Approach To Delirium

APPROACH TO
DELIRIUM
UNDER THE GUIDANCE OF UNIT 2
PRESENTED BY :
DR YASHASWINI G U
JR1,GENERAL MEDICINE DEPARTMENT
SOURCE: HARRISON 21st edition
DEFINITION:
• Delirium is a term used to describe an acute confusional state.

• It is a transient global disorder of attention, with clouding of
consciousness
• Many terms are used to describe delirium, including encephalopathy,

acute brain failure, acute confusional state, and postoperative
psychosis or ICU psychosis.
. Onset is usually rapid that fluctuates over hours or days
• The hallmark of delirium is deficit of attention, although
all cognitive domains—including memory, visuospatial tasks,
and language—are variably involved.
• Associated symptoms include altered sleep-wake
cycles,hallucinations or delusions, affect changes, and heart
rate and blood pressure instability
Two subtypes have been described—hyperactive and
hypoactive
• HYPERACTIVE -featuring hallucinations, agitation, and

hyperarousal, often accompanied by life-threatening autonomic
instability
• HYPOACTIVE- patients are withdrawn and quiet, with prominent
apathy and psychomotor slowing. Seen in benzodiazepine intoxication.
Patients who are hypoactive are more often overlooked on the medical
wards and in the ICU.
RISK FACTORS:
The most identified risk factors are
--
older age ,dementia and pre-existing cognitive dysfunction
--Other risk factors include -sensory deprivation, such as preexisting hearing and visual impairment ,poor overall health, malnutrition, and underlying medical or neurologic illness.
--In-hospital risks for delirium include the use of bladder catheterization, sleep and sensory deprivation, and the addition of three or more new medications..
--Surgical and anesthetic risk factors include procedures involving cardiopulmonary bypass, inadequate or excessive treatment of pain in the immediate postop period, and drugs like inhalational anesthetics.
EPIDEMIOLOGY:
• Delirium is a common disorder
• 15% to 45% of hospitalised patients, particularly elderly, are prone to
develop delirium. The average duration is about 1 week, full recovery
in most cases.
PATHOGENESIS:
• The attentional deficit that serves as the neuropsychological hallmark of delirium has a diffuse
localization within the brainstem, thalamus, prefrontal cortex, and parietal lobes.
• right parietal and medial dorsal thalamic lesions have been reported most commonly, pointing to
the importance of these areas in delirium pathogenesis
• EEG usually reveals symmetric slowing, a nonspecific finding that supports diffuse cerebral
dysfunction.
• Multiple neurotransmitter abnormalities, proinflammatory factors, and specific genes likely play a
role in the pathogenesis of delirium.
• Deficiency of acetylcholine may play a key role
• patients with preexisting dementia are particularly susceptible to episodes of delirium.
• In addition increase in dopamine can also lead to delirium
ETIOLOGY:
APPROACH TO DELIRIUM:
• Delirium is a clinical diagnosis that is made only

at the bedside.
• Screening tools can aid physicians and nurses in identifying patients
with delirium, including the Confusion Assessment Method (CAM);
the Nursing Delirium Screening Scale (NuDESC); the Delirium
Rating Scale;the ICU version of the CAM and MMSE
• A course that fluctuates over hours or days and may worsen at night
(termed sundowning) is typical but not essential for the diagnosis.
History:
• Information from a collateral source such as a spouse or another family member is
valuable.
• The three important pieces of history are the patient’s baseline cognitive function,
the time course of the present illness, and current medications.
• Baseline cognitive impairment is common in patients with delirium. Even when
no such history of cognitive impairment is elicited, there should still be a high
suspicion for a previously unrecognized underlying neurologic disorder
• Other elements of the history include screening for symptoms of organ failure or
systemic infection, which often contributes to delirium in the elderly.
• A history of illicit drug use, alcoholism, or toxin exposure is common in younger
delirious patients
• Medication histories should include all prescription as well as over-the-counter
and herbal substances taken by the patient and any recent changes in dosing or
formulation.
PHYSICAL EXAMINATION
• See for signs of infection such as fever, tachypnea, heart murmur, and
meningismus{headache,photophobia,nausea ,neck stiffness}
• The patient’s fluid status should be assessed; both dehydration and fluid overload with resultant
hypoxemia have been associated with delirium
• The appearance of the skin can be helpful, showing jaundice in hepatic encephalopathy, cyanosis
in hypoxemia, or needle tracks in patients using intravenous drugs
• An altered level of consciousness ranging from hyperarousal to lethargy to coma is present in most
patients with delirium
• Tangential speech, a fragmentary flow of ideas, or inability to follow complex commands often
signifies an attentional problem.
To assess attention, a simple bedside test of digit span forward is quick and fairly sensitive. In this
task, patients are asked to repeat successively random digits in a row, said to the patient at one per
second intervals. Healthy adults can repeat a string of five to seven digits before faltering; a digit
span of four or less usually indicates an attentional deficit and many patients with delirium have
digit spans of three or fewer digits .
• The presence of multifocal myoclonus or asterixis on the motor examination is nonspecific but usually
indicates a metabolic or toxic etiology of the delirium.
Laboratory and diagnostic evaluation:
TREATMENT:
Patients with systemic infections should be given appropriate antibiotics, and underlying electrolyte disturbances should Be judiciously corrected
• Simple methods of supportive care can be highly effective.

