The document provides information on cognition and delirium. It defines delirium as an acute organic disorder characterized by impaired consciousness, disorientation, and disturbed perception and restlessness. It describes 5 subtypes of delirium based on etiology in DSM-V. The history section outlines early references to delirium in Hippocrates and developments over centuries in understanding and defining delirium. Risk factors, common etiologies, clinical features, epidemiology, pathophysiology involving several neurotransmitters, and theories of delirium are discussed.

1. BY
SREENU M B

2. INTRODUCTION
• Cognition includes a number of specific functions, such as the
acquisition and use of language, the ability to be oriented in time
and space, and the ability to learn and solve problems.
• It includes judgment, reasoning, attention, comprehension, concept
formation, planning, and the use of symbols, such as numbers and
letters used in mathematics and writing.
• Memory, a facet of cognition, refers to the ability to recall or
reproduce what has been learned or experienced. It is more than
simple storage and retrieval; it is a complex cognitive mental
function.

3. DEFINITION
Delirium is the acute organic disorder characterized by
impairment of consciousness, disorientation and disturbance in
the perception and restlessness.

4. TYPE
S
• DSM V-CLASSIFIES DELIRIUM INTO 5 SUBTYPES DEPENDING ON THE
ETIOLOGY:
I. Substance intoxication delirium
II. Substance withdrawal delirium
III. Medication-induced delirium
IV. Delirium due to another medical condition
V. Delirium due to multiple aetiologies

5. HISTORY
• THE EARLIEST KNOWN REFERENCES TO DELIRIUM IN MEDICAL
LITERATURE ARE FOUND IN THE WRITINGS OF HIPPOCRATES. SOME
2,400 YEARS AGO, IN HIS BOOK OF EPIDEMICS, HIPPOCRATES
DESCRIBED IT FIRST.
• TRADITION HOLDS THAT THE WORD DELIRIUM WAS FIRST USED
IN THE
FORMAL MEDICAL CONTEXT BY CELSUS IN THE FIRST CENTURY
AD.
• HOWEVER, CELSUS USED THE TERM DELIRIUM TO DESCRIBE A SPECTRUM OF
MENTAL DISORDERS RANGING FROM GENERAL INSANITY TO ACUTE TRANSIENT
STATES OF MENTAL DISTURBANCE, INCLUDING PHRENITIS, LETHARGUS, HYSTERIA,
MELANCHOLIA, AND MANIA.

6. HISTORY
• THE ANCIENT GREEK TERMS phrenitis AND lethargus HAVE
GIVEN RISE TO THE MODERN ENGLISH WORDS FRENZY
AND LETHARGY, RESPECTIVELY.
• THIS DISTINCTION FIRST MADE BY ARETAEUS MAY
REPRESENT THE FIRST RECORDED DESCRIPTION OF
BOTH THE HYPERACTIVE AND HYPOACTIVE MOTOR
ELEMENTS OF DELIRIUM.

7. HISTOR
Y
• CENTURIES LATER IN 1583 PHILIPS BARROUGH IN
HIS TEXTBOOK “ THE METHOD OF PHYSICK”
CLARIFIED THE CONCEPT OF DELIRIUM.
• BARROUGH PROPOSED THAT DELIRIUM CONSTITUTED
A DERANGEMENT OF SOME COMBINATION OF THREE
MAIN INTERNAL SENSES, INCLUDING IMAGINATION,
COGNITION, AND MEMORY.

8. HISTOR
Y
• THE CONCEPT OF DERANGED SENSES WAS
ELABORATED BY THOMAS WILLIS IN HIS 1672 “treatise de
anima brutorum”. WILLIS ESTABLISHED THAT DELIRIUM
WAS IN FACT A SPECIFIC SET OF SYMPTOMS AND NOT A
DISEASE.
• IN THE 18TH CENTURY, ERASMUS DARWIN AND JOHN
HUNTER MADE SIGNIFICANT CONTRIBUTIONS TO THE
THEORY OF DELIRIUM.
• DARWIN WAS THE FIRST TO COMPARE THE DELIRIUM WITH
THE DREAM STATE, NOTING THAT BOTH STATES
CONSTITUTED AN INTERRUPTION OF “VOLUNTARY POWER”
AND A SUSPENSION OF THE ABILITY TO ATTEND TO ONE'S
EXTERNAL ENVIRONMENT.

9. HISTOR
Y
• JAMES SIMS FURTHER DISTINGUISHED TWO SPECIES OF DELIRIUM, WHICH HE REFERRED TO AS LOW OR
RAVING, WHICH CORRESPOND ALMOST PERFECTLY WITH THE MODERN CONCEPT OF HYPOACTIVE AND
HYPERACTIVE MOTOR SUBTYPES OF DELIRIUM.
• ARGUABLY THE MOST IMPORTANT CONTRIBUTION IN DEVELOPMENT OF THE CONCEPT OF DELIRIUM TOOK
PLACE IN THE 20TH CENTURY IN LIGHT OF
THE WORK OF GEORGE ENGEL AND JOHN ROMANO.
• THEY WERE ABLE TO DEMONSTRATE THAT DELIRIUM IS DUE TO A REDUCTION IN THE METABOLIC ACTIVITY OF
THE BRAIN.

10. HISTORY
• ENGEL AND ROMANO ILLUSTRATED THIS POINT THROUGH THE USE OF
ELECTROENCEPHALOGRAMS (EEGS), AS BACKGROUND ACTIVITY WAS
OBSERVED TO SLOW IN CONJUNCTION WITH METABOLIC RATE.
• THIS DECREASE WAS OBSERVED TO CORRESPOND PROPORTIONATELY
WITH DECREASES IN COGNITION, MEMORY, AND ATTENTION.
• INTERESTINGLY, THESE FINDINGS OF REDUCED ACTIVITY WERE
CONSISTENT IN ALL SUBTYPES OF DELIRIUM, REGARDLESS OF THE LEVEL
OF
PSYCHOMOTOR ACTIVITY.

11. EPIDEMIOLOGY
• DELIRIUM IS A COMMON DISORDER IN ELDERLY PATIENTS, WITH
MOST INCIDENCE AND PREVALENCE RATES REPORTED IN THE
ELDERLY.
AGE PREVALENCE
55 YEARS AND MORE 1%
85 YEARS AND MORE 13%
ELDERLY EMERGENCY ROOM SUBJECTS 5-10 %

12. EPIDEMIOLOGY
TYPE PREVALENCE
GENERAL SURGICAL PATIENTS 10-15%
HIP FRACTURES 50%
INTENSIVE CARE UNITS 70-87%
END OF LIFE CARE 83%
PATIENTS IN NURSING HOMES OR
POSTACUTE CARE SETTINGS
60%
• Yale- New Haven study (Inouye S. Ann Intern Med 1993: 119-474)
• 65% unrecognized by Physicians
• 43% unrecognized by Nurses

13. • DEMOGRAPHIC
CHARACTERISTI
CS• AGE 65 AND OLDER
• MALE SEX
• COGNITIVE
STATUS• DEMENTIA
• COGNITIVE
IMPAIRMENT
• HISTORY OF DELIRIUM
• DEPRESSION
• FUNCTIONAL
STATUS• FUNCTIONAL
DEPENDENCE
• IMMOBILITY
• HISTORY OF FALLS
• LOW LEVEL OF ACTIVITY
• SENSORY
IMPAIRMENT• HEARIN
G
• VISUAL
• DECREASED ORAL
INTAKE
• DEHYDRATION
• MALNUTRITION
• DRUG
S
• TREATMENT WITH PSYCHOACTIVE DRUGS
• TREATMENT WITH DRUGS WITH ANTICHOLINERGIC
PROPERTIES
• ALCOHOL ABUSE
• COEXISTING MEDICAL CONDITIONS
• SEVERE MEDICAL DISEASES
• CHRONIC RENAL OR HEPATIC DISEASE
• STROKE
• NEUROLOGICAL DISEASE
• METABOLIC DERANGEMENTS
• INFECTION WITH HUMAN IMMUNODEFICIENCY
VIRUS
• FRACTURES OR TRAUMA
• TERMINAL DISEASES
PREDISPOSING FACTORS FOR DELIRIUM

