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Delirium
Aka: Delirium
- See Also
- Altered Level of Consciousness
- Delirium in Cancer
- Altered Level of Consciousness Causes
- Polypharmacy
- Drug-Drug Interactions in the Elderly
- Toxin Induced Neurologic Changes
- Medication Causes of Delirium in the Elderly
- Epidemiology: Incidence
- Older, hospitalized adults: 30%
- Older surgical patients: 10-50% (varies based on Frailty and procedure complexity)
- Dyer (1995) Arch Intern Med 155:461-5 [PubMed]
- Intensive Care unit: 70%
- McNicoll 2003 J Am Geriatr Soc 51:591-8 [PubMed]
- Emergency department: 10%
- Elie 2000 CMAJ 163:977-81 [PubMed]
- Definition
- Acute Confusional State
- Develops over hours to days
- Contrast to Dementia with onset over months to years
- Waxes and wanes and is reversible
- Contrast to Dementia with a constant, progressive course (with minor fluctuations) and irreversible
- Lewy Body Dementia, as an exception, may present with fluctuations
- Inattention, disorganized thinking and altered level of consciosness
- Contrast to Dementia in which attention and long-term memory are typically preserved
- Types: Psychomotor
- Hypoactive Delirium
- Most common in the elderly and most commonly missed
- Presents with at least 4 criteria
- Unawareness, decreased alertness or lethargy
- Sparse or slow speech, slow movements or staring
- Hyperactive Delirium
- Less common in the elderly
- Presents with at least 3 criteria
- Hypervigilance, restlessness or anxiousness
- Fast or loud speech or swearing
- Irritability, impatience, combativeness, Agitation, anger or uncooperative
- Singing, laughing, euphoria
- Fast motor responses or easy startling
- Distractability, Tangentiality, persistent thoughts or Nightmares
- Mixed Delirium
- Mixed hyperactive and hypoactive features
- Risk Factors: Comorobid Conditions
- Age over 65 years (esp. male gender)
- Underlying Dementia
- Preexisting Major Depression
- Drug Abuse
- Chronic Pain
- Alcohol Abuse and Alcohol Withdrawal
- Prior brain injury (vascular or Traumatic Injury)
- Hearing Loss
- Decreased Visual Acuity
- Insomnia or other sleep deprivation
- Polypharmacy
- Hospitalization or post-surgery
- Multiple comorbid conditions
- Poor nutritional status
- Hepatic failure
- Chronic Renal Failure
- Poor functional status
- Alcohol Abuse
- Risk Factors: Precipitating Factors
- Infectious (precipitates 50% of Delirium cases in elderly)
- Precautions: Elderly with infectious causes
- Fever is absent in up to 20-30% of elderly patients with bacteremia
- Cough and fever are absent in 65% of elderly with Pneumonia
- Abdominal tenderness is absent in 65% of elderly with intra-abdominal infections
- Adedipe (2006) Emerg Med Clin North Am 24(2): 433-48 [PubMed]
- Pneumonia
- Urinary Tract Infection
- Intraabdominal infection
- Soft tissue infection (e.g. Pressure Ulcers)
- Meningitis or Encephalitis
- Cardiopulmonary
- Myocardial Infarction (esp. elderly women and diabetics)
- Congestive Heart Failure
- Dehydration, Hemorrhage or other shock state
- Hypoxia
- Hypercarbia
- Medications
- See Medications to Avoid in Older Adults
- See Medication Causes of Delirium in the Elderly
- See Polypharmacy
- Psychoactive medications, Anticholinergic Medications, Opioids or Benzodiazepines
- More than 3 medications added within 24 hours
- Endocrine and Metabolic
- Electrolyte abnormalities (e.g. Hypercalcemia)
- Acute Hepatic Failure (Hepatic Encephalopathy)
- Acute Renal Failure (Uremic encephalopathy)
- Hypoglycemia or Hyperglycemia
- Thiamine deficiency (e.g. Wernicke Encephalopathy)
- Hypothyroidism or Hyperthyroidism
- Neuropsychiatric
- Cerebrovascular Accident
- Sleep deprivation
- Seizure
