1. Delirium is a common clinical syndrome characterized by inattention and acute cognitive dysfunction that is often caused by a medical condition, head injury, intoxication or withdrawal. 2. Predisposing factors for delirium include advanced age, dementia, medical comorbidities, and functional impairment. Precipitating factors are acute medical events, medications, infections, dehydration, and immobilization. 3. Delirium is managed through addressing underlying causes, supportive care including reorientation, a calm environment, and avoiding restraints. Medications like haloperidol may also be used.

1. DELIRIUM
Dr. Rahul Sharma
Associate Professor
H.O.D. of Mental Health Nursing
Ph. D Coordinator
Seedling School of Nursing,
Jaipur National University, Jaipur

3. • Delirium is from Latin means and literally means the individual is
not at the top of his her form and traveling at a lower level than
normal [de-(off, away from) + lira (a Ridge between ploughed
furrows)].
• Delirium is a common clinical syndrome characterized by
inattention and acute cognitive dysfunction
• Delirium is an outcome of a general medical condition, head
injury and drug intoxication or withdrawal. It may accompany
dysfunction of various bodily organs such as the kidney and liver,
but it may also accompany primary pathological processes in the
brain.

5. • Traumatic brain injury
• Cerebro-vascular events
• Nutritional deficiency such as thiamine deficiency
• Exposure to toxins such as lead, carbon monoxide poisoning, mercury etc.
• Drugs or substance abuse
• Space occupying lesions
• Intracranial events (stroke, bleeding, infection)
• Epilepsy & cerebral tumours
• Hypoxia, anoxia
• Alcohol intoxication

6. PREDISPOSING FACTORS

7. • Advanced age
• Dementia
• Functional impairment in activities of daily living
• Medical co -morbidity
• History of alcohol abuse
• Male gender
• Sensory impairment (blindness, deafness)

8. PRECIPITATING FACTORS

9. • Acute pulmonary events
• Bed rest
• Fluid and electrolyte disturbance (including dehydration)
• Drug withdrawal (sedatives, alcohol)
• Infection (especially respiratory, urinary)
• Medications (wide range, esp. psychoactive, anticholinergics and opioid)
• Urinary retention, faecal impaction
• Indwelling devices (urinary catheters)
• Severe anaemia
• Use of restraints

11. 1. Cholinergic deficiency This is one of the best documented
mechanisms, It has been observed that those who have deficiency of
cholinergic are at more risk for developing delirium. Delirium is seen
in overdose of anticholinergic drugs, Such as atropine.
2. Imbalance of neurotransmitter production:- Disturbance of the
tryptophan: phenalanine ratio may increase or decrease the level of
serotonin resulting in delirium. Disturbance of the tryptophan:
phenylalanine ratio has been observed in post traumatic states and other
medical and surgical conditions.

12. 3. Inflammation:- Trauma and infection lead to increased production of
pro-inflammatory cytokines, which may produce delirium. Peripherally
secreted cytokines can cause responses from microglia, causing
inflammation of the brain.
4. Elevated cortisol:- Acute stress has been hypothesized as a cause of
delirium. This is consistent with the notion that elevated cortisol seen in
PTSD results in hippocampal shrinkage.
5. Neuronal injury:- Caused by a variety of metabolic or ischemic insults.
6. Other neurotransmitter:- Abnormalities associated with delirium
include elevated dopamine function (haloperidol is effective in controlling
symptoms). Possibly, also 5-HT, NA and GABA.

13. SUB – TYPES :
• Three clinical subtypes of delirium, based on arousal
disturbance and psychomotor behaviour have been described
1. Hyperactive (hyper aroused, hyper alert, or agitated)
2. Hypoactive (hypo aroused, hypo alert or lethargic)
3. Mixed (alternating features of hyperactive and hypoactive
types

16. In efforts to prevent delirium, the following points are recommended:
• Routine cognitive testing on admission and during hospitalization.
• Cease or minimize use of potentially problematic medications.
• Ensure the continued use of glasses and hearing aids as appropriate.
• Ensure adequate intake of fluids and nutrition.
• Early identification and treatment of dehydration.
• Early mobilization of the client.
• Avoid restraints (chemical and physical).
• Involving family members or one-to-one nursing to calm and reorientate
• Adequate pain relief, while avoiding anticholinergic complications.

17. MEDICAL MANAGEMENT:
The delirium management includes supportive therapy and
pharmacological management
a) Fluid and nutrition:
• These should be given carefully, because the patients may be unwilling
or physically unable to maintain a balance intake.
• The patients suspected of having alcohol toxicity or alcohol
withdrawal, therapy should include multivitamins, especially thiamine.

18. B) Environmental modification:
• Reorientation techniques or memory cues such as calendar, clocks, and
family photos may be helpful.
• The environment should be stable, quiet and well- lighted, and also
support from a familiar nurse and family should be encourage.
• Physical restrains should be avoided.
• These patients should never live alone.

19. c) Medication:
• Neuroleptics: Haloperidol 0.5-5mg, PO, BD/ TDS.
Risperidone 0.5-2mg, PO, QID or BD.
• Short-acting sedative: lorazepam 0.5-2mg, PO/IM/IV
• Vitamins: thiamine hydrochloride 100mg IV, followed by
50-100mg/d, IV/IM, and cyanocobalamin 1000mcg IM
monthly or 500mcg/wk. intranasally or 100mcg/d, PO.

20. Nursing Interventions

21. Eliminate or minimize risk factors
• 1. Administer medications judiciously; avoid high-risk medications.
• 2. Prevent and treat infections appropriately.
• 3. Prevent & treat dehydration and electrolyte disturbances.
• 4. Provide adequate pain control measures.
• 5. Maximize oxygen delivery (supplemental oxygen, blood, and BP
support as needed).
• 6. Use sensory aids as appropriate to the client's need.
• 7. Regulate bowel/bladder function.
• 8. Provide adequate nutrition as per the need of client such as small &
frequent feeds with easily digestible food items.

22. Provide a therapeutic environment
• Foster orientation : frequently reassure and reorient patient [unless
patient become agitated ]; utilize easily visible calendar , clocks
caregiver identification carefully explain all activities, communicate
clearly to avoid confusion and foster orientation.
• Provide appropriate sensory stimulation: provide facility for quite
room , adequate lite , one task at a time , noise reduction strategies to
have appropriate sensory stimulation.
• Facilitate sleep: Provide back massage, warm milk at bed time,
relaxation music, noise reduction measures.

23. • Foster familiarity: encourage family friends to stay at bed side,
maintain consistency of care giver, minimize relocation.
• Maximize mobility: Avoid restrain and urinary catherater
• Communication: communicate clearly, provide explanation in simple
language
• Reassurance: reassure and educate the client and family members
• Minimize invasive intervention
• Consider psychotropic medication as last resort.