14. COMMON ETIOLOGIES OF DELIRIUM
• CENTRAL NERVOUS SYSTEM DISORDER
• SEIZURE (POSTICTAL, NONCONVULSIVE STATUS,)
• MIGRAINE
• HEAD TRAUMA
• BRAIN TUMOR
• SUBARACHNOID HEMORRHAGE
• SUBDURAL, EPIDURAL HEMATOMA
• ABSCESS
• INTRACEREBRAL HEMORRHAGE
• CEREBELLAR HEMORRHAGE
• NONHEMORRHAGIC STROKE
• TRANSIENT ISCHEMIA

15. ETIOLOGY
• METABOLIC DISORDER
• ELECTROLYTE ABNORMALITIES
• DIABETES
• HYPOGLYCEMIA
• HYPERGLYCEMIA
• INSULIN RESISTANCE
• SYSTEMIC ILLNESS
• INFECTION (E.G., SEPSIS, MALARIA, ERYSIPELAS, VIRAL, PLAGUE, LYME
DISEASE,
SYPHILIS, OR ABSCESS)
• TRAUMA
• CHANGE IN FLUID STATUS (DEHYDRATION OR VOLUME OVERLOAD)

16. ETIOLOGY
• NUTRITIONAL DEFICIENCY
• BURNS
• UNCONTROLLED PAIN
• HEAT STROKE
• HIGH ALTITUDE (USUALLY >5,000 M)
• MEDICATIONS
• PAIN MEDICATIONS (E.G.,
POSTOPERATIVE MEPERIDINE
[DEMEROL] OR MORPHINE
[DURAMORPH])
• ANTIBIOTICS, ANTIVIRALS, AND
ANTIFUNGALS
• STEROIDS
• CARDIAC MEDICATIONS
• ANTIHYPERTENSIVES
• ANTINEOPLASTIC AGENTS
• ANTICHOLINERGIC AGENTS
• NEUROLEPTIC MALIGNANT
SYNDROME
• SEROTONIN SYNDROME

17. ETIOLOGY
• OVER-THE-COUNTER PREPARATIONS
• HERBALS, TEAS, AND NUTRITIONAL
SUPPLEMENTS
• BOTANICALS
• JIMSONWEED / Datura
• OLEANDER / Raktakarabi
• FOXGLOVE / Digitalis
• HEMLOCK / Bishlata
• DIEFFENBACHIA
• AMANITA PHALLOIDES

18. ETIOLOGY
• CARDIAC
• CARDIAC FAILURE
• ARRHYTHMIA
• MYOCARDIAL INFARCTION
• CARDIAC ASSIST DEVICE
• CARDIAC SURGERY
• PULMONARY
• CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
• HYPOXIA
• SIADH
• ACID BASE DISTURBANCE
• ENDOCRINE
• ADRENAL CRISIS OR ADRENAL
FAILURE
• THYROID ABNORMALITY
• PARATHYROID ABNORMALITY
• HEMATOLOGICAL
• ANEMIA
• LEUKEMIA
• BLOOD DYSCRASIA
• STEM CELL TRANSPLANT

19. ETIOLOGY
• RENAL
• RENAL FAILURE, UREMIA, SIADH
• HEPATIC
• HEPATITIS, CIRRHOSIS, HEPATIC FAILURE
• NEOPLASM
• NEOPLASM (PRIMARY BRAIN, METASTASES, PARANEOPLASTIC
SYNDROME)
• DRUGS OF ABUSE
• INTOXICATION AND WITHDRAWAL
• TOXINS
• INTOXICATION AND WITHDRAWAL
• HEAVY METALS AND ALUMINUM

20. Clinical features & findings:
• Impairment of consciousness: clouding
of consciousness ranging from drowsiness to stupor
and coma.
• Impairment of attention: difficulty in shifting, focusing
and sustaining attention.
• Perceptual disturbances: illusions and hallucinations, most
often visual.

21. Clinical features & findings:
Disturbance of cognition: impairment of abstract thinking
and Comprehension, impairment of recent and immediate
memory, increased reaction time.
Psychomotor disturbances: hypo or hyper- activity, aimless
groping or picking at the bed clothes (flocculation), enhanced
startle reaction.

22. Clinical features
• Disturbance of sleep wake cycle: insomnia or in
severe cases total sleep loss, daytime drowsiness,
disturbing dreams or nightmares.
• Emotional disturbances: depression, anxiety, fear,
irritability, euphoria, apathy.

23. PATHOPHYSIOLOG
Y
• THE PATHOPHYSIOLOGY OF DELIRIUM REMAINS POORLY UNDERSTOOD.
• ALTHOUGH THERE HAS BEEN RESEARCH TO FIND A FINAL COMMON
PATHWAY THAT EXPLAINS ALL DELIRIUM, GIVEN THE HETEROGENEITY OF
THE ETIOLOGIES AND THE PRESENTATIONS OF DELIRIUM, THERE MAY
NOT BE ONE MECHANISM THAT ENCOMPASSES THE ENTIRE
SYNDROME.
• EEG STUDIES HAVE DEMONSTRATED DIFFUSE SLOWING OF CORTICAL
BACKGROUND ACTIVITY, WHICH DOES NOT CORRELATE WITH
UNDERLYING CAUSES.

24. NEUROCHEMICA
L
• PATIENTS WITH DELIRIUM HAVE SHOWN EVIDENCE OF
NEUROCHEMICAL CHANGES IN
• ACETYLCHOLINE
• DOPAMINE
• GLUTAMATE
• γ-AMINOBUTYRIC ACID (GABA)
• SEROTONIN SYSTEMS.

25. ACETYLCHOLINE
• EXTENSIVE EVIDENCE SUPPORTS THE ROLE OF CHOLINERGIC DEFICIENCY IN DELIRIUM
AS IT IS INVOLVED IN RAPID EYE MOVEMENT (REM) SLEEP, ATTENTION, AROUSAL, AND
MEMORY.
• ADMINISTRATION OF ANTICHOLINERGIC DRUGS CAN INDUCE DELIRIUM IN HUMANSAND
ANIMALS, AND SERUM ANTICHOLINERGIC ACTIVITY IS INCREASED IN PATIENTS WITH
DELIRIUM.
• PHYSOSTIGMINE (ANTILIRIUM), A CHOLINERGIC AGENT, REVERSES DELIRIUM ASSOCIATED
WITH ANTICHOLINERGIC DRUGS.
• THIS SUGGESTS THE POSSIBILITY OF INTERACTIONS BETWEEN OTHER SYSTEMS
AND THE CHOLINERGIC SYSTEM IN THE PATHOPHYSIOLOGY OF DELIRIUM.
EVEN IN CASES OF DELIRIUM THAT ARE NOT INDUCED BY DRUGS.

