Delirium

Introduction Delirium or acute confusional state is a transient global disorder of cognition. The condition is a medical emergency associated with increased morbidity and mortality rates. Early diagnosis and resolution of symptoms are correlated with the most favorable outcomes. Therefore, it must be treated as a medical emergency. Delirium is not a disease but a syndrome with multiple causes that result in a similar constellation of symptoms. Delirium is defined as a transient, usually reversible, cause of cerebral dysfunction and manifests clinically with a wide range of neuropsychiatric abnormalities. The clinical hallmarks are decreased attention span and a waxing and waning type of confusion. Delirium often is unrecognized or misdiagnosed and commonly is mistaken fordementia, depression, mania, an acute schizophrenic reaction, or part of old age (patients who are elderly are expected to become confused in the hospital). The word delirium is derived from the Latin term meaning "off the track." This syndrome was reported during Hippocrates' time, and, in 1813, Sutton described delirium tremens. Later, Wernicke described the encephalopathy that bears his name. Mortality/Morbidity In patients who are admitted with delirium, mortality rates are 10-26%. Patients who develop delirium during hospitalization have a mortality rate of 22-76% and a high rate of death during the months following discharge. In patients who are elderly and patients in the postoperative period, delirium may result in a prolonged hospital stay, increased complications, increased cost, and long-term disability. Age Delirium can occur at any age, but it occurs more commonly in patients who are elderly and have compromised mental status. Delirium can occur on top of an underlying dementia. This diagnosis here requires not only a careful mental status but also a thorough history from the patient's family and the staff as well as a comprehensive chart review. Causes Almost any medical illness, intoxication, or medication can cause delirium. Often, delirium is multifactorial in etiology, and the physician treating the delirium should investigate each cause contributing to it. Medications are the most common reversible cause of delirium. DSM-IV-TR classification of delirium

Delirium due to general medical condition Substance intoxication delirium Substance withdrawal delirium Delirium due to multiple etiologies Delirium not otherwise specified

Some of the other common reversible causes include the following: Hypoxia Hypoglycemia Hyperthermia Anticholinergic delirium Alcohol or sedative withdrawal

Other causes of delirium include the following: Infections Metabolic abnormalities Structural lesions of the brain Postoperative states Miscellaneous causes, such as sensory deprivation, sleep deprivation, fecal impaction, urinary retention, and change of environment In persons who are elderly, medications at therapeutic doses and levels can cause delirium. Although numerous risk factors have been described, a recent study identified 5 important independent risk factors. Use of physical restraints Malnutrition Use of a bladder catheter Any iatrogenic event Use of 3 or more medications

Dementia is one of the strongest most consistent risk factors. Underlying dementia is observed in 25-50% of patients. The presence of dementia increases the risk of delirium 2-3 times. Low educational level, which may be an indicator of low cognitive reserve, is associated with increased vulnerability to delirium. Dysphoric mood and hopelessness are also risk factors for incident delirium. Structural changes

Closed head injury or cerebral hemorrhage Cerebrovascular accidents, such as cerebral infarction, subarachnoid hemorrhage, and hypertensive encephalopathy Primary or metastatic brain tumors Brain abscess Metabolic causes Fluid and electrolyte abnormalities, acid-base disturbances, and hypoxia Hypoglycemia Hepatic or renal failure Vitamin deficiency states (especially thiamine and cyanocobalamin) Endocrinopathies associated with the thyroid and parathyroid Hypoperfusion states Shock Congestive heart failure Mild cognitive impairment and vascular risk factors can be independent risk factors for postoperative delirium. Drugs are a common risk factor for delirium, and drug-induced delirium is commonly seen in medical practice, especially in hospital settings. The risk of anticholinergic toxicity is greater in elderly persons, and the risk of inducing delirium by medications is high in frail, elderly persons and in those with dementia.

