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Taline S Toroussian (CA-1)
02/03/10 (My Birthday)
PACU Presentation
Delirium
Definition:
DSM-IV TR Criteria-1).Disturbance of consciousness with reduced ability to focus,
sustain or shift attention 2).-A change in cognition not accounted for by a preexisting
dementia 3).-Disturbance develops over a short period of time (usually hours to days) and
tends to fluctuate during the course of the day
Classifications:
1).Delirium due to a general medical condition
2).Substance Induced Delirium
3).Substance Withdrawal Delirium
4).Delirium due to multiple etiologies
5).Delirium not otherwise specified
Motoric Subtypes:
-Hypoactive: Decreased Activity, Lethargy, Apathy
-Hyperactive: Increased Activity, Delusions, Hyper alert
-Mixed
Epidemiology:
Emergency department patients: 10-15%
Hospitalized medically ill: 10-30%
Hospitalized elderly patients: 10-40%
ICU patients: 30%
Hospitalized cancer patients: 25%
Post operative patients: 30-40%
– Post CABG:51%
– Post repair of fractured hip:50%
Terminally ill patients:80%
Adapted from Brown and Boyle 2002
Consequences:
Increased Mortality
– 3 year mortality for hospitalized elderly with index episode of delirium
was 75% vs. 51% for non-delirious controls (Curyto et al 2001)
– Delirious patients experienced an adjusted risk of death of almost 2.0
compared to nondelirious controls (Inouye et al 1998)
Even after controlling for age, gender, ADL, dementia and
APACHE II
Increased Morbidity
– Poor functional recovery
– Increased risk of complications
–
–
Increased nursing home placement
Increased costs
Risk Factors:
Elderly
– Decreased cholinergic activity
– Vascular Changes
– Pharmacokinetic changes
CNS disorders
– Dementia represents one of the greatest risk factors
– Stroke
– Parkinson's disease
Multiple Medications
Burn Patients
Low serum albumin
Drug dependency
Etiology: Identification of underlying cause is paramount to treatment
1).Intoxication with drugs
-Many drugs implicated especially anticholinergic agents such as atropine
or scopolamine, NSAIDs, antiparkinsonism agents, antimicrobials,
steroids, opiates, sedative-hypnotics and illicit drugs
2).Withdrawal Syndromes
-Alcohol, sedative-hypnotics and barbiturates
3).Metabolic Causes
-Hepatic, renal or pulmonary insufficiency
-Endocrinopathies such as hypothyroidism, hyperthyroidism,
hypopituitarism or hypoglycemia
-Disorders of fluid and electrolyte balance (ie. hypoglycemia,
hypercalcemia, uremia, hypo or hypernatremia)
4).Infections
-Sepsis, meningitis, pneumonia, and UTI
5).Head trauma
-Subdural hematoma
6).Epilepsy
7).Neoplastic Disease
-CNS metastasis
8).Vascular disorders
-Cerebrovascular
-Cardiovascular
Pathogenesis:
-Dopamine: An excess of dopamine may be a source of the agitation, delusions
and psychoses in delirious patients
-Acetylcholine: Decreased Cholinergic activity produces deficits in: Information
Processing, Arousal, Attention and ability to focus
Other suggested mechanisms:
-GABA which is increased in hepatic encephalopathy or decreased in alcohol
withdrawal
-Cytokines: Implicated in delirium resulting from infection or inflammatory
causes
Clinical Features:
-Prodrome
Subsyndromal symptoms: Subsyndromal symptoms include a change in level of
awareness and ability to focus, sustain or shift attention. This loss of mental clarity is
often subtle and may precede more flagrant signs of delirium so when a family member
says the patient “isn’t acting quite right” it should be taken seriously.
-Temperol Course: Usual for patient with delirium to be lucid during morning rounds and
be unstable in the evening. So can easily miss the diagnosis if a physician relies on only
a single point assessment so behavior changes should be actively solicited from all staff
especially the evening/night shifts
-Diffuse cognitive impairment: Attention deficits
-Memory Impairment: Long and short term
-Disorientation: Commonly to time and place, rarely to person
-Executive dysfunction
-Thought disturbances: Disorganized
-Language Disturbances: Word finding problems, Dysgraphia
-Perceptual disturbances: Misperceptions and Hallucinations (Visual>>>Auditory)
Differential Diagnosis:
1).Sundowning: frequently seen but poorly understood phenomenon of behavioral
deterioration seen in the evening hours, typically in demented, institutionalized patients.
Patients with established sundowning and no obvious medical illness may be suffering
the effects of impaired circadian regulation or nocturnal factors in the institutional
environment (eg, shift changes, noise, reduced staffing). Sundowning should be
presumed to be delirium when it is a new pattern.
2).Dementia: Alzheimers or Lewy bodies
3).Primary Psychiatric Illnesses: Depression, Schizophrenia, Panic Disorder, Bipolar
Treatment
Two important aspects
-Identify and reverse the reason for the delirium
-Reduce psychiatric or behavioral symptoms of delirium
1).Environmental Manipulations
Aims: Cognitively non-demanding/Limit the risk of harm to self and/or
others
Types: Avoid interruption of sleep/Room close to nursing
station/Sitter/Clocks and Calendar/Adequate lighting/Sensory Aids
Major classes of medications utilized
1).Antipsychotics
a).Typical:
Low potency: Not recommended since highly anticholinergic
High Potency: Haloperidol the “gold standard”
-Virtually no anticholinergic properties
-Little risk of hypotension
-Does not suppress respiration
-Can be given IV
-Little cardiotoxicity (Rarely QT prolongation)
-Fast Acting
b).Atypical: The literature is almost devoid of controlled studies; Use,
however is supported on the basis of clinical experience, case reports and
small case studies
-Quetiapine (Seroquel):Start with 12.5-25mg qhs and titrate to effect
-Aripiprazole (Abilify)
-Risperidone (Risperidal)
-Olanzapine (Zyprexa and Zydis):An open trial in 79 hospitalized
cancer patients with delirium (Breitbart et al 2002)76% had complete
resolution with no extrapyramidal side effects;30% experienced sedation
2).Cholinesterase Inhibitors
Physostigmine: Diagnostic tool for anticholinergic toxicity; rarely needed
for treatment although has been used in PACU for emergence delirium
even when no anticholinergic agents have been used with resolvement of
symptoms.
3).Benzodiazepines: Most appropriate for alcohol or sedative-hypnotic withdrawal
Benzodiazepines have a more rapid onset of action than the antipsychotics, but they
commonly worsen confusion and sedation. In a prospective study of intensive care unit
patients, lorazepam was an independent risk factor for incident delirium, increasing the
risk by approximately 20 percent. Surveys of practicing physicians suggest that
benzodiazepines are overprescribed for patients with delirium. These medications are the
drugs of choice for delirium only in cases of sedative drug and alcohol withdrawal. They
may also be useful adjuncts to neuroleptics to reduce extrapyramidal side effects.
Prevention
Four basic principles of prevention:
-Avoiding factors known to cause or aggravate delirium
-Identifying and treating the underlying acute illness
-Providing supportive care to prevent further physical and cognitive
decline
-Controlling dangerous and disruptive behaviors so the first three steps can
be accomplished