Transcript Delirium - QStation

Delirium
Danielle Hansen, DO
August 16, 2006
Objectives
1. The physician will identify
common causes of delirium.
2. The physician will know how to
evaluate patients with delirium.
3. The physician will know how to
treat delirium.
Definition
1. Disturbance of consciousness and
attention difficulties.
2. Change in cognition or development of
perceptual disturbance.
3. Onset over short time and fluctuates
during the course of the day.
4. Caused by medical condition, substance
intoxication, or medication side effect.
DSM-IV
Epidemiology
70
60
50
40
30
20
10
0
ICU
Surgery
Hospice
Medicine
ECF
ER
Epidemiology
Prolonged Hospitalizations
Functional Decline
High Risk of Institutionalization
Mortality 14% and 22% at one month and
at six months, respectively
Cole and Primeau, 1993
Pathogenesis
Structural Brain Lesions
Global Cortical Functional Impairment
Neurotransmitter Dysfunction
Cytokine Activation
Structural Brain Lesions
Ascending Reticular
Activating System

Arousal and Attention
Parietal and Frontal
Lobes

Attention
Frontal Lobe

Insight and Judgment
Global Cortical Functional
Impairment
Normal EEG
Global Cortical Functional
Impairment
Slowing of dominant alpha rhythm
Abnormal slow wave activity
Neurotransmitter Dysfunction
Acetylcholine
Neuropeptides
(ie. Somatostatin)
Endorphins
Serotonin
Norepinephrine
GABA
Risk Factors
History of Dementia or Brain Disease
Advanced Age
Sensory Impairment
Polypharmacy
Dehydration/Malnutrition
Immobility
Infection
Bladder Catheters
Causes
Toxins
Metabolic Derangements
Brain Disorders
Systemic Organ Failure
Physical Disorders
Toxins
Drugs


Prescription Medications
Drugs of Abuse
Infection
Poisons
Metabolic Derangements
Electrolyte Disturbance
Endocrine Disturbance
Hyper/Hypoglycemia
Hypercarbia/Hypoxemia
Inborn Errors of Metabolism
Nutritional Deficiencies
Brain Disorders
CNS Infections
Seizures
Head Injury
Hypertensive Encephalopathy
Psychiatric Disorders
Systemic Organ Failure
Cardiac
Hematologic
Liver
Pulmonary
Renal
Icteric sclera
Cyanosis
Physical Disorders
Burns
Electrocution
Hyper/Hypothermia
Trauma
Evaluation
History
Physical Exam
Neurologic Exam
Diagnostic Instruments
Medication Review
Laboratory Testing
Neuroimaging
Lumbar Puncture
EEG
Confusion Assessment Method
Feature
Assessment
1. Acute onset and fluctuating course
Usually obtained from a family member or nurse and shown by
positive responses to the following questions: “Is there
evidence of an acute change in mental status form the
patient’s baseline?” “Did the abnormal behavior fluctuate
during the day, that is, tend to come and go, or increase and
decrease in severity?
2. Inattention
Shown by positive response to the following: “Did the patient
have difficulty focusing attention, for example, being easily
distractible or having difficulty keeping track of what was being
said?”
3. Disorganized thinking
Shown by positive response to the following: “Was the
patient’s thinking disorganized or incoherent, such as rambling
or irrelevant conversation, unclear or illogical flow of ideas, or
unpredictable switching from subject to subject?”
4. Altered level of consciousness
Shown by any answer other than “alert” to the following:
“Overall, how would you rate this patient’s level of
consciousness?” Alert/vigilant/lethargic/stupor/coma.
The diagnosis of Delirium requires the presence of features 1 AND 2 plus 3 OR 4.
Principles of Prevention and
Treatment
1. Avoid aggravating or causative factors.
2. Identify and treat underlying acute
illness.
3. Provide supportive and restorative care
to prevent further physical and cognitive
decline.
4. Control dangerous and disruptive
behaviors.
Supportive Care
Limit number of room changes
Glasses, hearing devices
Orienting stimuli
Hydration/nutrition
Mobility
Pain management
Behavior Management
Constant observation
Frequent reassurance and reorientation
Physical restraints
Psychotropic Medications
Haloperidol 0.5-1mg PO/IV/IM



Low incidence of hypotension or sedation
Onset of action 30-60 minutes (IM/IV)
Extra pyramidal side effects
Lorazepam 0.5-1mg


Onset of action 5 minutes (IV)
Worsen confusion and sedation
Atypical Antipsychotics

Increase risk of CV events and mortality
Competency Exam
78 y/o white male is brought to the ER from an
ECF via EMS for reports of mental status
change. Upon arrival in the ER, the patient is
found to be pleasantly confused, A&O x 1. His
vital signs are: BP 106/70, P 96, R 16, T 96.0.
The patient is unable to provide a full history but
records from the ECF accompany him and his
daughter arrives at the ER shortly after the
patient. His PMHx is significant for HTN, Afib,
DM, OA.
1. All of the following are included in your
initial work up of this patient except:
A.
CBC, CMP
B.
U/A C&S
C.
Chest X-ray
D.
Accucheck
E.
Psych Eval
E. Psych Eval
2. Which of the following could be the
etiology of this patient’s “mental status
change?”
A. Opiate analgesics
B. Parietal lobe CVA
C. Urinary Tract Infection
D. Electrolyte Abnormalities
E. All of the Above
E. All of the Above
3. Your workup reveals a urinary tract infection.
The patient is admitted to the general medical
floor. At 11:00PM, the nurse calls you stating the
patient is combative and has pulled out his IV.
After the behavior modification failed, you order:
A. Ativan 0.5mg
B. Haldol 0.5mg
C. Risperdal 1mg
D. Soft Wrist Restraints
E. Pysch Consult
B. Haldol