26. DOPAMINE
• DOPAMINERGIC EXCESS ALSO APPEARS TO CONTRIBUTE TO
DELIRIUM, POSSIBLY OWING TO ITS REGULATORY INFLUENCE ON
THE RELEASE OF ACETYLCHOLINE.
• ONE SUGGESTED MECHANISM IS THE INVOLVEMENT OF DOPAMINE
IN MAINTAINING AND SHIFTING ATTENTION.
• DOPAMINERGIC DRUGS (E.G., LEVODOPAAND BUPROPION ARE
RECOGNIZED PRECIPITANTS OF DELIRIUM, AND DOPAMINE
ANTAGONISTS (E.G., ANTIPSYCHOTIC AGENTS) EFFECTIVELY TREAT
DELIRIUM SYMPTOMS.

27. GLUTAMAT
E
• GLUTAMATE, THROUGH ITS EXCITATORY NEUROTOXICITY EFFECTS
(MEDIATED VIA THE N-METHYL-D-ASPARTATE [NMDA] RECEPTOR), MAY
CAUSE NEURONAL DEATH AND CAN BE ASSOCIATED WITH DELIRIUM.
• DRUGS THAT ARE NMDA ANTAGONISTS, SUCH AS KETAMINE
AND PHENCYCLIDINE (PCP) ARE ASSOCIATED WITH DELIRIUM.
• ONE PROPOSED MECHANISM OF WERNICKE'S ENCEPHALOPATHY IS
THROUGH GLUTAMATE ABNORMALITIES.

28. GABA
• GABA, AN INHIBITOR OF BRAIN ACTIVITY, HAS BEEN IMPLICATED
IN CONTRIBUTING TO DELIRIUM SECONDARY TO
BENZODIAZEPINE AND ALCOHOL WITHDRAWAL.
• HEPATIC ENCEPHALOPATHY HAS BEEN ASSOCIATED WITH
INCREASED SERUM AMMONIAAND GABA LEVELS.

29. OTHER
NEUROTRANSMITTERS
• PERTURBATIONS OF OTHER NEUROTRANSMITTERS, SUCH AS NOREPINEPHRINE,
SEROTONIN, GABA, GLUTAMATE, AND MELATONIN, MAY ALSO HAVE A ROLE IN THE
PATHOPHYSIOLOGY OF DELIRIUM, BUT THE EVIDENCE IS LESS WELL DEVELOPED.
THESE NEUROTRANSMITTERS MAY EXERT THEIR INFLUENCE THROUGH
INTERACTIONS WITH THE CHOLINERGIC AND DOPAMINERGIC PATHWAYS.
• OXIDATIVE METABOLISM
DISTURBANCE IN BRAIN OXYGEN SUPPLY VERSUS DEMAND HAS BEEN ONE OF THE
THEORIES PROPOSED FOR DELIRIUM. IMPAIRED OXIDATIVE METABOLISM APPEARS
TO BEA PREDISPOSING FACTOR FOR LATER DEVELOPMENT OF
DELIRIUM.

30. BLOOD–BRAIN BARRIER
ALTERATIONS
• ONE HYPOTHESIS OF DELIRIUM IS THAT IT IS A CNS RESPONSE TO
SYSTEMIC INFLAMMATION DURING A STATE OF BLOOD–BRAIN
BARRIER COMPROMISE.
• IN POSTCARDIAC SURGERY PATIENTS, CHEMOKINES, WHICH IS AN
INFLAMMATORY MARKER, HAVE BEEN ASSOCIATED WITH
DELIRIUM BY DISRUPTING THE BLOOD–BRAIN BARRIER.
• SIMILAR ALTERATIONS HAVE BEEN FOUND IN PATIENTS
DEVELOPING DELIRIUM AFTER TRAUMA, PRIMARY
HYPERPARATHYROIDISM AND DELIRIUM TREMENS.

31. INJURY

32. AMMONIA
• HEPATIC ENCEPHALOPATHY IS CAUSED BY MANY FACTORS.
• ONE FACTOR IDENTIFIED IN THE PATHOGENESIS OF THIS SYNDROME HAS BEEN
AMMONIA.
• AMMONIA AND SEVERAL OTHER FACTORS ARE KNOWN TO INDUCE AND
AGGRAVATE ASTROCYTE SWELLING, WHICH INITIATE A CASCADE OF EVENTS
LEADING TO DELIRIUM.
• ONE OTHER MECHANISM COULD BE THAT ELEVATED AMMONIA LEVELS CAN
CONTRIBUTE TO INCREASED GLUTAMATE AND GLUTAMINE LEVELS, WHICH ARE
PRECURSORS TO GABA.
• CYTOKINES, INCLUDING INTERLEUKIN-1, INTERLEUKIN-2, INTERLEUKIN-6, TUMOR
NECROSIS FACTOR-Α (TNF-Α), AND INTERFERON, MAY CONTRIBUTE TO DELIRIUM BY
INCREASING THE PERMEABILITY OF THE BLOOD–BRAIN BARRIER AND ALTERING

33. • FINALLY, CHRONIC STRESS BROUGHT ON BY ILLNESS OR TRAUMA
ACTIVATES THE SYMPATHETIC NERVOUS SYSTEM AND
HYPOTHALAMIC– PITUITARY–ADRENOCORTICAL AXIS, RESULTING IN
INCREASED CYTOKINE LEVELS AND CHRONIC HYPERCORTISOLISM.
• CHRONIC HYPERCORTISOLISM HAS DELETERIOUS
EFFECTS ON HIPPOCAMPAL SEROTONIN (5-
HYDROXYTRYPTAMINE) 5-HT1A RECEPTORS, WHICH MAY
CONTRIBUTE TO DELIRIUM.

34. THEORIES FOR POST OP
DELIRIUM
• ACETYLCHOLINE INTERACTION WITH MEDICATIONS USED DURING
SURGERY
• INCREASE OF NEUROTRANSMITTERS, SEROTONIN AND DOPAMINE
DURING
SURGERY
• PREVIOUS ABNORMALITY LEVELS OF MELATONIN
• DAMAGE TO NEURONS BY OXIDATIVE STRESS OR INFLAMMATION
CAUSED BY A SURGICAL PROCEDURE• POST OP ABNORMAL BRAIN
WAVES

35. PERIOPERATIVE DRUGS:
ANESTHETICS
OPIOIDS
BENZODIAZEPINES
RISK FACTORS
PREDISPOSING
PRECIPITATING
COMORBIDITIES
DIABETES
AMI
ETC

36. DIAGNOSTIC CRITERIA OF THOSE SUBTYPES
WHATEVER THE TYPE IS 3 CRITERIAS HAS TO BE REMEMBERED
THESE 3 CRITERIAS WILL BE THE SAME IN ALL 5
VARIETIES
1.DISTURBANCE OF CONSCIOUSNESS (I.E., REDUCED CLARITY OF AWARENESS
OF THE ENVIRONMENT) WITH REDUCED ABILITY TO FOCUS, SUSTAIN, OR SHIFT
ATTENTION.
2.A CHANGE IN COGNITION (SUCH AS MEMORY DEFICIT, DISORIENTATION, LANGUAGE
DISTURBANCE) OR THE DEVELOPMENT OF A PERCEPTUAL DISTURBANCE THAT IS NOT
BETTER ACCOUNTED FOR BY A PREEXISTING, ESTABLISHED, OR EVOLVING
DEMENTIA.DAYS) AND TENDS TO FLUCTUATE DURING THE COURSE OF THE

37. ADDITIONAL CRITERIAS FOR INDIVIDUAL
CATEGORIES
DELIRIUM DUE TO GENERAL MEDICAL CONDITION
• THERE IS EVIDENCE FROM THE HISTORY, PHYSICAL EXAMINATION, OR
LABORATORY FINDINGS THAT THE DISTURBANCE IS CAUSED BY THE
DIRECT PHYSIOLOGICAL CONSEQUENCES OF A GENERAL MEDICAL
CONDITION.
SUBSTANCE INTOXICATION DELIRIUM
• THERE IS EVIDENCE FROM THE HISTORY, PHYSICAL
EXAMINATION, OR LABORATORY FINDINGS OF EITHER (1) OR (2):
• THE SYMPTOMS IN CRITERIA A AND B DEVELOPED DURING SUBSTANCE
INTOXICATION
• MEDICATION USE IS ETIOLOGICALLY RELATED TO THE DISTURBANCE*
*CRITERIA A - DISTURBANCE OF CONSCIOUSNESS (I.E., REDUCED CLARITY OF AWARENESS OF THE ENVIRONMENT) WITH REDUCED
ABILITY TO FOCUS, SUSTAIN, OR SHIFT ATTENTION.
CRITERIA B - A CHANGE IN COGNITION (SUCH AS MEMORY DEFICIT, DISORIENTATION, LANGUAGE DISTURBANCE) OR THE
DEVELOPMENTOF A PERCEPTUAL DISTURBANCE THAT IS NOT BETTER ACCOUNTED FOR BY A PREEXISTING, ESTABLISHED, OR EVOLVING.

