LATIN WORD

Deliro=to be crazy

MODERATOR- DR ABHAY JAIN

[PROFESSOR & HEAD OF DEPARTMENT]

PRESENTED BY-DR ANKUSH SHARMA[JR2]

Department of psychiatry
RDGMC
 1-CELSUS used term delirium in first century AD
2-PHILLIP BARROUGH clarified cocept of delirium
Derrangement in imagination,cognition,memory

3-ERASMUS DARWIN AND JOHN HUNTER IN 18th

century- darwin compared delirium with dream
John hunter defined delirium as a cessation of conciousness of
ones own existence

4-same 18th century JAMES SIMS distinguished two species of

delirium as low and raving
5-1818 REES argued on specific variant of delirium and unique
etiology
6-20th century JOHN ROMANO AND GEORGE ENGEL
confirmed the work of countless astute clinicians and
demonstrated mechanism of delirium
 Acute confusional state
Acute brain failure
Encephalitis
Encephalopathy
Intensive care unit psychosis
Toxic metabolic state
Central nervous system toxicity
Paraneoplastic limbic encephalitis
Cerebral insufficiency
Organic brain syndrome
Increased nursing care
Increased length of stay
Increased risk of cognitive decline
Increased risk of functional decline
Increased mortality
Delay in postoperative mobilization
Prevention of early rehabilitation
Increased rate of nursing home placement
Increased need for home care services
Increased distress to caregivers
Barrier to psychosocial closure in terminally ill
patient
 A. A disturbance in attention (i.e., reduced ability to direct, focus, sustain,
and shift atten-tion) and awareness (reduced orientation to the
environment).
B. The disturbance develops over a short period of time (usually hours to a
few days), rep- resents a change from baseline attention and awareness,
and tends to fluctuate in se- verity during the course of a day.
C. An additional disturbance in cognition (e.g., memory deficit,
disorientation, language, visuospatial ability, or perception).
D. The disturbances in Criteria A and C are not better explained by another
preexisting, established, or evolving neurocognitive disorder and do not
occur in the context of a severely reduced level of arousal, such as coma.
E. There is evidence from the history, physical examination, or laboratory
findings that the disturbance is a direct physiological consequence of
another medical condition, sub- stance intoxication or withdrawal (i.e., due
to a drug of abuse or to a medication), or exposure to a toxin, or is due to
multiple etiologies.
 1-predisposing
2-precipitating
1- Demographic characteristics
Age 65 and older , Male sex
2- Cognitive status
Dementia ,cognitive impairement,history of delirium,depression
3- Functional Status
Functional dependence
Immobility
History of falls
Low level of activity
4- Sensory Impairment
Hearing,visual
5- Decreased Oral Intake
Dehydration,malnutrition
6- Drugs
Treatment with psychoactive drugs,drugs of anticholinergic properties, Alcohol
abuse
7- Coexisting Medical Conditions
Severe medical diseases Chronic renal or hepatic disease ,Stroke, Neurological
disease ,Metabolic derangements ,Infection with human immunodeciency virus
,Fractures or trauma, Terminal diseases
1-Drugs
Sedative, hypnotics ,Narcotics ,Anticholinergic drugs ,Treatment
with multiple drugs, Alcohol or drug withdrawal
2- Primary Neurologic Diseases
Stroke, nondominant hemispheric, Intracranial bleeding,
Meningitis or encephalitis
3- Intercurrent Illnesses
Infections, Iatrogenic complications ,Severe acute illness ,Hypoxia
,Shock, Anemia, Fever or hypothermia ,Dehydration ,Poor
nutritional status ,Low serum albumin levels ,Metabolic
derangements
4-Surgery
5- Environmental
Admission to intensive care unit, Use of physical restraints, Use of
bladder catheter ,Use of multiple procedures, Pain, Emotional
stress, Prolonged sleep depravation
 SPECIFY IF-(Acute: Lasting a few hours or days.
Persistent: Lasting weeks or months.)

