Transcript Delirium

Delirium
Paul Borghesani MD-PhD
Assistant Professor
Psychiatry and Behavioral Sciences
[email protected]
Delirium:
Defining delirium
“an acute mental disturbance characterized
by confused thinking and disrupted attention
usually accompanied by disordered speech
and hallucinations”
aka
acute confusional state
acute brain failure
encephalopathy
global cognitive impairment
Hippocrates “phrenitis”
“the great imitator”
Delirium:
A gestalt
Etiology
Pathophysiology
?
Neuronal level
Systems level
Cognitive
dysfunction
Goals for today
Review the epidemiology and importance of
detecting delirium
Learn the key features and subtypes of delirium
Explore the pathophysiology of delirium
Learn how to evaluate and treat delirium
Learn to recognize co-morbid delirium in mental
illness
Who could be delirious?
An agitated, combative patient who does not follow
instructions
An obtunded, minimally interactive patient
An emotionally erratic patient who makes
contradictory remarks and who staff cannot logically
engage
A calm, confused patient who is suspicious and
oppositional
Clinical case:
31 y/o with confusion
A 31 y/o previously healthy male is brought in by his roommate
secondary to acute change in mental status. The patient is
confused and bewildered and appears anxious and agitated. He
denies medical problems and states that he takes medications for
anxiety but cannot explain any details. He reports nausea,
headache, tremor and myoclonus. He has mildly elevated WBC
but his labs and vitals are within normal limits.
Questions:
1)What factors suggest this is delirium?
2)What is a possible etiology?
Clinical case:
31 y/o with confusion
A 31 y/o previously healthy male is brought in by his roommate
secondary to acute change in mental status. The patient is
confused and bewildered and appears anxious and agitated. He
denies medical problems and states that he takes medications for
anxiety but cannot explain any details. He reports nausea,
headache, tremor and myoclonus. He has mildly elevated WBC
but his labs and vitals are within normal limits.
Questions:
1)What factors suggest this is delirium?
2)What is a possible etiology?
Clinical keys of delirium
Abrupt onset
Fluctuating symptoms
Difficulty sustaining attention
Appear to have cognitive dysfunction
Clinical case:
31 y/o with confusion
A 31 y/o previously healthy male is brought in by his roommate
secondary to acute change in mental status. The patient is
confused and bewildered and appears anxious and agitated. He
denies medical problems and states that he takes medications for
anxiety but cannot explain any details. He reports nausea,
headache, tremor and myoclonus. He has mildly elevated WBC
but his labs and vitals are within normal limits.
Questions:
1)What factors suggest this is delirium?
2)What is a possible etiology?
Clinical case:
Serotonin syndrome (SS)
Can be caused by any antidepressant
Most cases are associated with polypharmacy
Typical symptoms include
- mental status changes, tremor, myoclonus, hyperreflexia, GI symptoms,
diaphoresis, fever, inducible clonus
Most often confused with neuroleptic malignant
syndrome
- SS is associated with GI symptoms, myoclonus, mild or no laboratory changes
- NMS is associated with more severe rigidity and laboratory changes (low Fe,
dramatically elevated creatine kinase, elevated WBCs)
Perry and Wilborn. Annals of Clinical Psychiatry. 24(2) 155 (2012)
Epidemiology and diagnosis of
delirium
Epidemiology of delirium:
It’s common!
Common in the general population
- 0.4% of all people
- 1.0% in individuals over 55 (over 10% in those > 85)
- 60% of nursing home residents
Common in the medical setting
- 10-30% of elderly in the ER
- 20% of all medical admissions
- 4-53% among hip fracture patients
- 4-28% of elective surgery patients
- 13-72% of cardiac surgery patients
Hall R et at. Best Pract & Research Clin Anaesth, 2012
Inouye, S.K. N Engl J Med, 2006.
Consequences of delirium
Increased length of stay
Increased mortality and morbidity
- Perhaps between 25-75%, as high as MI and sepsis
Prolonged cognitive difficulties
Institutionalization
Delirium:
DSM-5 diagnostic criteria
A. A disturbance in attention and awareness
B. The disturbance develops over a short period of time,
represents a change in function, and fluctuates
C. There is a disturbance in cognition
memory, disorientation, language, visuospatial ability, or perception
D. A and C are not better explained by an established
neurocognitive disorder
E. Evidence from the history, PE or laboratory findings that this
represents another medical condition, substance intoxication
or withdrawal, toxin exposure or due to multiple etiologies.