- CNS Hemorrhage (Subarachnoid Hemorrhage, Subdural Hematoma, Epidural Hematoma)
- CNS Neoplasm
- Iatrogenic
- Physical Restraints
- Medical procedures
- Indwelling Urinary Catheter
- Other tethers (e.g. telemetry monitoring wires)
- Intensive Care setting
- Miscellaneous
- Hypothermia or hyperthermia (e.g. Heat Stroke)
- Toxin Induced Neurologic Changes
- Causes: Life Threatening Delirium (Mnemonic - "WHHHHIMPS")
- Wernicke Encephalopathy or Alcohol Withdrawal
- Hypoxia or hypercarbia
- Hypoglycemia
- Hypertensive Encephalopathy
- Hyperthermia or Hypothermia
- Intracerebral Hemorrhage
- Meningitis or Encephalitis
- Poisoning (or iatrogenic medication induced)
- Status Epilepticus
- History: Obtain from family or Caregiver
- Evaluate risk factors and causes as listed above
- Home Medications
- All bottles of currently taken medications should be brought to evaluation
- Substance use
- Alcohol Abuse
- Benzodiazepine use
- Exam
- Review Vital Signs
- See Toxin Induced Vital Sign Changes
- Neurologic Exam
- Careful and complete Neurologic Exam
- Abdomen, Pelvis and Rectum
- Occult abdominal infection (e.g. Diverticulitis, Appendicitis)
- Perirectal Abscess
- Skin Exam
- Infected Decubitus Ulcer
- Focus areas for cause
- Hypoxia
- Dehydration
- Infection
- Uncontrolled pain
- Signs
- Fluctuating levels of consciousness
- Inattention
- The cornerstone of Delirium
- Unable to count backwards from 20 or name months or weekdays backwards
- Perseveration
- Decreased alertness
- Disorientation
- Extremes of activity (Somnolence to Agitation)
- Disorganized Thought Processes
- Memory Impairment (especially short term)
- Perceptual disturbances
- Persecutory Delusions are common
- Visual Hallucinations rare except in organic cause
- Emotional lability
- Motor changes
- Myoclonus
- Asterixis
- Labs: Initial
- See Altered Level of Consciousness (includes labs)
- All patients
- Comprehensive metabolic panel (Electrolytes, Liver Function Tests, Renal Function tests)
- Complete Blood Count
- Urinalysis and Urine Culture
- Other labs to consider
- Thyroid Function Tests
- Vitamin B12
- Venous Blood Gas or Arterial Blood Gas
- Blood Alcohol level
- Urine Drug Screen
- Acetaminophen level
- Salicylate level
- Serum Ammonia
- Lactic Acid
- Medication levels (e.g. serum Lithium level or anticonvulsant level)
- C-Reactive Protein (CRP) or Erythrocyte Sedimentation Rate (ESR)
- Lumbar Puncture
- Imaging
- Chest XRay
- Evaluate for occult Pneumonia
- CT Head Indications
- Focal neurologic deficit
- Altered Level of Consciousness
- Recent Head Trauma
- Fever with encephalopathy
- MRI Brain Indications
- Persistent Delirium without obvious cause
- Diagnostics
- Electrocardiogram
- Exclude QTc Prolongation and QRS Widening
- Electroencephalogram
- Diffuse slow waves
- Evaluation
- See Confusion Assessment Method
- See Altered Level of Consciousness (includes labs)
- See Richmond Agitation Sedation Scale (or RASS)
- Focus areas
- Key to evaluation is identifying underlying Delirium cause
- Carefully review medication list and possible ingestions
- Identify sources of infection including a full skin exam
- Identify focal neurologic deficits
- Identify subtle signs of Trauma
- Evaluation: Urgent Indications
- Dramatic Vital Sign change (with associated signs or symptoms)
- Systolic Blood Pressure <90 mmHg
- Heart Rate <50/min or >120/min
- Respirations >30/min
- Temperature <96 F (36 C) or >101 F (38 C)
- Serious findings suggestive of underlying cause
- New focal deficits
- New respiratory distress (e.g. Hypoxia, Dyspnea)
- Cerebrovascular Accident
- Chest Pain
- Hematuria
- Serious psychiatric findings
- See Agitated Delirium
- Escalating aggressive behavior or threats of Violence
- Persistent danger to self or others