Hyperactive: The individual has a hyperactive level of

psychomotor activity that may be accompanied by
mood lability, agitation, and/or refusal to cooperate
with medical care.
Hypoactive: The individual has a hypoactive level of
psychomotor activity that may be accompanied by
sluggishness and lethargy that approaches stupor.
Mixed level of activity: The individual has a normal level of
psychomotor activity even though attention and
awareness are disturbed. Also includes individuals
whose activity level rapidly fluctuates.
1- disturbance in the sleep-wake cycle
[ nighttime agitation, difficulty falling asleep, excessive
sleepiness throughout the day, or wakefulness throughout
the night. In some cases, com- plete reversal of the night-day
sleep-wake cycle can occur. Sleep-wake cycle disturbances
have been proposed as a core criterion for the diagnosis.]

2- emotional disturbances
[such as anxiety, fear, depression, irritability, anger, euphoria,
and apathy. There may be rapid and unpre- dictable shifts
from one emotional state to another. The disturbed
emotional state may also be evident in calling out,
screaming, cursing, muttering, moaning, or making other
sounds. These behaviors are especially prevalent at night
and under conditions in which stimulation and
environmental cues are lacking.]
Delirium is the final common symptom of
multiple
neurotransmitter abnormalities
Global cortical dysfunction
Reduction of acetylcholine synthesis
Altered CSF levels of serotonin, norepinephrine,
dopamine, GABA, endorphins
Cytokines, cortisol, oxygen free radicals
Alcohol withdrawal: increased cerebral
noradrenergic activity
Systemic illness
Infection
Sepsis,Pneumonia,Urinary tract infection
Fluid-electrolyte disturbance
Dehydration
Nutritional deficiency
Burns
Uncontrolled pain
Heat stroke
Cardiac
CHF,Arrythmia,MI,Cardiac Surgery
Pulmonary
COPD,SIADH,Hypoxia
Endocrine
Adrenal crisis,Thyroid abnormality
Hematologic
Anaemia,leukemia,blood dyscrasia
Analgesics
NSAIDs, opioids
Antibiotics
Acyclovir, cephalosporins,
penicillin, quinolones,
sulfonamides, tobramycin
Anticholinergics
Anticonvulsants
Carbamazepine, phenytoin,Valproate
Antidepressants
TCAs, SSRIs
Cardiovascular
Amiodarone, Bblockers,digoxin, diuretics
Corticosteroids
Dopamine agonists
H2 antagonists
Cimetidine, famotidine,ranitidine
Sedative/Hypnotic
Miscellaneous
Baclofen, donepezil, interferons,
oral hypoglycemics
 Stress of surgery
Post op pain
Insomnia
Pain medication
Electrolyte imbalance
Infection
Fear
Blood loss
Drug
Endocrine
Low oxygen hypoxia
Infections
Retention- urinary
Inflammatory arthritis ; Intoxication
Underperfused
Metabolic
Stool fecal impaction
 While the majority of individuals with delirium
have a full recovery with or without treatment,
early recognition and intervention usually shortens
the duration of the delirium
Delirium may progress to stupor, coma, seizures, or
death, particularly if the under- lying cause
remains untreated. Mortality among hospitalized
individuals with delirium is high, and as many as
40% of individuals with delirium, particularly
those with malignan- cies and other significant
underlying medical illness, die within a year after
diagnosis.
. The prevalence of delirium in the community overall is low (1%2%)
but in- creases with age,
rising to 14% among individuals older than 85 years.
The prevalence is 10%30% in older individuals presenting to
emergency departments, where the delirium often indicates a
medical illness.
The prevalence of delirium when individuals are admitted to the
hospital ranges from 14% to 24%, and estimates of the incidence of
delirium arising during hospitalization range from 6% to 56% in
general hospital populations.
Delirium occurs in 15%53% of older individuals postoperatively
and in 70%87% of those in intensive care.
Delirium oc- curs in up to 60% of individuals in nursing homes or
postacute care settings and in
up to 83% of all individuals at the end of life.
 Laboratory findings of underlying medical
conditions or intoxications /withdrawl
EEG-
there is often generalized slowing on
electroencephalog- raphy, and fast activity is
occasionally found (e.g., in some cases of
alcohol withdrawal delirium). However,
electroencephalography is insufficiently
sensitive and specific for di- agnostic use.
 Psychotic disorders and bipolar and depressive disorder
Acute stress disorder
Malingering and factitious disorder
Other neurocognitive disorders.