DSM-5
Delirium:
DSM-5 specifiers
Specify etiology
- Substance intoxication delirium
- Substance withdrawal delirium
- Medication-induced delirium
- Delirium due to another medical condition
- Delirium due to multiple etiologies
Specify characteristics
- acute (hours to days) or persistent (weeks to months)
- hyperactive, hypoactive or mixed
DSM-5
Classification of delirium:
Hyperactive subtype
Agitated, uncooperative and often combative
Psychotic and responding to internal stimuli
Loud and fast speech
Wandering, restless
Appear intoxicated
Classification of delirium:
Hypoactive subtype
Somnolent, inattentive, and uninterested
Poor memory and cognitive abilities
Will be described as having lapses or variable
behavior
Reduced amount and rate of speech
Often missed because they can be left alone
Classification of delirium:
Mixed subtype
Combination of both
Hypoactive and mixed account for about 80% of all
cases
Delirium:
Other DSM-5 delirium syndromes
Other specified delirium
- the full criteria for delirium are not met
- you choose to specify WHY the criteria are not met
- e.g., “attenuated delirium syndrome”
Unspecified delirium
- the full criteria for delirium are not met
- you choose NOT to specify why the criteria are not med
- often appropriate in the ED when etiologies are unknown
DSM-5
Clinical case:
44 y/o non-compliant patient
A 44 y/o male is sustained multiple injures after being hit by a car.
Two days after surgical admission psychiatry is consulted
secondary to his variable refusal of care and an attempted
elopement. He is described as intermittently yelling, throwing food,
and RISing. He is homeless, has known mental illness and a
history of alcoholism. The surgical team is asking if he has
capacity to refuse care. When you meet with him he is disoriented
to time and circumstance and is often incomprehensible because
of mumbling and tangentiality.
Questions:
1)What suggests he is having visual hallucinations?
2)What is a possible etiology of his delirium?
Clinical case:
44 y/o non-compliant patient
A 44 y/o male is sustained multiple injures after being hit by a car.
Three days after surgical admission psychiatry is consulted
secondary to his variable refusal of care and an attempted
elopement. He is described as intermittently yelling, throwing food,
and RISing. He is homeless, has known mental illness and a
history of alcoholism. The surgical team is asking if he has
capacity to refuse care. When you meet with him he is disoriented
to time and circumstance and is often incomprehensible because
of mumbling and tangentiality.
Questions:
1)What suggests he is having visual hallucinations?
2)What is a possible etiology of his delirium? (Hint: he vitals are
unstable)
Clinical case:
Delirium tremens
Onset 2-3 days after last drink
Peaks 4-5 days
Severe autonomic hyperactivity
- fever, tachycardia, tachypnea, hypertension, tremor diaphoresis
Delirium
- confusion, disorientation, agitation, perceptual disturbances including visual
hallucinations
- may/may not be accompanied by seizures
Treat with benzodiazepines
The confusion assessment method (CAM):
An alternative to the DSM-5
Feature 1: Acute onset or fluctuating course
- usually obtained from an informant
Feature 2: Inattention
- from your evaluation, are they distractible or unable to follow the
conversation
Feature 3: Disorganized thinking
- rambling, confused, derailment, illogical, loose associations
Feature 4: Altered level of consciousness
- normal to comatose
Must have Features 1 & 2 and either 3 or 4
Levels of consciousness
Agitated (out of control)
Hyperalert (vigilant)
Alert (normal)
Drowsy (lethargic)
Obtunded (difficult to wake)
Stuporous (v. difficult to wake)
Comatose (unable to wake)
http://www.icudelirium.org/docs/CAM_ICU_training.pdf
Using the PRE-DELIRIC:
PREdiction of DELIRium in ICu patients
van den Boogaard et al. BMJ 2012
Diagnosis of delirium:
Differentiating it from mental illness
Age of onset and history of mental illness
Assess risk factors for delirium
Disorientation
Reduced level of alertness and fluctuations
Speech not typically dysarthric in mental illness
(except in intoxication or withdrawal)
Visual hallucinations are atypical
Diagnosis of delirium:
Differentiating it from dementia
Delirum
Dementia
Attention
impaired
intact early, impaired late
Course
acute, fluctuating
chronic, progressive
Speech
rambling, mumbling
impoverished
Perception
illusions and hallucinations
often normal
Thinking
disorganized
impoverished
Alertness
agitated/obtunded
normal
Algahtani and Abdu. Neurosciences 17(3) 205 (2012)
Clinical case:
79 y/o with confusion
A 79 y/o male who is being treated for a pneumonia is referred to
psychiatry consults for after waking up at night screaming and
disoriented. The consult resident establishes that the patient’s
attention is poor, their memory is impaired, and their speech and
behavior is disorganized. They believe he is delirious and are
considering treatment with haloperidol.
Questions:
1)What is the KEY historical point missing?