- Diagnosis: Criteria (DSM-5 Criteria)
- Key criteria (all 5 must be present)
- Disturbed awareness and attention
- Altered Level of Consciousness
- Altered content (e.g. inattention, lost focus)
- Short duration of symptom onset (Hours to days)
- Rapid deterioration in all higher cortical functions
- Mental status fluctuates widely throughout the day
- Altered cognition or perception from baseline
- Decreased short-term memory, disturbed language or perception (Hallucinations, Delusions)
- History, exam or labs suggests medical cause, Intoxication or medication side effect
- Not due to pre-existing Dementia (or related fluctuations such as sun downing)
- Other factors may be associated
- Psychomotor behavioral disturbance (e.g. change in activity, sleep)
- Emotional disturbance (e.g. fear, depression, euphoria)
- Autonomic Instability (Abnormal Vital Signs)
- References
- (2013) DSM-5, APA
- Differential Diagnosis
- See Altered Level of Consciousness Causes
- Dementia
- Psychosis
- Major Depression
- Management: General
- See Agitated Delirium
- See Agitation in Dementia
- Provides a similar approach as for Agitated Delirium (esp. non-medication management)
- Non-pharmacologic calming techniques are preferred
- Provide a quiet, non-activating environment
- Limit probes, beeping monitors, automatic Blood Pressure cuffs, bright lights
- Limit multiple intravenous lines, nasal oxygen, Bladder catheters
- Avoid Physical Restraints if at all possible
- Admission for Delirium is generally warranted
- Exception: Mild or resolved Delirium symptoms with reliable family and safe environment
- Discharge to home with close supervision and closer interval follow-up
- Consider geriatric unit admission if available for Delirium in elderly patients
- Management: Antipsychotics
- Precautions
- Antipsychotics are associated with increased mortality in the elderly
- Avoid in Parkinsonism due to high risk of Extrapyramidal Side Effects
- Use only short-term and only when non-pharmacologic measures fail
- Limit to monitored settings
- See each agent for contraindications and adverse effects before use
- Agents: First-Line
- Haloperidol 0.25 to 0.5 mg PO or IM every 4 hours (or 0.5 to 1.0 mg twice daily)
- Agents: Second-line
- Risperidone (Risperdal) 0.5 mg orally twice daily
- Olanzapine (Zyprexa) 2.5 to 5 mg orally twice daily
- Quetiapine (Seroquel) 25 mg orally twice daily
- Management: Benzodiazepines
- Use with caution
- May paradoxically exacerbate Agitation
- Indications
- Parkinsonism (in which Antipsychotics are avoided if possible due to Extrapyramidal Side Effects)
- Drug Withdrawal or Alcohol Withdrawal
- Neuroleptic Malignant Syndrome
- Preparations
- Lorazepam 0.5 to 1 mg orally or IV every 4 hours as needed
- Course
- Reversible in over 80% of cases
- Prevention
- Optimize hydration and nutrition
- Early mobilization of patients
- Avoid Sedatives for sleep (see Sleep Hygiene)
- Reduce restraints and catheters
- Reorient patient frequently (involve family presence)
- Correct vision (glasses) and hearing (aids)
- Avoid psychoactive and Anticholinergic Medications
- See Medications to Avoid in Older Adults (STOPP, Beers' Criteria)
- Anticholinergic Medications
- Benzodiazepines
- Narcotics
- Resources
- Delirium and acute problematic behavior in the long-term care setting
- http://www.guideline.gov/content.aspx?id=12379
- References
- Ho Han (2013) Crit Dec Emerg Med 27(11): 11-23
- Khoujah and Magidson (2016) Crit Dec Emerg Med 30(10): 3-10 -Cole (2004) Am J Geriatr Psychiatry 12(1):7-21
- Inouye (2006) N Engl J Med 354(11): 1157-65 [PubMed]
- Kalish (2014) Am Fam Physician 90(3): 150-8 [PubMed]
- Miller (2008) Am Fam Physician 78(11): 1265-70 [PubMed]