Download Delirium - the Peninsula MRCPsych Course

Dr Annette Downey
Consultant Psychiatrist, Exeter
& cognitive analytic therapist
MRCPsych Course, Derriford
June 2011
Definition
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F05 Delirium, not induced by alcohol and other psychoactive
substances
An etiologically nonspecific organic cerebral syndrome characterized by
concurrent disturbances of consciousness and attention, perception,
thinking, memory, psychomotor behaviour, emotion, and the sleep-wake
schedule. The duration is variable and the degree of severity ranges from
mild to very severe. Includes: acute or subacute:
· brain syndrome
· confusional state (nonalcoholic)
· infective psychosis
· organic reaction
· psycho-organic syndrome
Excludes: delirium tremens, alcohol-induced or unspecified ( F10.4 )
F05.0 Delirium not superimposed on dementia, so described F05.1
Delirium superimposed on dementia Conditions meeting the above
criteria but developing in the course of a dementia (F00-F03).
F05.8 Other delirium Delirium of mixed origin
F05.9 Delirium, unspecified
Rates of Delirium
• 30% of hospital inpatients over the age of
65.
• At least 10% of unselected acute medical
admissions in a typical UK hospital.
• Community prevalence of 1-2%
– but 14% in the over 85s
• Usually under diagnosed and
unrecognized by clinical staff
Features for Diagnosis of Delirium
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Disturbance of consciousness, with reduced ability to
focus, sustain or shift attention
A change in cognition (memory/orientation/language)
or the development of a perceptual disturbance that is
not better accounted for by a pre existing /evolving
dementia
The disturbance is over a short time (usually hours to
days) & tends to fluctuate during the course of the day
There is evidence from the history, physical
examination or lab findings of a direct physiological
consequence of a general medical condition,
substance intoxication or substance withdrawal.
Historical Perspective
• Latin: ‘de’ – ‘out of’; lira – ‘the furrow’.
• Old English – delire – to go astray, go wrong,
rave, to wander in mind or to go mad
• Hippocrates 2500 years ago recognized a
clinical syndrome of symptomatic acute mental
disorder associated with fever, which features
cognitive & behavioural disturbance as well as
sleep disruption, which improved when the fever
improved.
Clinical Types of Delirium
• Hyperactive (classical) or florid type – increased
sympathetic activity – increased HR, sweating,
dilated pupils flushed, increased BP; restless &
seek reassurance. Keep other patients awake &
high falls risk
• Hypoactive - poor oral intake, slumped over their
tray, fall asleep mid-conversation – high risk of
pressure sores, malnutrition & dehydration
• Mixed – fluctuates between the two – behaviour
& sleep charts helpful – are often discharged too
early
Predisposing & precipitating
Factors
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Usually multi-factorial (isn’t all of psychiatry?!)
The more factors the higher the risk
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Increased vulnerability mentally & physically
Age related
Dementia/cognitive impairment
Severity of illness
Metabolic/electrolyte imbalance eg dehydration,malnutrition.
Psychoactive medications – neuroleptics/narcotics/anticholinergics, more
than 3 medications added
Use of a bladder catheter
Previous delirium
Visual impairment
Male
Fractures on admission
Use of physical restraint
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Neuropathophysiology
• Neurotransmitters
– Hypothesis of acetylcholine deficiency
• BUT – No cholinergic medication can prevent delirium - Is
this a causal relationship?
• ALSO – other neurotransmitters have been implicated eg
dopaminergic medications of Parkinsons, as well as
dopamine antagonists eg haloperidol treating delirium
• WHAT about the role of serotonin – ‘The serotonin
syndrome’? –seems the same as hyperkinetic delirium.
• OTHER neurotransmitters – Noradrenalin/
GABA/glutamate/Melatonin; or a neurotransmitter balance?
Glucocorticoids
• Hypothalamo-pituitary Axis
• The bodies reaction to physical illness is to
produce glucocorticosteroids
• The hippocampus has high numbers of
receptors
• Hypercortisolism is demonstrated in delirium
assoc with LRTI/ Post op delirium/post stroke
delirium
• BUT most patients with delirium have normal not
supressed cortisol levels.
Cytokines
• Interleukin-2 therapy causes delirium &
this is dose dependent
• Mechanism?
Christ in the Storm, Rembrandt
Other Types of Delirium
• Delirium tremens
• Benzodiazepine withdrawal
Patient Experience
• ‘I was certainly paranoid in the ICU [delirious I suppose],
I was absolutely sure [still am] that an ICU nurse tried to
kill me to sell my organs on ebay - heard the whole
conversation whilst he was sedating me with serious
drugs as I kept ripping ouy my central and trach...’
• ‘When I was in ICU, after waking-up from a drug-induced
coma, I thought I was being held hostage in some kind of
medical lab! I had soft restraints on my hands and I
remember using my foot to try to pull a machine closer to
the bed because I thought I would be able to send out an
"email S.O.S." - I am sure it was an ultrasound machine
or ECG machine.’
Delirium Presents With:
• Sudden onset
• Poor concentration/attention (WORLD)
• Global impairment of time, place and person,
recent memory, and slowed thinking.