• Reorientation by the nursing staff and family -combined with visible
clocks, calendars, and outside-facing windows can reduce confusion.
• Sensory isolation should be prevented by providing glasses and
hearing aids to patients who need them.
• Sundowning can be addressed to a large extent through vigilance to
appropriate sleep-wake cycles.
• During the day, a well-lit room should be accompanied by activities
or exercises to prevent napping.
• . At night, a quiet, dark environment with limited interruptions by staff
can assure proper rest; melatonin can be considered before bed to
promote sleep.
• These sleep-wake cycle interventions are especially important in the ICU
setting as the usual constant 24-h activity commonly provokes delirium.
• Simple standard nursing practices such as maintaining proper nutrition
and volume status as well as managing pain, incontinence, also help
alleviate discomfort and resulting confusion.
• when necessary, very-low-dose typical or atypical antipsychotic medications
administered on as-needed basis can be used
• they should be reserved for patients who display severe agitation and significant
potential to harm themselves or staff.
• Although many clinicians use benzodiazepines to treat acute confusion, their use
should be limited to cases in which delirium is caused by alcohol or
benzodiazepine withdrawal
• The two major symptoms of delirium that may require pharmacological treatment
are psychosis and insomnia. Most commonly used drug for psychosis is
haloperidol and risperidone. Depending on age, weight, and physical condition of
patient, the initial dose of haloperidol may range from 2 to 4 mg intramuscularly,
repeated in an hour if the patient remains agitated.
• Insomnia is best treated with short-acting benzodiazepines (e.g. lorazepam 1 to 2
mg at bedtime}
PREVENTION:
• In light of the high morbidity associated with delirium, development
of an effective strategy to prevent delirium in hospitalized patients is
extremely important.
• Successful identification of high-risk patients is the first step,
followed by initiation of appropriate interventions.
• All hospitals and health care systems should work toward decreasing the
incidence of delirium and promptly recognizing and treating the disorder when it
occurs
DELIRIUM TREMENS
• Delirium tremens is a more serious manifestation of alcohol withdrawal.
• Besides tremor and hallucination, there may be global confusion, sleepiness,

restlessness, and autonomic overactivity-hypertension ,flushed, sweating with
tachycardia, fever, dilated pupils. The patient mutters or screams unintelligibly.
• Most attacks of delirium tremens subside in 1 to 2 days but mortality is 15%.
• Treatment includes parenteral vitamin B complex and maintenance of fluid and

electrolytes and benzodiazepines {loraz,diazepam} are most useful.
•
THANK YOU

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APPROACH TO

• Delirium is a term used to describe an acute confusional state.

• Many terms are used to describe delirium, including encephalopathy,

• HYPERACTIVE -featuring hallucinations, agitation, and

• Delirium is a clinical diagnosis that is made only

• Simple methods of supportive care can be highly effective.

• Besides tremor and hallucination, there may be global confusion, sleepiness,

• Treatment includes parenteral vitamin B complex and maintenance of fluid and

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