38. ADDITIONAL CRITERIAS FOR INDIVIDUAL
CATEGORIES
SUBSTANCE WITHDRAWAL DELIRIUM
• THERE IS EVIDENCE FROM THE HISTORY, PHYSICAL EXAMINATION,
OR LABORATORY FINDINGS THAT THE SYMPTOMS IN CRITERIA A
AND B DEVELOPED DURING, OR SHORTLY AFTER, A WITHDRAWAL
SYNDROME.
DELIRIUM DUE TO MULTIPLE ETIOLOGIES
• THERE IS EVIDENCE FROM THE HISTORY, PHYSICAL
EXAMINATION, OR LABORATORY FINDINGS THAT THE DELIRIUM
HAS MORE THAN ONE ETIOLOGY (E.G., MORE THAN ONE
ETIOLOGICAL GENERAL MEDICAL CONDITION, A GENERAL
MEDICAL CONDITION PLUS SUBSTANCE
INTOXICATION OR MEDICATION SIDE
EFFECT).

39. ADDITIONAL CRITERIAS FOR INDIVIDUAL
CATEGORIES
DELIRIUM NOT OTHERWISE SPECIFIED
• THIS CATEGORY SHOULD BE USED TO DIAGNOSE A DELIRIUM THAT DOES NOT
MEET
CRITERIA FOR ANY OF THE SPECIFIC TYPES OF DELIRIUM DESCRIBED IN THIS
SECTION.
•
EXAMPLES INCLUDE A CLINICAL PRESENTATION OF DELIRIUM THAT IS
SUSPECTEDTO BE DUE TO A GENERAL MEDICAL CONDITION OR SUBSTANCE
USE BUT FOR WHICH THERE IS INSUFFICIENT EVIDENCE TO ESTABLISH A
SPECIFIC ETIOLOGY
• DELIRIUM DUE TO CAUSES NOT LISTED IN SECTION DESCRIBED
PREVIOUSLY (E.G., SENSORY DEPRIVATION)

40. DELIRIUM DUE TO SUBSTANCE
INTOXICATION.
DRUGS OF ABUSE
• INTOXICATION WITH A VARIETY OF DRUGS OF ABUSE
IS KNOWN TO CAUSE DELIRIUM.
• COCAINE
• PCP
• HEROIN
• ALCOHOL
• NITROUS OXIDE
• AMPHETAMINE AND ITS DERIVATIVES (E.G., SPEED AND
ECSTASY)
• MARIJUANA.

41. • EXPERIMENTATION WITH DRUGS OF ABUSE EXTENDS TO SYNTHETIC COMPOUNDS
KNOWN AS RAVES, WHICH ARE OFTEN USED IN DANCE CLUBS
• 3,4-METHYLENE-DIOXYMETHAMPHETAMINE (MDMA), ALSO KNOWN AS ECSTASY, A
METHAMPHETAMINE ANALOG, HAVE BEEN ASSOCIATED WITH DELIRIUM AND FATALITIES.
• SPECIAL K, OR KETAMINE, AN ANESTHETIC AGENT OFTEN USED BY VETERINARIANS
• PCP (ALSO KNOWN AS ANGEL DUST) ARE NMDA RECEPTOR ANTAGONISTS AND ARE
OTHER
EXAMPLES OF STREET DRUGS ASSOCIATED WITH DELIRIUM.
• FLUNITRAZEPAM (ROHYPNOL) AND γ-HYDROXYBUTYRATE (GHB) ARE OTHER
COMMON CHOICES OF RECREATIONAL DRUG USERS WITH THE POTENTIAL FOR

42. DELIRIUM DUE TO SUBSTANCE WITHDRAWAL
ALCOHOL WITHDRAWAL
• THE CLASSIC AGITATED WITHDRAWAL DELIRIUM IS DELIRIUM TREMENS.
• THIS SYNDROME, SYNONYMOUS WITH SEVERE ALCOHOL WITHDRAWAL,
PRESENTS
WITH
• DELIRIUM
• AUTONOMIC HYPERACTIVITY
• FREQUENT VISUAL AND TACTILE HALLUCINATIONS
• CARRIES A SIGNIFICANT RISK OF SEIZURES AND DEATH IF UNTREATED.
• PATIENTS ADMITTED TO THE HOSPITAL MAY PRESENT SEVERAL
DAYS INTO ADMISSION WITH ALCOHOL WITHDRAWAL AND MAY BE AT
RISK FOR DELIRIUM TREMENS.

43. BENZODIAZEPINE
WITHDRAWAL
• BENZODIAZEPINE WITHDRAWAL MAY APPEAR SIMILAR TO ALCOHOL
WITHDRAWAL AND MAY ALSO BE ACCOMPANIED BY SEIZURES.
• THE ONSET OF SYMPTOMS IS DEPENDENT ON THE HALF-LIFE
OF THE PARTICULAR BENZODIAZEPINE.
• EXAMPLE: ALPRAZOLAM WITHDRAWAL (SHORT HALF-LIFE) MAY
PRESENT IN 1 TO 2 DAYS
• DIAZEPAM (VALIUM) WITHDRAWAL (LONG HALF-LIFE) MAY PRESENT 5
TO 7 DAYS AFTER THE LAST DOSE.

44. OPIATE
WITHDRAWAL
• OPIATE WITHDRAWAL PRESENTS WITH
• SEVERE FLU-LIKE SYNDROMES
• GASTROINTESTINAL (GI) CRAMPING
• DIARRHEA
• DIAPHORESIS
• AUTONOMIC HYPERACTIVITY
• CRAVING.
• DELIRIUM MAY ALSO OCCUR WITH OPIOID WITHDRAWAL AND HAS
BEEN REPORTED WITH SWITCHING OF OPIATES EG: FROM
TRANSDERMAL FENTANYL TO MORPHINE.
• THE PRESENTATION MAY OCCUR BECAUSE OF UNKNOWN PRIOR USE
OFOPIATES IN THE CONTEXT OF

45. DELIRIUM IN POST-OP
PATIENTS
DELIRIUM FOLLOWING CORONARY ARTERY BYPASS GRAFT
• THE INCIDENCE OF DELIRIUM AFTER CORONARY ARTERY BYPASS
(CABG) PROCEDURE HAS RANGED FROM 3 TO 35 PERCENT.
• SEVERAL FACTORS PLAY A ROLE IN THE DEVELOPMENT OF DELIRIUM IN
POST CABG PATIENTS.
• IN ONE STUDY DELIRIUM WAS DETECTED IN 74 OF 220 (33.6 PERCENT)
PATIENTS UNDERGOING CABG PROCEDURE.