2)What should be done before recommending haloperidol?
Etiology, pathophysiology and
clinical assessment of delirium
Etiology:
General principles
Trying to establish and etiology of delirium is
essential
Often multifactorial
Take heed of the vulnerable patient!
- always think about the vulnerability X exposure interaction
The most important graph in medicine
Exposure
High
Sick
Low
Not sick
Low
High
Risk
Etiology of delirium:
Risks
Age, age, age and age
Cognitive dysfunction
- intellectual disabilities, visual impairment, depression, dementia
Prior neuropathology
- stroke, tumor, vasculitis, trauma, history of trauma
Major medical/surgical illness
- hip fracture, ICU stays,
Etiology of delirium:
Exposures
Metabolic and systemic illness
- sepsis, organ failure, electrolyte abnormalities, hypoxia, hypoglycemia, UTI
Endocrinopathies
CNS infections and lesions
Nutritional deficiencies
- thiamine, niacin, B12, folate
Intoxication and withdrawal
Others…
- heat stoke, electrocution, sleep deprivation, MEDICATIONS
Algahtani and Abdu. Neurosciences 17(3) 205 (2012)
Etiology of delirium:
Medications
Anticholinergics/antihistamines
Analgesics
Steroids/sympathomimetics
Sedatives
Anticonvulsants
Antiarrythmics/antihypertensives
Antibiotics (PCN, cephalosporins, quiolones)
“I watch death”
Etiology of delirium:
Life threatening causes
Wernicke’s encephalopathy
Hypoxia
Hypoglycemia
Hypertensive encephalopathy
Intracerebral hemorrhage
Meningitis/encephalitis
Poisoning
Note the mnemonic “WHHHIMP”
Pathophysiology of delirium:
Several hypotheses
Neurotransmitter hypothesis
- hypocholinergic state
i. supported by deliriogenic effects of anticholinergic medications and
dementia
- dopamine (and norepinephrine) excess
ii. supported by intoxicating effects of numerous dopaminergic agonists and
the beneficial effects of antipsychotics
Neuroinflammatory hypothesis
- elevated cortisol, elevated CRP, elevated procalcitonin
- alteration of the BBB and microglia activation disrupts brain function
Hypoxia hypothesis
- disrupted oxygen supply or neurovascular coupling causing neuronal
dysfunction
Neurovascular coupling
Examples of neuropathology associated with delirium
Atrophy
CT
White matter hyperintensities
MRI
Hughes, Patel and Pandharipande. Curr Opinion in Critical Care 2012
Neuroimaging in delirium:
Not generally recommended
Structural changes
- atrophy
- vascular lesions and white matter hyperintesities
- white matter changes (evaluated with diffusion tensor MRI)
Perfusion/metabolic changes
- Reduced blood flow (SPECT imaging)
- Reduced metabolism (PET imaging)
EEG
- diffuse slowing with moderate amplitude common but nonspecific
- useful in ruling out non-convulsive status epilepticus, hepatic encephalopathy
(triphasic waves) and some viral encephalopathies
Functional MRI:
Defining large networks potentially disrupted in delirium
Fox et al. PNAS 2005
Clinical assessment of delirium:
General principles
Review chart for fluctuating course, recent illness,
baseline function
Review medications including PRNs
Review history of substance use, CNS pathology
and mental illness
Gather collateral with emphasis on recent change in
function
Physical exam findings in delirium
Hypotension
- dehydration, sepsis, cardiac disease
Tachycardia
- dehydration, sepsis, cardiac disease, hyperthyroidism, intoxication
Fever
- infection, withdrawal states, NMS
Hypothermia
- sepsis, myxedema, Wernicke’s encephalopathy
Using the MMSE in delirium
Scores < 24 have been suggested to be a threshold
4 key questions of the MMSE
- Year
- Date
- Backward spelling (“DLROW”)
- Figure copying
Fayes et al. J Pain Symptom Manage 30: 41 (2005)
Clinical assessment of delirium:
Laboratory tests
Recommended tests
- Electrolytes, glucose, calcium, CBC, LFTs, UA, Utox and drug levels when
appropriate
Not necessarily recommended, but should be
considered
- CXR, blood cultures, blood gasses, EEG
Use only in appropriate cases
- Neuroimaging (structural with CT or MRI, functional with PET or SPECT)
Clinical case:
24 y/o with acute confusion
A 24 y/o male with history of bipolar disorder presents to the ED
on a hot Seattle summer day with acute confusion, agitation, and
aggressive behavior. He is hyperthermic and has various routine
laboratory abnormalities including elevated WBCs and
hypernatremia. Although poorly cooperative with the exam you
note some rigidity, tremor, tachycardia, diaphoresis, and
tachypnea.
