Transcript Delirium

www.company.com
www.company.com
Delirium Definition
• Acute onset of fluctuating cognitive
impairment and disturbance of
consciousness.
www.company.com
DSM IV Criteria
 Disturbance of consciousness with reduced ability to focus,
sustain or shift attention.
 A change in cognition or development of perceptual
disturbances that is not better accounted for a preexisting,
existed or evolving dementia.
 The disturbance develops over a short period of time and
tends to fluctuate during the course of the day
 There is evidence from this history,physical examination or
labs that the disturbance is caused by the physiological
consequence of a medical condition, substance
intoxication, substance withdrawal, or multiple etiologies.
www.company.com
Clinical characteristics
• Altered consciousness: such as decreased level
of coconsciousness.
• Altered attention: diminished ability to focus,
sustain, or shift attention.
• Disorientation: especially to time & place.
• Decreased memory.
• Rapid onset.
• Brief duration: usually days to weeks.
• fluctuations
www.company.com
Clinical characteristics
• Sometimes worse at night (sun downing)
• Disorganization of thoughts.
• Perceptual disturbances: such as illusion and
hallucinations.
• Disruption of sleep-wake cycle: fragmented
sleep at night, with or without daytime
drowsiness.
• Mood alterations: irritability, dysphoria, anxiety,
euphoria.
• Altered neurological function: as autonomic
hyperactivity or instability.
www.company.com
Types of delirium
• Hypoactive
confusion, somnolence,  alertness
• Hyperactive
agitation, hallucinations, aggression
• Mixed (>60%)
features of both
www.company.com
Epidemiology
• approximately 0.4% of people > 17y.
• approximately 1.1% of people > 55y.
• approximately 10-30% of hospitalized patients
• approximately 40-50% of patients recovering
from hip fracture surgery.
www.company.com
Etiology
• It is usually multifactorial
A. General medical condition
B. Substance related
C. Presence of risk factors
www.company.com
Etiology:
Medical condition
• CNS pathology: tumors, trauma, strokes,
seizures
• Infections
• Electrolyte abnormalities
• Endocrine dysfunctions (hypo or hyper)
• Liver failure hepatic encephalopathy
• Renal failure uremic encephalopathy
• Pulmonary disease with hypoxemia
• Cardiovascular disease: CHF, arrhythmias, MI
• Deficiency states: Thiamine, nicotinic or folic
acid, B12
www.company.com
Etiology: Substance-related
Intoxication
–
–
–
–
–
–
Alcohol
Hallucinogens
Opioids
Marjuana
Stimulants
sedatives
www.company.com
Etiology: Substance-related
Withdrawal
– Alcohol
– Benzodiazepines
– barbiturates
www.company.com
Etiology: Substance-related
Medication-induced
– Anticholinergics (furosemide, digoxin, theophylline,
cimetidine, prednisolone, TCA’s, captopril)
– Analgesics (morphine, codeine..)
– Steroids
– Antiparkinson (anticholinergic and dopaminergic)
– Sedatives (benzodiazepines, barbiturates)
– Anticonvulsants
– Antimicrobials (penicillin, cephalosporins, quinolones)
– Antidepressants
www.company.com
Etiology: Substance-related
Toxins
– Carbon monoxide
– organophosphates
www.company.com
Predisposing risk factors
•
•
•
•
>60 years of age
Male gender
Visual impairment
Underlying brain
pathology such as
stroke, tumor,
vasculitis, trauma,
dementia
• Major medical illness
• Recent major surgery
• Depression
• Functional
dependence
• Dehydration
• Substance
abuse/dependence
• Hip fx
• Metabolic
abnormalities
• Polypharmacy
www.company.com
Precipitating risk factors
•
•
•
•
•
•
•
•
Medications
Severe acute illness
UTI
Hyponatremia
Hypoxemia
Shock
Anemia
Pain
•
•
•
•
Orthopedic surgery
Cardiac surgery
ICU admission
High number of
hospital procedures
www.company.com
The pathophysiology of delirium
• Many hypotheses exist including:
 Neurotransmitter abnormalities
 Inflammatory response with increased
cytokines
 Changes in the blood-brain barrier
permeability
 Widespread reduction of cerebral oxidative
metabolism
 Increased activity of the hypothalamicpituitary adrenal axis
www.company.com
How to evaluate a patient with suspected delirium
• Look with particular attention to level of
consciousness, behavior and level of
cooperativeness
• Look at the overall time course
• Review medication list including scheduled,
doses, recent medications discontinued or
started
• Evaluate for recent medical illness and
interventions
• Screen for history of substance dependence to
determine risk of withdrawal
www.company.com
How to evaluate a patient with suspected delirium
• Review diagnostic studies including labs,
imaging, vital signs
• Interview patient paying close attention to
concentration, level of somnolence, mood
lability, executive function, short term memory
deficits, kinetics. Use MMSE.
• Gather collateral information from family/friends
regarding baseline function, personality, psych
history
www.company.com
Treatment
• First and foremost treat the underlying cause.
• Physical Support : for orientation (calendar,
clock, family pictures, windows),
– have family or friends visit frequently making sure they
introduce themselves, minimize staff switching.
– Patient shoud be neither sensory deprived nor
stimulated by the environment.
www.company.com
Treatment
• Pharmacotherapy: two major symptoms
should be treated are psychosis & insomnia.
– For psychosis:
• Typical antipsychotics (haloperidol) initial dose 26mg IM, repeated if the patient remains agitated.
• Atypical antipsychotics (risperidone) are also used
but limited.
www.company.com
Treatment
– For insomnia:
• Benzodiazepine short or intermediate half-life
(lorazepam) 1-2mg at bed time
www.company.com
www.company.com
Cast
Muhammed Ismail
Ahmed Tarek
Mo 'amen Gomaa
Marwan Saber
www.company.com