT ATTENTION. 3 MEMORY -IMMEDIATE AND RECENT MEMORY ABSENT -REMOTE MEMORY PRESENT -NEW LEARNING ABSENT 4 PSYCHOMOTOR ACTIVITY: CAN BE HYPERACTIVE OR HYPOACTIVE -INCREASED REACTION TIME -FLOW OF SPEECH CAN BE INCREASED OR DECREASED -ENHANCED STARTLE REACTION
  • 11. 5 THINKING AND REASONING -THOUGHT PROCESS IS DISORGANIZED -MILD TANGENTIALITY TO FRANK INCOHERENCE -FLEETING (NOT FIXED) PARANOID DELUSIONS 6 PERCEPTION -TRANSIENT VISUAL HALLUCINATIONS -TACTILE HALLUCINATION IN ALTERED SENSORIUM 7 EMOTIONS -IRRITABILITY,DYSPHORIA,EUPHORIA,APATHY,LABILITY 8 OTHERS -ALTERATION IN SLEEP WAKE CYCLE(CIRCADIAN RHYTHM DISTURBANCES) -AUTONOMIC HYPERACTIVITY(TACHYCARDIA, INCREASED BP) 9 MOTOR SYMPTOMS -ASTERIXIS(FLAPPING TREMORS) -TONE AND REFLEX ABNORMALITY -TREMORS -CORPHOLOGIA/FLOCILLATION(PICKING BEHAVIOUR) -OCCUPATIONAL DELIRIUM-BEHAVIOUR AS IF IN THEIR WORKPLACE WHILE BEING IN THE HOSPITAL BED. 10 OTHER NEUROLOGICAL SYMPTOMS -NYSTAGMUS,INCOORDINATION,URINARY INCONTINENCE.
  • 12. PREVENTION OF DELIRIUM Identification of high risk patients. Close monitoring for early signs of delirium is warranted among patients who are at high risk. Constipation, dehydration and polypharmacy need to be avoided. Adequate lighting, ventilation and clear communication can help prevent delirium. Donepezil,melatonin and a melatonin receptor agonist ramelteon has been tried in the prevention of post-operative delirium with varying results.
  • 13. Benzodiazepines are better avoided or used with caution, if there is a risk for delirium, except in cases of alcohol withdrawal. There exists some evidence to suggest prophylactic use of haloperidol. Multifactorial intervention programmes like HELP or Hospital Elder Life Programme includes frequent reorientation, reduced use of psychotropic drugs, early mobilization, proper nutrition and hydration, sleep rhythm maintenance and provisions for vision and hearing adaptation.
  • 14. MANAGEMENT OF DELIRIUM IDENTIIFY THE CAUSE HISTORY AND EXAMINATION,DRUG REVIEW,INVESTIGATIONS NON PHARMACOLOGICAL MANAGEMENT ARRANGE-APPROPRIATE LIGHTING,FREQUENT REORIENTATION,FREQUENT VISITS BY CLOSE FRIENDS AND RELATIVES MANAGE- DEHYDRATION,CONSTIPATION,IMMOBILITY,PAI N,MALNUTRITION,INSOMNIA AVOID- ANTICHOLINERGIC MEDICATIONS,SENSORY DEPRIVATION PHARMACOLOGICAL MANAGEMENT ANTIPSYCHOTICS-HALOPERIDOL(1ST CHOICE),QUETIAPINE
  • 15. Investigations are needed to find out the causes of delirium. CBC, electrolytes, urine routine, liver function, renal function, thyroid function are indicated in all patients with delirium. Neuroimaging may also be indicated. EEG in delirium shows generalized slowing of background rhythm, except in delirium tremens. Some sources claim that EEG in delirium tremens may show fast activity. The degree of generalized slowing may correlate with the degree of delirium. However ,EEG findings are often clouded by the effect of prescribed drugs including benzodiazepines. Treatment should include both symptomatic and cause target approach.
  • 16. Pharmacological and non Pharmacological methods can be used. Correction of underlying cause is very important. Physical support to prevent accidents, moderately lit room, and frequent orientation to time ,place ,a friend or relative in room are all useful. One on one nursing care may be required in severe cases. Pharmacotherapy for psychotic symptoms and insomnia, like haloperidol i.m. or droperidol i.v. along with lorazepam can be given. It is better to avoid long acting benzodiazepines unless the underlying cause warrants it, like alcohol. Delirium generally resolves within a week of treating the cause, and maximum duration as per ICD10 is 6months.without treatment ,however progression to stupor, coma or death can occur. Lethal condition with up to 10% mortality rates.