Questions:
1)What other labs would you like to know?
2)What is a possible diagnosis?
Treatment, prevention and
prognosis of delirium
Management:
Basic principles
Search for the underlying cause!
- Medications only treat symptoms, not etiology.
Minimize psychoactive medications
Provide supportive care
- oxygen, hydration and nutrition
- positioning and mobilization
- avoid restraints
- maximize non-pharmacologic care
The goal is an alert and manageable patent, not a
sedated and lethargic patient
Treating delirium:
Non-pharmacologic approaches
Promote sleep hygiene
- visible clock, provide light cycle, avoid night time awakenings
Low stimuli environment
- reduce IV “beeps”, move away from the nursing station
Encourage family visits, consistent staffing
Minimize interrupting patient and unnecessary
moves/tests
Inouye et al., A multicomponent intervention to prevent delirium in hospitalized older
patients.
N Engl J Med, 1999. 340(9): p. 669-76.
Pharmacologic treatment of delirium:
Use only if patient is dangerous or physically/mentally
uncomfortable
Haloperidol is first line
- not if concern for Parkinson’s, Lewy body or Parkinson’s Plus syndrome
- start with 0.5 mg BID PO/IV with 0.5 mg q4 hours PRN
- IV may cause less EPS but it has a short duration of actions
Atypical antipsychotics (no IV forms)
- Risperidone: start at 0.25-0.5 mg PO BID
- Olanzapine: start 2.5-5 mg PO BID (IM form available)
- Quetiapine: start at 12.5-25 mg BID (often preferred given low risk of EPS,
can cause orthostasis)
- All can cause metabolic syndrome if used long term and acutely disrupt
glucose management complicating diabetes treatment
Pharmacologic treatment of delirium:
Guidelines regarding QTc prolongation
Potentially causing V-fib/Torsades des pointes
- men: < 430 normal, 431 - 450 increased, > 451 high
- women: < 450 normal, 451 - 470 increased, > 471 high
- watch for an increase of > 30 msec from baseline
Contributing factors include
- age, female gender, hx of heart disease, CHF, hepatic disease
- low K/Mg, bradycardia, alcohol use, drug use (stimulants), rapid infusion of
drugs
Antipsychotics to be leery of:
- Typical : pimozide, thioridazine, IV haloperidol
- Atypical : ziprasidone > quetiapine > risperidone (newer agents also)
Clinical case:
24 y/o with odd behavior
A 24 y/o male with a history of schizophrenia presents with
fluctuating behavior and cognitive disorganization that is different
from his baseline. He is intermittently mute, postures while
standing, resists movements (negativism), and engages in
echolalia and echopraxia. At times he is conversant, at others fully
unresponsive.
Questions:
1) Is this delirium or catatonia?
2) What medications might be helpful?
Clinical case:
Catatonic symptoms in delirium
Catatonia has 3 or more of the following
- stupor, catalepsy, waxy flexibility, mutism, negativism, posturing,
mannerisms, stereotypy, agitation, grimacing, echolalia, echopraxia
Catatonia can occur in any mental or medical
disorder but should NOT be attributed exclusively to
delirium
Catatonia is frequently treated with benzodiazepines
which can worsen delirium
Recommendation: resolve delirium first, then deal
with catatonia if it remains
Prognosis:
General considerations
Will continue until the underlying cause resolves
Typically resolves in days, but can take substantially
longer in those with known CNS disease
Subsyndromal symptoms can return, even after
days, and caretakers should be informed
Clinical case:
24 y/o with agitation and psychosis
A 24 y/o women with a history of depression is brought to the ED
because of increasing disorganization and hostility. She is
intermittently communicative, and when speaking is pressured and
preoccupied with being chosen by god to save the world. At other
times he stares off into space, mute while performing odd gestures
with her hands. At other times she is tearful, angry and accuses
her family of trying to poison her.
Questions:
1) What is odd about this presentation?
2) Why is the history of depression important here?
3) What is a possible diagnosis?
Clinical case:
Delirious mania (Bell’s Mania)
Delirium may be present in 10-20% of manic
patients
Acute onset of both manic and delirium symptoms
- psychosis and catatonic symptoms are also common
Difficult to treat with antipsychotics and mood
stabilizers
ECT and benzodiazepines seem most effective
As always….rule out all medical causes of delirium
Jacobowski et al. Journal of Psychiatric Practice. 19(1):15 (2013)
Essential take home points
Delirium is common and represents the brain under
stress
Establish the patients baseline function
Always review medication and substance use
Search for an etiology and rectify
Use antipsychotics only when necessary, behavioral
measures should be used first