46. • MULTIPLE RISK FACTORS WERE IDENTIFIED FOR DELIRIUM IN THIS
STUDY.
• INCREASING AGE
• BLOOD UREA LEVEL
• CARDIO-THORACIC INDEX
• HYPERTENSION
• SMOKING HABITS
• BLOOD REPLACEMENT DURING BYPASS
• ATRIAL FIBRILLATION (AF)
• PNEUMONIA
• BLOOD BALANCE IN THE POSTOPERATIVE PERIOD WERE
ALL ASSOCIATED WITH DELIRIUM.
• INTERESTINGLY, NO SPECIFIC FACTOR ASSOCIATED WITH THE CABG
PROCEDURE ITSELF (PERFUSION PRESSURE, NUMBER OF GRAFTS)
WAS CORRELATED WITH AN INCREASED RISK FOR DELIRIUM
POSTOPERATIVELY.

47. DELIRIUM FOLLOWING HIP/JOINT
REPLACEMENT
• DELIRIUM IS A COMMON ADVERSE EVENT IN PATIENTS UNDERGOING
HIP REPLACEMENT, WITH ESTIMATES IN THE RANGE OF 15 TO 60
PERCENT.
• SEVERAL STUDIES HAVE INDICATED THAT POST–HIP REPLACEMENT
DELIRIUM HAS BEEN ASSOCIATED WITH INCREASED MORBIDITY AND
MORTALITY.
• STUDIES SHOW THAT COGNITIVE IMPAIRMENT AT ADMISSION HAD THE
HIGHEST PREDICTIVE VALUE FOR POSTOPERATIVE DELIRIUM, AND
CONTRARY TO PREVIOUS FINDINGS, AGE WAS AN INDEPENDENT
PREDICTIVE FACTOR FOR DELIRIUM.
• POSTOPERATIVE DELIRIUM WAS FOUR TIMES AS FREQUENT IN ACUTEAS IN ELECTIVE HIP REPLACEMENT

48. DIAGNOSI
S
PULS
E
TACHYCARDIA
BRADYCARDIA
HYPOTHYROIDISM
STOKES-ADAMS SYNDROME
INCREASED INTRACRANIAL
PRESSURE
HYPERTHYROIDI
SM INFECTION
HEART FAILURE
PHYSICAL EXAMINATION OF THE DELIRIOUS
PATIENT

49. TEMPERATUR
E
FEVE
R
SEPSIS
THYROID
STORM
VASCULITIS
BLOOD
PRESSURE
HYPOTENSION
SHOCK
HYPOTHYROIDISM
ADDISON'S
DISEASE
HYPERTENSIO
N
ENCEPHALOPATHY
INTRACRANIAL
MASS

50. RESPIRATIO
N
TACHYPNEA
DIABETES
PNEUMONIA
CARDIAC
FAILURE FEVER
ACIDOSIS (METABOLIC)
SHALLOW ALCOHOL OR OTHER
SUBSTANCE
INTOXICATION

51. CAROTID
VESSELS
BRUITS OR DECREASED
PULSE TRANSIENT
CEREBRAL ISCHEMIA
SCALP AND FACE EVIDENCE OF TRAUMA
NECK EVIDENCE OF NUCHAL RIGIDITY
MENINGITIS
SUBARACHNOID HEMORRHAGE

52. EYE
S
PAPILLEDEMA
TUMOR
HYPERTENSIVE
ENCEPHALOPATHY
PUPILLARY
DILATATION
ANXIETY
AUTONOMIC
OVERACTIVITY (E.G.,
DELIRIUM TREMENS)

53. MOUTH TONGUE OR CHEEK
LACERATIONS
EVIDENCE OF
GENERALIZED TONIC-
CLONIC SEIZURES
THYROID ENLARGED HYPERTHYROIDIS
M

54. HEART
ARRHYTHMIA
INADEQUATE CARDIAC
OUTPUT POSSIBILITY OF
EMBOLI
CARDIOMEGALY
HEART FAILURE
HYPERTENSIVE
DISEASE
CONGESTION
PRIMARY PULMONARY
FAILURE PULMONARY EDEMA
PNEUMONIA
LUNGS

55. BREAT
H
ALCOHOL
KETONE
S
DIABETE
S
LIVE
R
ENLARGEMEN
T
CIRRHOSIS
LIVER
FAILURE

56. NERVOUS
SYSTEM
REFLEXE
S
ASYMMETRY WITH BABINSKI'S
SIGNS
MASS LESION
CEREBROVASCULA
R DISEASE
PREEXISTING
DEMENTIA
ABDUCENT NERVE
(SIXTH CRANIAL
NERVE)
WEAKNESS IN LATERAL
GAZE
INCREASED
INTRACRANIAL
PRESSURE
LIMB
STRENGTH
ASYMMETRICAL
MASS LESION
CEREBROVASCULA
R DISEASE
AUTONOMIC NERVOUS
SYSTEM
HYPERACTIVIT
Y

57. LABORATORY
WORKUP
STANDARD STUDIES
• BLOOD CHEMISTRIES (INCLUDING
ELECTROLYTES, RENAL AND HEPATIC INDEXES,
AND GLUCOSE)
• COMPLETE BLOOD COUNT WITH WHITE CELL
DIFFERENTIAL
• THYROID FUNCTION TESTS
• SEROLOGIC TESTS FOR SYPHILIS
• HUMAN IMMUNODEFICIENCY VIRUS (HIV)
ANTIBODY TEST
• URINALYSIS
• ELECTROCARDIOGRAM
• ELECTROENCEPHALOGRAM
• CHEST X-RAY
• BLOOD AND URINE DRUG SCREENS
• ADDITIONAL TESTS WHEN INDICATED
• BLOOD, URINE, AND CEREBROSPINALFLUID
(CSF) CULTURES
• B12, FOLIC ACID CONCENTRATIONS
• COMPUTED TOMOGRAPHY OR MAGNETIC
RESONANCE IMAGING BRAIN SCAN
• LUMBAR PUNCTURE AND CSF EXAMINATION

58. RATING SCALES IN
DELIRIUM
CONFUSION ASSESSMENT METHOD
• CONFUSION ASSESSMENT METHOD (CAM) HAS BEEN VALIDATED IN A NUMBER
OF SETTINGS, INCLUDING THE INTENSIVE CARE UNIT IN ELDERLY
• 95 PERCENT SENSITIVITY AND 88 PERCENT SPECIFICITY.
• THE ADMINISTRATION TIME IS APPROXIMATELY 2 MINUTES.
• THE INSTRUMENT DETECTED DELIRIUM IN 83.3 PERCENT OF PATIENTS IN THE
INTENSIVE CARE UNIT, THE HIGHEST PUBLISHED RATE IN THE INTENSIVE CARE
UNIT SETTING.

59. DELIRIUM RATING SCALE
(DRS)
3 ITEMS IN SCALE
• ITEM 1: TEMPORAL ONSET OF SYMPTOMS
• ITEM 2: PERCEPTUAL DISTURBANCES
• ITEM 3: THE PRESENCE OF ANY TYPE OF HALLUCINATION IS
RATED.