• Psychomotor disturbance – either reduced or
agitated
• Disturbed sleeping pattern – eg up all night
• Emotional lability
• Hallucinations – often visual and complex
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June 2011
Confusion Assessment method
(CAM) for Delirium
Inouye, S. Ann Int Med 1990;113:941-948.
Criteria:
• 1. Acute change in mental status,
• AND Observation by a family member, caregiver, or primary care physician
• 2. Symptoms that fluctuate over minutes or hours,
• AND Observation by nursing staff or other caregiver
• 3. Inattention -Patient history, Poor digit recall, inability to recite months of
year backwards
• PLUS4. Altered level of consciousness,
• OR Hyper-alertness, drowsiness, stupor, or coma
• 5. Disorganized thinking, Rambling or incoherent speech
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The first 3 criteria PLUS the fourth OR the fifth criterion must be
present to confirm a diagnosis of delirium.
Video demonstration of the CAM
method
Delirium Differential
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Depression (pseudodementia)
Dementia (chronic confusion)
Motor slowness (Parkinsons /ism)
General physical frailty
Learning disability
Dissociative states/personality
(pseudodementia also).
• Impoverished Social Environment
• Iatrogenic (eg secondary to medication)
• Cognitive Impairment not dementia
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June 2011
Differentiating:
Delirium and Dementia
• Acute often at night
• Fluctuates with lucid
periods
• Lasts hours /days
• Reduced awareness
• Impaired attention
• Disorientated for time
• Visual illusions and
hallucinations
• Disrupted sleep
Annette Downey
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Insidious onset
Stable over a day
Lasts months/years
Clear awareness
Good Attention
Disorientation in later
stages
• Impoverished thinking
• Sleep is usually normal
June 2011
Causes of Delirium
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Infection
Stroke
Drugs
MI
Fractures
Carcinoma
Electrolytes
Heart failure
Diabetes
• Peripheral vascular
disease/gangrene
• Alcohol withdrawal
• GI bleed
• Respiratory failure
• PE
• Anaemia
• Perforated DU
• Subdural
• Brain tumour
Management begins with
obtaining a full history
• Informant History – relatives & carers for
baseline status
• Record chronological progression
• Wide symptom variation
• Length of symptoms
• Insidious or rapid onset
• Gradual or stepwise progression
• Day to day fluctuations
• Describe a typical day
• Consider effect of symptoms on function
Annette Downey
June 2011
Initial Clinical management
• Establish baseline status
• Medical investigations – FBC, glucose, urea,
electrolytes, Ca, LFTs, TFTs, inflammatory markers,
urine dipstick, +/-MSU
• Blood cultures indicated?
• ABG/ CXR/ ECG
• Rectal examination?
• Prompt rehydration/antibiotics & O2
• SC fluids may be a good idea
• Are medications being taken or discarded?
• Accurate fluid & nutritional charting
• Watch out for pressure sores/pneumonia/DVTs
Supportive & behavioural
management
• Appropriate lighting levels for
the time of day
• Regular & repeated cues to
orientation
• Clocks/calandars
• Hearing aids/spectacles
• Continuity of care from nursing
staff
• Encourage mobility & activity
• Approach & handle gently
• Turn off noisy alarms etc
• Analgesia regularly
• Warm milky drinks, relative
quiet & single cubicle if poss
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Encourage family visits
Explain the confusion to family
Fluid & food intake
Adequate CNS oxygen
delivery (sats above 95%)
Sleep hygeine
Avoid ward & hospital transfers
Avoid physical restraint
Rx constipation
Avoid anticholinergics
Avoid catheters where poss
Medication
• Review the ongoing need for
repeat prescriptions
• Consider omitting respiridone, olanzapine/
quetiapine.
• Do Not Stop AChEIs such as donepezil,
rivastigmine, galantamine
• Scrutinize opiates – tramadol
• Follow your local hospital guidelines for the use
of prn sedative medications ie rapid
tranquilization policy for mental health trusts.
Medical treatment
There is not much research to support clinical
practice
• Haloperidol PO 0.5 mg
• Avoid polypharmacy
at 2 hourly intervals
• Side effects are
(max of 5 mg per day)
common
or IM 1-2 mg
• Titrate slowly and
monitor carefully
• Anxiolytics especially for
• Dosette boxes and
lewy body dementia &
blister packs very
patients with parkinsons
helpful in agreement
–lorazepam PO 0.5-1mg
with carers
(max 3 mg per day)
-clonazepam
Annette Downey
June 2011
Communication
• Frightening confusing experience for patients
• Use lucid periods opportunistically
• Warn that it might recur & advise early attendance at GP
surgery
• With relatives/carers – family meetings on the ward –
again opportunistically
– Initially information gathering
– Then education/explanation
about delirium
Help with orientation – photos,
assist at meal times, playing card games,
talking about past times.
Discussing the future
Prognosis
• Delirium is a marker for physical & cognitive
decline
• It is an independent risk factor for poorer
outcomes following admission
• There is a trend to longer inpatient stays
• Increased risk of falls, pressure sores, urinary
incontinence
• Higher readmission rates
• Increased long term institutionalism
• Increased mortality
Adopt A Person Centred Approach
Annette Downey
June 2011
• Each person has a unique life history, set
of relationships and preferences
• The persons actions are not under their
control
• Important to avoid getting angry and
frustrated; avoid challenging the person.
Annette Downey
June 2011