PLM
CM
th
OUTLINE
INTRODUCTION
CLINICAL FEATURES OF DELIRIUM
RISK FACTORS
EPIDEMIOLOGY
PATHOGENESIS
APPROACH TO THE PATIENT: DELIRIUM
o HISTORY
o PHYSICAL EXAMINATION
o ETIOLOGY
o LABORATORY AND DIAGNOSTIC EVALUATION
TREATMENT: DELIRIUM
PREVENTION
Confusion
Delirium
INTRODUCTION
a mental and behavioral state of reduced
comprehension, coherence, and capacity to
reason
one of the most common problems encountered
in medicine
accounting for a large number of emergency
department visits, hospital admissions, and
inpatient consultations
an acute confusional state
remains a major cause of morbidity and mortality
rates
costing billions of dollars yearly in health care
costs in the United States alone
often goes unrecognized despite clear evidence
that it is usually the cognitive manifestation of
serious underlying medical or neurologic illness.
Reversibilty
of delirium
Persistence
and
High
recurrence
rates
Effective
primary
prevention
strategy for
delirium
Two
Most
consistently
identified
risks
RISK FACTORS
begins with identification of patients at
highest risk, including those preparing for
elective surgery or being admitted to the
hospital
no single validated scoring system has been
widely
accepted
as
a
screen
for
asymptomatic patients
multiple well-established risk factors for
delirium
older
age
and
baseline
cognitive
dysfunction
Individuals who are over age 65 or exhibit low
scores on standardized tests of cognition
develop delirium upon hospitalization at a
rate approaching 50%.
Its uncertain if the two is truly independent
risk factors.
Other predisposing factors:
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o
o
In-hospital
risks
for
delirium
Development
of
postoperative
delirium
Relationship
between
delirium and
dementia
Dementia
with
Lewy
bodies
Delirium
elderly
in
Development
of delirium
Delirium
EPIDEMIOLOGY
a common disease
reported incidence has varied widely with the
criteria used to define the disorder
Estimates of delirium in hospitalized patients
range from 14 to 56%, with higher rates reported
for elderly patients and patients undergoing hip
surgery.
Older patients in the ICU have especially high
rates of delirium that range from 70 to 87%.
not recognized in up to 1/3 of delirious inpatients
Delirium in the ICU:
o Diagnosis
is
problematic
(cognitive
dysfunction is often difficult to appreciate in
the setting of serious systemic illness and
sedation)
o should be viewed as an important
manifestation of organ dysfunction not
unlike liver, kidney, or heart failure.
Outside the acute hospital setting
o delirium occurs in nearly 2/3 of patients in
nursing homes and in over 80% of those at
In
previous
decades
Now
PATHOGENESIS
Pathogenesis
and incompletely understood
anatomy of delirium
Attentional deficit
serves as the neuropsychological
hallmark of delirium
appears to have a diffuse
localization with the brainstem,
thalamus, prefrontal cortex, and
parietal lobes.
Focal lesions
such as ischemic strokes
rarely, have led to delirium in
otherwise healthy persons
right parietal and medial dorsal
thalamic lesions have been
reported most commonly, pointing
to the relevance of these areas to
delirium pathogenesis
Cortical
and Widespred disturbances in these
subcortical regions
regions cause delirium
Cause of delirium in most cases
rather than a focal neuroanatomic
cause
Electroencephalogram usually show symmetric slowing, a
(EEG)
nonspecific finding that supports
diffuse cerebral dysfunction, in
persons with delirium
Acetylcholine
often plays a key role in delirium
deficiency
pathogenesis
Medications
with can
precipitate
delirium
in
anticholinergic
susceptible individuals,
Therapies
with designed to boost cholinergic tone
cholinergic properties
e.x. cholinesterase inhibitors
have, in small trials, been shown to
relieve symptoms of delirium
Dementia patients
susceptible to episodes of delirium
Those
with
Alzheimers
pathology
o known to have a chronic
cholinergic deficiency state
due to degeneration of
acetylcholine-producing
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Other
neurotransmitters
Exposure to known
inciting factors
neurons
in
the
basal
forebrain
Dementia with Lewy bodies
o Another common dementia
associ- ated with decreased
acetylcholine levels
o clinically mimics delirium in
some patients
are also likely to be involved in this
diffuse cerebral disorder
For
example,
increases
in
dopamine can also lead to
delirium.
o Patients with Parkinsons
disease
treated
with
dopaminergic
medications
can develop a delirium-like
state that features visual
hallucinations, fluctuations,
and confusion.
reducing dopaminergic tone with
dopamine antagonists such as
typical and atypical antipsychotic
medications
has
long
been
recognized
as
effective
symptomatic
treatment
in
patients with delirium.