60. OTHER SCALES
• MMSE
• SHORT PORTABLE MENTAL STATE
QUESTIONNAIRE (SPMSQ)

61. DIFFERENTIAL
DIAGNOSIS
DELIRIUM SHOULD BE DIFFERENTIATED
FROM
• DEMENTIA
• DEPRESSION
• PSYCHOTIC DISORDER
• SCHIZOPHRENIFORM DISORDER
ALL OF THEM CAUSE GLOBAL COGNITIVE
DEFICIT.
• DISSOCIATIVE

62. FEATURE DEMENTIA DELIRIUM
ONSET SLOW RAPID
DURATION MONTHS TO YEARS HOURS TO WEEKS
ATTENTION PRESERVED FLUCTUATES
MEMORY IMPAIRED REMOTE MEMORY IMPAIRED RECENT AND
IMMEDIATE MEMORY
SPEECH WORD-FINDING DIFFICULTY INCOHERENT (SLOW
OR RAPID)
SLEEP WAKE CYCLE FRAGMENTED SLEEP FREQUENT DISRUPTION
(E.G. DAY NIGHT
REVERSAL)
THOUGHTS IMPOVERISHED DISORGANIZED
AWARENESS UNCHANGED REDUCED
ALERTNESS USUALLY NORMAL HYPERVIGILANT OR
REDUCED
VIGILANCE
OCCASIONALLY, DELIRIUM OCCURS IN A PATIENT WITH DEMENTIA, A CONDITION KNOWN AS
BECLOUDED DEMENTIA.

63. • HYPOACTIVE DELIRIUM CAN RESEMBLE DEPRESSION. HOWEVER
CLOUDING OF CONSCIOUSNESS IS ABSENT IN DEPRESSION
• HYPERACTIVE DELIRIUM CAN MIMIC ACUTE PSYCHOSIS. HOWEVER IN
DELIRIUM HALLUCINATIONS ARE PREDOMINANTLY VISUAL AND DELUSION
ARE NOT WELL SYSTEMATIZED.
• AN EEG CAN DIFFERENTIATE IT FROM BOTH DEPRESSION & PSYCHOSIS

64. TREATMENT
TREATMENT HAS 2
COMPONENTS
PHARMACOLOGICALNON PHARMACOLOGICAL

65. • IN TREATING DELIRIUM, THE PRIMARY GOAL IS TO TREAT THE
UNDERLYING CAUSE.
• THE OTHER IMPORTANT GOAL OF TREATMENT IS TO PROVIDE
PHYSICAL, SENSORY, AND ENVIRONMENTAL SUPPORT.
• PHYSICAL SUPPORT IS NECESSARY SO THAT DELIRIOUS PATIENTS DO NOT
GET INTO SITUATIONS IN WHICH THEY MAY HAVE ACCIDENTS.
• PATIENTS WITH DELIRIUM SHOULD BE NEITHER SENSORY DEPRIVED NOR
OVERLY STIMULATED BY THE ENVIRONMENT.
NON PHARMACOLOGICAL

66. TREATME
NT
• FAMILIAR PICTURES AND DECORATIONS, THE PRESENCE OF A CLOCK OR A CALENDAR,
ANDREGULAR ORIENTATIONS TO PERSON, PLACE, AND TIME HELP MAKE PATIENTS WITH
DELIRIUMCOMFORTABLE
.
• CONTINUITY IN BOTH NURSING AND MEDICAL STAFF CAN HELP DECREASE PATIENT
FEARSANDPARANOIA BECAUSE OF UNFAMILIAR
FACES.
• DELIRIUM CAN SOMETIMES OCCUR IN OLDER PATIENTS WEARING EYE PATCHES
AFTERCATARACT SURGERY, SUCH PATIENTS CAN BE HELPED BY PLACING PINHOLES IN THE
PATCHESTO LET IN SOME STIMULI OR BY OCCASIONALLY REMOVING ONE PATCH AT A TIME
DURINGRECOVERY
.
• INTERRUPTIONS OF SLEEP SHOULD BE MINIMIZED WHEN
POSSIBLE.
• ADEQUATE NUTRITION IS IMPORTANT FOR RECOVERY FROM THE DELIRIUM
AND THEUNDERLYING ILLNESS, AS WELL AS FOR PROVIDING USEFUL
ORIENTATION.

67. TREATME
NT
• PSYCHOSOCIAL SUPPORT CAN BE PROVIDED BY BOTH STAFF AND FAMILY
OR FRIENDS.
• PHYSICAL RESTRAINS SHOULD BE AVOIDED WHENEVER POSSIBLE
• FAMILY MEMBERS MAY BE AVAILABLE TO PROVIDE CONSTANT
OBSERVATION, WHICH CAN MINIMIZE THE NEED FOR PHYSICAL
RESTRAINTS.
Dr.Subrata Nask

68. PHARMACOLOGICAL
• PSYCHOACTIVE MEDICATIONS ARE INDICATED FOR DELIRIUM
ASSOCIATED WITH DRUG WITHDRAWAL OR FOR BEHAVIORS THAT
POSE A SAFETY RISK FOR THE PATIENT AND OTHERS.
• TWO GENERAL CLASSES OF AGENTS—THE ANTIPSYCHOTICS AND
THE BENZODIAZEPINES—ARE MOST FREQUENTLY USED.
• ANTIPSYCHOTICS ARE BENEFICIAL IN PATIENTS HAVING
• PERCEPTUAL DISTURBANCES ASSOCIATED WITH
• SLEEP–WAKE CYCLE ABNORMALITIES
• BEHAVIORAL DYSCONTROL

69. • HALOPERIDOL IS THE MOST PREFERRED DRUG AMONGST THE
ANTIPSYCHOTICS
• REASON:
• HIGHLY POTENT
• FEWER ANTICHOLINERGIC FEWER INCIDENT OF HYPOTENSION
• DISADVANTAGE:
• FREQUENCY OF EXTRAPYRAMIDAL SIDE EFFECTS IS HIGHER
• CANT BE USED IN PATIENTS LIKE DELIRIUM WITH PARKINSONISM

70. FACTS ABOUT HALOPERIDOL DOSAGE
• THE INITIAL DOSE 2 TO 6 MG INTRAMUSCULAR INJECTION.
• REPEATED IN AN HOUR IF THE PATIENT REMAINS AGITATED.
• ORAL MEDICATION IN LIQUID CONCENTRATE OR TABLET FORM SHOULD BEGIN AS SOON AS
POSSIBLE
• TWO DAILY ORAL DOSES SHOULD SUFFICE, WITH TWO THIRDS OF THE DOSE BEING
GIVEN AT BEDTIME.
• TO ACHIEVE THE SAME THERAPEUTIC EFFECT, THE ORAL DOSE SHOULD BE
APPROXIMATELY 1.5
TIMES THE PARENTERAL DOSE.
• THE EFFECTIVE TOTAL DAILY DOSE OF HALOPERIDOL MAY RANGE FROM 5 TO 40 MG FOR
MOST PATIENTS WITH DELIRIUM.

71. • OTHER ANTIPSYCHOTIC DRUGS FOUND EQUALLY
EFFECTIVE AS HALOPERIDOL
• THIORIDAZINE
• DROPERIDOL
• CHLORPROMAZINE
• HOWEVER, ANTICHOLINERGIC SIDE EFFECTS ARE MORE PROMINENT
WITH THEIR USAGE.