  • 17. CONFUSION ASSESSMENT METHOD(CAM) FEATURE 1 ACUTE ONSET OR FLUCTUATING COURSE FEATURE 2 INATTENTION FEATURE 3 DISORGANIZED THINKING FEATURE 4 ALTERED LEVEL OF CONSCIOUSNESS Diagnosis of delirium by CAM requires the presence of features 1 & 2 and either 3 or 4
  • 18. PERSISTENT DELIRIUM Though classically considered a transient or episodic condition, delirium may be persistent in some cases at least. PerD or persistent delirium is a term used to describe those patients meeting the criterion of delirium even after twelve months of duration. Those with non-progressive delirium meeting some but not all criterion of delirium is called subsyndromal delirium.
  • 19. EXCITED DELIRIUM AND BELLS MANIA Excited delirium is a type of agitated delirium in which the person may exhibit superhuman like powers. In addition,agitation,restlessness,anxiety,hallucinations,tachycardia,diaphoresis and bizarre behaviour are also noted, making the overall presentation similar to delirium tremens. It often occurs with substance abuse like that of cocaine. Bells mania was a term originally used by Luther Bell to describe a condition similar to excited delirium.
  • 20. ENCEPHALOPATHY It is a loosely defined term, often used interchangeably with delirium. There does not exist any consensus regarding the definition of encephalopathy. It can be used to denote either a disease or a clinical finding. In practice, the term encephalopathy is used to denote any condition that affects the functioning of brain. Many times, the underlying cause is used as a preceding term while describing encephalopathy. Hence, hepatic encephalopathy is a term used to denote encephalopathy secondary to liver dysfunction. Other common causes include hypoxia,hypertension,uraemia,HIV, wernicke’s, septic, traumatic and toxic.
  • 23. HYPOACTIVE DELIRIUM Delirium can present either as hyperactive delirium and hypoactive delirium. In hyperactive delirium the patient is generally aroused, hyper vigilant, agitated, aggressive, and may experience hallucinations and delusions. This hyperactive form is the typical and expected form of presentation of delirium. Hypoactive delirium, on the other hand, presents with decreased reactivity, motor and speech retardation, and facial inexpression. Hyperactivity and hypo activity can co-exist, and is termed mixed delirium.
  • 24. Hypoactive delirium is often under diagnosed, and is associated with a poor outcome, than hyperactive variant. It also has the potential to be misdiagnosed as depression. There are studies that suggest that up to 50% of all delirium cases are hypoactive. Depressive disorder and dementia are important differentials to hypoactive delirium. EEG may be of special use in identifying hypoactive delirium. General management approaches remain similar to hyperactive variant, though less agitation control is often needed. Duration of illness and overall prognosis appears slightly bad, in comparison with hyperactive variant. This could be partially due the high chances delayed diagnosis.
  • 25. TWILIGHT AND ONEROID TWILIGHT- Acute onset, variable duration interruption in continuity of consciousness where episodes of abnormal consciousness come as in islands between normal consciousness. ONEROID- Waking dream like state with disorientation and hallucinatory behaviour.
  • 26. DELIRIUM V/S DEMENTIA S.NO. FEATURE DELIRIUM DEMENTIA 1 ONSET ACUTE INSIDIOUS 2 COURSE FLUCTUATING PROGRESSIVE 3 DURATION WEEKS TO MONTHS OFTEN PROGRESSIVE AND IRREVERSIBLE 4 ATTENTION AND CONCENTRATION IMPAIRED INTACT UNTIL LATE STAGES 5 ORIENTATION IMPAIRED INTACT UNTIL LATE STAGES 6 MEMORY IMPAIRED IMMEDIATE MEMORY INTACT IMMEDIATE MEMORY 7 PERCEPTION HALLUCINATIONS AND ILLUSIONS VARIABLE 8 THOUGHT DELUSIONS COMMON VARIABLE 9 DIURNAL VARIATION PRESENT ABSENT 10 PROGNOSIS OFTEN REVERSIBLE OFTEN IRREVERSIBLE