DSM-IV-TR diagnostic criteria for delirium is as follows:

Disturbance of consciousness (ie, reduced clarity of awareness of the environment) occurs, with reduced ability to focus, sustain, or shift attention. Change in cognition (eg, memory deficit, disorientation, language disturbance, perceptual disturbance) occurs that is not better accounted for by a preexisting, established, or evolving dementia. The disturbance develops over a short period (usually hours to days) and tends to fluctuate during the course of the day. Evidence from the history, physical examination, or laboratory findings is present that indicates the disturbance is caused by a direct physiologic consequence of a general medical condition, an intoxicating substance, medication use, or more than one cause. Other diagnostic instruments are the Delirium Symptom Interview (DSI) and the Confusion Assessment Method (CAM).[20] Delirium symptom severity can be assessed by the Delirium Rating Scale (DRS) and the Memorial Delirium Assessment Scale (MDAS).

Symptoms Signs and symptoms of delirium usually appear in a short period of time, from a few hours to a few days. The symptoms often fluctuate throughout the day. Therefore, a person may have

periods of no symptoms. The primary signs and symptoms of delirium include the following factors.

Reduced awareness of the environment This may result in: An inability to stay focused on a topic Wandering attention Getting stuck on an idea rather than responding to questions or conversation Being easily distracted by unimportant things Cognitive impairment, or poor thinking skills This may appear as: Poor memory, particularly of recent events Disorientation, or not knowing where one is, who one is or what time of day it is Difficulty speaking or recalling words Rambling or nonsense speech Difficulty understanding speech Difficulty reading or writing Other common symptoms Seeing things that don't exist (hallucinations) Agitation, irritability or combative behavior Little or no activity or little response to the environment Disturbed sleep habits Extreme emotions, such as fear, anxiety, anger or depression Treatments and drugs The first goal of treatment for delirium is to address any underlying causes or triggering factors is by stopping use of a particular medication, for example, or treating an infection. Treatment then focuses on creating an optimal environment for healing the body and calming the brain. Supportive care Supportive care aims to prevent complications by protecting the airway, providing fluids and nutrition, assisting with movement, treating pain, addressing incontinence and keeping people with delirium oriented to their surroundings. A number of simple, nondrug approaches have been found to help:

Clocks and calendars to help a person stay oriented A calm, comfortable environment that includes familiar objects from home Regular verbal reminders of current location and what's happening Involvement of family members Avoidance of change in surroundings and caregivers Uninterrupted periods of sleep at night, with low levels of noise and little light Open blinds during the day to promote daytime alertness and a regular sleep-wake cycle Avoidance of physical restraints and bladder tubes Use of music, massage and relaxation techniques to ease agitation Opportunities to get out of bed, walk and perform self-care activities Provision of glasses, hearing aids and interpreters as needed

Medications Drug treatment is used to calm a person only when severe agitation or confusion: Prevents the performance of a necessary medical exam or treatment Endangers the person or threatens the safety of others Doesn't lessen with nondrug treatments

*The usual drug of choice is an antipsychotic medication such as haloperidol and other neuroleptic dopamine blockers., which may lessen the disorganized thinking that accompanies delirium.

Dementia
Introduction Dementia is a progressive decline in memory and at least one other cognitive area in an alert person. These cognitive areas include attention, orientation, judgment, abstract thinking and personality. Men appear to be affected slightly more frequently than women, but this difference may not be significant. Dementia is rare in under 50 years of age and the incidence increases with age; 8% in >65 and 30% in >85 years of age. Familial cases tend to be younger. Causes and Risk Factors There are several risk factors for dementia: Age Downs Syndrome Head injury Fewer years of education Female Genetics

Symptoms Dementia symptoms vary depending on the cause, but common signs and symptoms include: Memory loss Difficulty communicating Inability to learn or remember new information Difficulty with planning and organizing Difficulty with coordination and motor functions Personality changes Inability to reason Inappropriate behaviour Paranoia

Agitation Hallucinations

Diagnosis There are three purposes why diagnosing dementia is essential. 1. By determining the probable cause, treatable disorders can be identified, such as medication toxicity (benzos, H2 blockers and anticholinergics), and thyroid disease. 2. There are symptoms and comorbidities that are treatable, such as depression, delirium (see below), delusions, hallucinations, and agitation. 3. Caregivers must be identified and environmental issues taken into consideration. A diagnosis of dementia is based on: memory loss - both in short and long-term, plus one or more of the following: aphasia language problems apraxia organizational problems agnosia unable to recognize objects or tell their purpose disturbed executive function personality and inhibition
Executive function is an umbrella term for cognitive processes such as planning, working memory,attention, problem solving, verbal reasoning, inhibition, mental flexibility, multitasking, and initiation and monitoring of actions.