Screening
tools
Using CAM
Acutely
confused
patients
Not
essential
for
diagnosis
Observation
Other
hallmark
features
Accurate
history
Information
from
collateral
source
3
Most
important
pieces
of
history
Premorbid
cognitive
function
Delirium by
definition
disorganized thinking or
Time
course
of
cognitive
change
Medications
Other
important
elements of
the history
General
Neurologic
Altered level
consciousness
of
Patients w/ normal
level
of
consciousness
evaluation
Some but not all patients exhibit the
characteristic pattern of sundowning,
a wors- ening of their condition in the
evening.
In these cases, assessment only
during morning rounds may be falsely
reassuring.
ranging from hyperarousal to lethargy
to coma is present in most patients
with delirium
can be assessed easily at the bedside
Attention
Forman
neuropsychological
testing
New
focal
neurologic deficits
Signs
of
neurodegenerative
conditions
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Motor examination
Etiologies
Prescribed,
pver-thecounter,
and
herbal
medications
Metabolic
abnormalities
ETIOLOGY
Some can be easily discerned through a
careful history and physical examination
others require confirmation with laboratory
studies, imaging, or other ancillary tests
A large, diverse group of insults can lead
to delirium, and the cause in many
patients is often multifactorial.
common precipitants of delirium
Drugs with anticholinergic properties,
narcotics, and benzodiazepines are
especially common offenders, but nearly
any compound can lead to cognitive
dysfunction in a predisposed patient.
elderly patient with baseline dementia
may become delirious upon exposure to a
relatively low dose of a medication
less susceptible individuals may become
delirious only with very high doses of the
same medication
importance of correlating the timing of
recent medication changes, including
dose and formulation, with the onset of
cognitive dysfunction
common causes of delirium, especially in
younger patients
increase in delirious young persons
presenting to acute care settings due to
recent rise in availability of so-called club
drugs,
o methylenedioxymethamphetamine
(MDMA, ecstasy),
o -hydroxybutyrate (GHB)
o phencyclidine (PCP)-like agent
ketamine
Many common prescription drugs such as
oral narcotics and benzodiazepines are
often abused and readily available on the
street.
Alcohol intoxication with high serum
levels can cause confusion
withdrawal from alcohol
o more commonly leads to a classic
hyperactive delirium
Alcohol and benzodiazepine withdrawal
o should be considered in all cases
of delirium
o patients who drink only a few
servings of alcohol every day can
experience
relatively
severe
withdrawal
symptoms
upon
hospitalization
electrolyte disturbances of sodium,
calcium, magnesium, or glucose
o can cause delirium
mild derangements
o can lead to substantial cognitive
disturbances
in
susceptible
individuals
Other common metabolic etiologies:
Systemic
infections
Exposure
to
unfamiliar
environment of a
hospital
Cerebrovascular
etiologies
Seizures
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Terminal
restlessness
EEG
Management
of delirium
Simple
methods of
supportive
care
TREATMENT: DELIRIUM
begins with treatment of the underlying
inciting factor
o patients with systemic infections should
be given appropriate antibiotics
o underlying electrolyte disturbances
judiciously corrected
These treatments often lead to prompt
resolution of delirium.
Blindly targeting the symptoms of delirium
pharmacologically
o only serves to prolong the time patients
remain in the confused state
o may
mask
important
diagnostic
information
medications used to boost cholinergic
tone in delirious patients
o led to mixed results
o not currently recommended
Acute
management
o
o
o
o
PREVENTION
It is extremely important to develop effective strategy to
prevent delirium in hospitalizations, because of:
o high morbidity associated with delirium
o
tremendously increased health care costs that
accompany it
First step:
o Successful identification of high-risk patients
followed by:
o initiation of appropriate interventions
One trial randomized more than 850 elderly inpatients to
simple standardized protocols used to manage risk factors for
delirium, including cognitive impairment, immobility, visual
impairment, hearing impairment, sleep deprivation, and
dehydration.
Significant reductions in the number and duration of
episodes of delirium were observed in the treatment group,
but unfortunately, delirium recurrence rates were
unchanged.
Recent trials in the ICU have focused on identifying sedatives,
such as dexmedetomidine, that are less likely to lead to
delirium in critically ill patients.
All hospitals and health care systems should work toward
developing standardized protocols to address common risk
factors with the goal of decreasing the incidence of delirium.
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