72. ATYPICAL ANTIPSYCHOTICS
• ATYPICAL ANTIPSYCHOTICS HAVE SHOWN SOME PROMISE IN
BEING EFFECTIVE IN MANAGING DELIRIUM
• DRUGS COMMONLY USED
• RISPERIDONE
• OLANZAPINE
• QUETIAPINE
• ALL IN LOW DOSE HAS BEEN FOUND TO BE EFFECTIVE IN
MANAGING AGGRESSION IN DELIRIUM

73. ATYPICAL
ANTIPSYCHOTICS
RISPERIDON
E
0.5–1 MG A DAY EPS CONCERNS LIMITED DATA IN DELIRIUM
OLANZAPINE 5–10 MG A DAY HIGHER MORTALITY IN
DEMENTIA
QUETIAPIN
E
25–150 MG A DAY
PATIENTS WITH PARKINSON'S DISEASE AND DELIRIUM WHO REQUIRE ANTIPSYCHOTIC MEDICATIONS, CLOZAPINE
OR
QUETIAPINE HAVE SOME SUPPORT IN THE LITERATURE AND ARE LESS LIKELY TO EXACERBATE PARKINSONIAN

74. BENZODIAZEPIN
ES
• BENZODIAZEPINES ARE USED IN THE MANAGEMENT OF DELIRIUM TO
SEDATE THE AGITATED PATIENT.
• WHEN THE AGITATION IS ASSOCIATED WITH SEDATIVE-HYPNOTIC
WITHDRAWAL (SUCH AS ALCOHOL, BENZODIAZEPINES, BARBITURATES),
BENZODIAZEPINES ARE THE TREATMENT OF CHOICE.
• INSOMNIA IS BEST TREATED WITH BENZODIAZEPINES WITH SHORT
OR INTERMEDIATE HALF-LIVES (E.G., LORAZEPAM 1 TO 2 MG AT
BEDTIME).
• BENZODIAZEPINES WITH LONG HALF-LIVES AND BARBITURATES SHOULD
BE AVOIDED UNLESS THEY ARE BEING USED AS PART OF THE
TREATMENT FOR THE UNDERLYING DISORDER (E.G., ALCOHOL
LORAZEPAM 0.5–3 MG/DAY AND AS NEEDED EVERY 4 HR
BEST USE IN DELIRIUM SECONDARY TO
ALCOHOL/BENZODIAZEPINE
WITHDRAWAL CAN WORSEN DELIRIUM
Dr.Subrata Nask

75. • PATIENTS EXPERIENCING ALCOHOL WITHDRAWAL SHOULD BE GIVEN
THIAMINE
INTRAMUSCULARLY OR INTRAVENOUSLY TO PREVENT KORSAKOFF'S
SYNDROME
• PATIENTS WITH BENZODIAZEPINE INTOXICATION CAN BE GIVEN
INJ.FLUMAZENIL
• DOSE:
• 0.2MG IV OVER 15-30 SEC.
• IF AFTER 30 SEC NO RESPONSE ADMINISTER 0.3MG OVER 30 SEC 1 MINUTE LATER
• IF NO RESPONSE THEN 0.5MG OVER 30 SEC AT 1 MINS INTERVAL.
• MAX DOSAGE 3 MG.

76. • USE OF CHOLINESTERASE INHIBITORS, SUCH AS PHYSOSTIGMINE,
HAS BEEN SHOWN TO REDUCE THE SEVERITY OF THE DELIRIUM,
PARTICULARLY IN PATIENTS WITH ANTICHOLINERGIC POISONING
• CURRENTLY TRIALS ARE ONGOING TO COMPARE IF DEXMEDETOMIDINE IS
A MORE EFFECTIVE MEDICATION THAN HALOPERIDOL IN THE TREATMENT
OF AGITATION AND DELIRIUM IN PATIENTS RECEIVING MECHANICAL
VENTILATION IN AN INTENSIVE CARE UNIT

77. ELECTROCONVULSIVE THERAPY
(ECT)
• ECT IS ALSO A TREATMENT FOR DELIRIUM WHEN OTHER APPROACHES
HAVE FAILED. .
• IT HAS BEEN USED AS A LAST RESORT FOR DELIRIOUS PATIENTS WITH
SEVERE AGITATION WHO ARE NOT RESPONSIVE TO
PHARMACOTHERAPY, SUCH AS HIGH DOSES OF IV HALOPERIDOL.
SLEEP–WAKE CYCLE
• ATTEMPTS TO RESTORE SLEEP INTEGRITY
• MOVING THE SCHEDULE OF EXISTING SEDATING MEDICATIONS TO THE HOUR OF SLEEP
• REDUCING OR MOVING ACTIVATING MEDICATIONS AND STIMULANTS SUCH AS
CAFFEINE TO THE MORNING.
• BRIEF, JUDICIOUS USE OF SEDATING AGENTS, SUCH AS ZOLPIDEM OR TRAZODONE, TO
RESET THE SLEEP–WAKE CYCLE MAY BE APPROPRIATE.

78. TREATMENT IN SPECIAL
POPULATIONS
PARKINSON'S DISEASE
• THE ANTIPARKINSONIAN AGENTS ARE FREQUENTLY IMPLICATED IN CAUSING DELIRIUM
• DECREASING THE DOSAGE OF THE ANTIPARKINSONIAN AGENT HAS TO BE WEIGHED
AGAINST
A WORSENING OF MOTOR SYMPTOMS
• IF THE DELIRIUM PERSISTS AFTER ATTENUATION OF THE ANTIPARKINSONIAN
AGENTS, CLOZAPINE IS RECOMMENDED
• IF A PATIENT IS NOT ABLE TO TOLERATE CLOZAPINE, ALTERNATIVE ANTIPSYCHOTIC
AGENTS SHOULD BE CONSIDERED.

79. TERMINALLY ILL
PATIENTS
THE FOCUS INITIALLY SHOULD BE AGGRESSIVE SEARCH FOR THE
ETIOLOGY
PALLIATIO
N
COMFORT
ASSISTANCE WITH
DYING

80. NURSING INTERVENTIONS
A.Hospitalization:
• Admit The Patient In Psychiatric Ward
• Give Comfortable Bed ToThe Patient.
• If patient is agitated then use of physical restraint may
be necessary
• Check the vital signs.

81. B. Therapeutic need
• Give the drugs prescribed by the psychiatrist regularly
• When we give oral medicine to the patient see that
whether patient swallows the medicine or not.
• Observe for any side effects.
• Record the dose frequency in nurse record

82. C.Provide safe environment:
Restrict the environmental stimuli, keep unit calm and well-
illuminated.
• There should always be somebody at the patient’s bedside
reassuring and supporting
• As the patient is responding to a terrifying unrealistic world of
hallucinatory illusions and delusions, special precautions are needed
to protect him from himself and to protect others.

83. D.Alleviating patient’s fear and anxiety
• Remove any object in the room that seems to be a source of
misinterpreted perception.
• As much as possible have the same person all the time by
the patient's bedside.
• Keep the room well lighted especially at the night time.

84. E.Meeting the physical needs of the patient’s
• Appropriate care should be provided after physical assessment.
• Use of appropriate nursing measures to reduce high fever, if
present
• Maintain intake and output chart.
• Mouth and skin should be taken care of
• Monitor vital signs.
• Observe patient for any extreme drowsiness and sleep as this may
be an indication that the patient is slipping into a coma

85. F. Facilitate orientation
• Repeatedly explain to the patient where he is and
what date, day and time it is
• Introduce people with name even is the patient
misidentifies the people.
• Have a calendar in the room and tell him what day it
is.
• When the acute stage is over take the patient out and
introduce him to others.

86. NURSING MANAGEMENT
Biologic Assessment
• To assess the symptoms, the nurse needs to know what is
normal for the individual.
• Caregivers, family members, or significant others should be
interviewed because they can often provide valuable
information. Family members may be the only resource for
accurate information.
• History should include a description of the onset, duration,
range, and intensity of associated symptoms

87. Physical Examination and Review of Systems
If the patient is cooperative, a physical examination will be conducted in
the emergency room. Vital signs are crucial. A review of systems must
be conducted in each patient suspected of having delirium or other
organic mental disorders.
Physical Functions
Functional assessment includes physical functional status (activities of
daily living), use of sensory aids (eye glasses and hearing aids), usual
activity level and any recent changes, and pain assessment.