Assessment An assessment for dementia may include the following: History, both from the patient and close observers

During the history taking, the clinician seeks to elicit the development of the illness. The clinician should obtain a detailed rendition of changes in the patient's daily
routine involving such factors as self-care, job responsibilities, and work habits; meal preparation; shopping and personal support; interactions with friends; hobbies and sports; reading interests; religious, social, and recreational activities; and ability to maintain personal finances. Understanding the past life of each patient provides an invaluable source of baseline data regarding changes in function, such as attention and concentration, intellectual abilities, personality, motor skills, and mood and perception. Such a method provides the opportunity to appraise both the impact of the illness and the patient-specific baseline for monitoring the effects of future therapies. Focused physical Examination Mental Status Examination

Mental status examination is a means of surveying functions and abilities, to allow a definition of personal strengths and weakness. It also establishes the basis for future comparison, essential for documenting therapeutic effectiveness, and it allows comparisons between different patients, with a generalization of findings from one patient to another. Lab work including CBC, basic metabolic profile, TSH, Vitamin B12, STS In particular, most systemic medical or primary cerebral diseases that lead to psychopathological disturbances also manifest with a variety of peripheral or central abnormalities. If brain injury or space occupying lesion such as a tumor is in question, CT, or MRI.

*Additionally, depression, delirium (discussed below), agitation, hallucinations, and delusions are important comorbidities that must be taken into consideration. Behavorial issues may require a referral to a specialist.

Treatment There are both pharmacologic and non-pharmacologic interventions that may be beneficial for patients with dementia. Non-pharmacologic Interventions Social activities Adequate sleep Adherence to a strict schedule Maintenance of a proper stimulation level Adequate hydration Reformatting task (occupation therapy) Support caregivers

*Caregivers can be taught strategies to reduce behavioral disturbances in patients with dementing illnesses such as Alzheimer's disease. One approach involves the three R's (repeat, reassure, and redirect). With this approach, the caregiver repeats an instruction or answer to a question as needed and redirects the patient to another activity to divert attention from a problematic situation. A predictable routine is also important and may avert certain
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behavioral problems. For example, scheduled toileting or prompted voiding can reduce urinary incontinence.

Pharmacologic Interventions (course is typically 10 years, but 2-20 possible) Prevention

* Vitamin E, and cognitive stimulation such as education (may slow the progression of functional symptoms in patients with Alzheimer's disease) Memory/attention Acetylcholinesterase Inhibitors

Treatment with cholinesterase inhibitors can provide modest improvement of symptoms, temporary stabilization of cognition, or reduction in the rate of cognitive decline in some patients with dementia Alzheimers Type. Four cholinesterase inhibitors are currently available: donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl), and tacrine (Cognex). These agents raise acetylcholine levels in the brain by inhibiting acetylcholinesterase.
TABLE 1

Cholinesterase Inhibitors for the Treatment of Cognitive Deficits in Patients with Mild to Moderate Alzheimer's Disease
Drug Suggested dosage Side effects Specific cautions

Donepezil (Aricept)

Initial dosage is 5 mg once daily; if necessary, dosage can be increased to 10 mg once daily after 4 to 6 weeks.

Mild side effects, including nausea, vomiting, and diarrhea; these effects can be reduced by taking donepezil with food.Initial increase of agitation in some patients; agitation typically subsides after a few weeks.

Conflicting evidence about possible interactions with cimetidine (Tagamet), theophylline, warfarin (Coumadin), and digoxin(Lanoxin)

Rivastigmine Initial dosage of 1.5 mg Nausea, vomiting, diarrhea, Weight loss Interacting drugs (Exelon) twice daily (3 mg per headaches, dizziness, include aminoglycosides and day) is generally well abdominal pain, fatigue, procainamide (Procanbid). tolerated; dosage can malaise, anxiety, and agitation; be increased as these effects can be reduced tolerated but no more by taking rivastigmine with quickly than by 1.5 mg food. twice daily (3 mg per day) every 4 weeks to maximum of 6 mg twice

Drug

Suggested dosage

Side effects

Specific cautions

daily (12 mg per day). Twice-daily dosing is as efficacious as thricedaily dosing and has comparable tolerability. Galantamine Initial dosage is 4 mg Mild side effects, including (Reminyl) twice daily (8 mg per nausea, vomiting, and day) taken with the diarrhea; these galantamine morning and evening with food.No apparent meals for 4 weeks; association with sleep dosage is then disturbances (which can occur increased to 8 mg twice treatments) daily (16 mg per day) for at least 4 weeks. An increase to 12 mg twice daily (24 mg per day) should be considered on an individual basis, depending on clinical benefit and tolerability. Tacrine Initial dosage is 10 mg (Cognex) and four times daily (40 mg procainamide per day) for 4 weeks; dosage is increased to 20 mg four times daily (80 mg per day) for 4 weeks, then to 30 mg four times daily (120 mg per day) for 4 weeks, etc., until maximum tolerated dosage is achieved. Maximum dosage is 40 mg four times daily (160 mg per day). Contraindicated for use in patients with hepatic or renal impairment effects can be reduced by taking with other cholinergic

High incidence of side effects, Interacting drugs include problems; these effects can be theophylline including reduced by taking tacrine with gastrointestinalHepatotoxicity is a food. The most common side problem; hence, liver tests should effect of tacrine is an be performed every other week for increase in aliver test called 16 weeks and every 3 months alanine aminotransferase thereafter.

(ALT) as a result of liver damage. When a patient starts taking tacrine, blood is drawn on a weekly basis to measure ALT. If there is an increase in blood ALT, the dosage of tacrine can be reduced. Other side effects of tacrine include

NMDA antagonists * Memantine * Others (Ginkgo biloba, caffeine, nicotine, methylphenidate, NSAIDs)

Behavioral * Antipsychotics

* Antidepressants * Mood stabililizers

*Selective serotonin reuptake inhibitors(SSRI), such as citalopram (Celexa) and sertraline (Zoloft), appear to be effective and have few side effects; thus, they are the agents of choice for the treatment of depression in patients with dementia.

Clinical Features of Delirium Contrasted with Dementia

Feature Dementia Delirium Onset Slow Rapid Duration Months to years Hours to weeks Attention Preserved Fluctuates Memory Impaired remote memory Impaired recent and immediate memory Speech Word-finding difficulty Incoherent (slow or rapid) Sleep & wake cycle Fragmented sleep Frequent disruption (e.g., day & night reversal) Thoughts Impoverished Disorganized Awareness Unchanged Reduced Alertness Usually normal Hypervigilant or reduced vigilance (Adapted from Lipowski ZJ. Delirium: Acute Confusional States. Oxford: Oxford University Press; 1990, with permission.)
Case study A 78-year-old female was brought to the Emergency Department by her daughter for vomiting, new onset urinary incontinence, confusion, and incoherent speech for the past 2 days. The patient was disoriented and could see people climbing trees outside the window. She had difficulty sustaining attention, and her level of consciousness waxed and waned. She had been talking about her deceased husband. Patient was also trying to pull out her intravenous access line. Past history included diabetes mellitus, hyperlipidemia, osteoarthritis, and stroke.

The patient's family physician had recently prescribed Tylenol with codeine for the patient's severe knee pain 5 days earlier. On examination, the patient was drowsy and falling asleep while practitioners were talking to her. Patient was not cooperative with the physical examination and with a formal mental status examination. Limited examination of the abdomen indicated that it was flat and soft with normal bowel sounds. The patient moves all 4 limbs and plantar is bilateral flexor. Laboratory test results revealed elevated BUN and creatinine levels, and the urine analysis was positive for urinary tract infection. CT scan of the head showed cortical atrophy. Delirium or Dementia? Sources: http://emedicine.medscape.com/article/288890-treatment http://www.mayoclinic.com/health/delirium/DS01064/DSECTION=symptoms Kaplan and Saddocks Synopsis of Psychiatry: Behavioral Signs/Clinical Psychiatry, 10th edition