88. Interventions for the Biologic Domain
• Important interventions for a patient experiencing acute confusional
state include providing a safe and therapeutic environment,
maintaining fluid and electrolyte balance and adequate nutrition,
and preventing aspiration and decubitus ulcers, which are often
complications
• Behaviors exhibited by the delirious patient, such as hallucinations,
delusions, illusions, aggression, or agitation (restlessness or
excitability), may pose safety problems.
• The patient must be protected from physical harm by using low
beds, guardrails, and careful supervision

89. Psychological Domain
Assessment
• Mental status examination
Interventions for psychological domain
• Staff should have frequent interaction with patients and support
them if they are confused or hallucinating.
• Patients should be encouraged to express their fears and
discomforts that result from frightening or disconcerting psychotic
experiences.

90. Interventions for the Social Domain
The environment needs to be safe to protect the patient from injury. A
predictable, orienting environment will help to re-establish order to
the patient’s life. That is, a calendar, clocks, and other items may be
provided to help orient the patient to time, place, and person
• support from family
Families can be encouraged to work with staff to reorient the patient
and provide a supportive environment

91. EVALUATION AND TREATMENT OUTCOMES
• Correction of the underlying physiologic alteration
• Resolution of confusion among family members
• verbalization of understanding of confusion
• Prevention of injury

92. Nursing diagnosis
1. Risk for trauma related to impairment in cognitive and psychomotor function
 Store frequently use items within easy access.
 - Keep the dim light on at night.
 - Soft restraints may be required if client is very disoriented and hyperactive.
 - Frequently orient the client to place, time, and situations

93. 2.Disturbed thought process related to cerebral degeneration as evidenced by
disorientation, confusion, and memory deficits.
 - Frequently orient to reality.
 - Use clock and calendars with large number that are easy to read.
 - Monitor for medication side effects.
 - Keep simple explanation.
 - Talk about real people and real events.

94. 3.Self-care deficit related to disorientation, confusion, and memory deficits as
evidence by in ability to fulfil the need.
 - Provide guidance and assistance for independent action.
 - Provide the structural schedule of activities that does not change from day to
day.
 - Involve the family members in the care of the patients.

95. DELIRIUM TREMENS
 Delirium tremens is a psychotic condition caused by the complications from
alcohol withdrawal. It involves tremors, hallucination, anxiety, and
disorientation.
 • Delirium tremens typically occurs in people with a high intake of alcohol
for more than a month.
 • When it occurs, it often lies for three days into the withdrawal syndromes
and last for two to three days.

96. SIGNS AND SYMPTOMS
The main symptoms of delirium tremens are;
 - Nightmares,
 - Disorientation,
 - Hallucinations,
 - Fever,
 - Confusion,
 - High blood pressure

97. causes
 - Delirium tremens is mainly caused by the long period of drinking alcohol
and stopped suddenly.
 - Head injury,
 - Infections,
 - Illness in the people with a history of having use of alcohol.

98. Characteristic features
 - Clouding of consciousness with disorientation.
 - Poor attention span with distractibility.
 - Visual, tactile also hallucination and illusion.
 - Disturbance with tachycardia, fever, sweating, hypertension.
 - Shouting and evidence fear.
 - Insomnia.
 - Will have disorientation related to time and place.
 - Death may occur due to cardiovascular collapse, infection,
hypertension, or self-inflicted injury.

99. MANAGEMENT OF DELIRIUM TREMENS:
1. Keep the patients in a quiet and safe environment.
2. Sedation is usually given with diazepam 10mg, or
lorazepam 4mg, IV or followed by oral administration.
3. Maintain fluid and electrolyte balance.
4. Reassure patient and family

100. RECENT STUDIES
• RECENT STUDIES SHOW THAT DELIRIUM STRONGLY PREDICTS
FUTURE NEW- ONSET DEMENTIA, AS WELL AS ACCELERATING
EXISTING DEMENTIA.
• NEWER STUDIES ON ACH ENHANCERS
• STUDIES DONE ON RIVASTIGMINE SHOW PROMISING RESULTS, BUT SHOULD BE
COMMENCED BEFORE ONSET IF POSSIBLE
• SOME EVIDENCE FOR DONEPEZIL
• 5HT ANTAGONIST - ODANSETRON (8MG/DAY) HAS BEEN FOUND
EFFECTIVE ESPECIALLY IN HYPOACTIVE TYPE, BUT EFFICACY IS
FOUND IN BOTH TYPES.
• STIMULANTS ARE NOW FOUND TO BE EFFECTIVE IN HYPOACTIVE
TYPE - MODAFINIL, METHYLPHENIDATE, DEXAMPHETAMINE

101. RECENT STUDIES
• DRUG MODIFYING NE TRANSMISSION
• ALPHA 2 AGONISTS - CLONIDINE, DEXMEDETOMIDINE
• NEW STUDIES ON DEXMEDETOMIDINE PRE OP AND POSTOP
SHOWS IT REDUCES TRANSITION TO DELIRIUM FROM 40% TO 3-4%
AND REDUCED NEED FOR OPIATE ANALGESICS POST OP
(MALDONADO ET AL, PSYCHOSOMATICS 2009)

102. Sherry Dahlke, MSN, RN, GNC; Alison Phinney, PhD, RN
•Journal of Gerontological Nursing. 2018;34(6):41-47
More than half of hospitalized older adults will experience delirium, which—
if left untreated—can lead to detrimental outcomes. Despite the prevalence
and severity of delirium, nurses recognize less than one third of cases.
Because little is known about how nurses manage this problem, a
qualitative study was conducted to explore how nurses care for hospitalized
older adults at risk for delirium.

103. The data revealed that nurses care for older adults by Taking a Quick
Look, Keeping an Eye on Them, and Controlling the Situation. The context
in which nurses choose their priorities and interventions was reflected in
the themes of the Care Environment and Negative Beliefs and Attitudes
about older adults. Nurses are caring for an older population whose care
requirements are different than those of younger people and in a context
where this challenging work is rarely addressed. To improve care, the older
population must be acknowledged, and nurses must possess the
knowledge and resources needed to meet this population’s unique needs.

104. Conclusion
• Delirium often persists beyond discharge from the hospital. Discharge
planning should routinely include family education and referrals to
community health care providers. If the patient will return to a
residential long- term care setting, communication with facility staff
about the patient’s hospital stay and treatment regimen is crucial.

105. SUMMARY
• DELIRIUM IS A STATE CHARACTERIZED BY AN ACUTE DECLINE IN
BOTH THE LEVEL OF CONSCIOUSNESS AND COGNITION WITH
PARTICULAR IMPAIRMENT IN ATTENTION.
• THERE ARE MULTIPLE ETIOGIES OF DELIRIUM
• 65% UNRECOGNIZED BY PHYSICIANS
• EARLY DIAGNOSIS AND EVALUATION OF CAUSE IS ESSENTIAL
• TREATMENT INCLUDE PHARMACOLOGICAL AND
NON PHARMACOLOGICAL ASPECT
• NON PHARMACOLOGICAL APPROACH IS MORE ESSENTIAL IN
TREATMENT

106. Bibliography:
• R Sreevani, a guide to mental health and psychiatric nursing,
jaypee publishers,
3rd edition, pg.no: 310-311
• Ahuja Niraj, Vyas JN, A Text of Postgraduate Psychiatry, Jaypee
Publications,
2nd Edition. Pg.no: 712-789
• Townsend c Mary, text book on “Psychiatric Mental Health
Nursing.”
Jaypee publications.
5th edition, page 387-405

107. THANK YOU