Delirium Lea C. Watson, MD, MPH Robert Wood Johnson Clinical Scholar UNC Department of Psychiatry

Nurse pages med student: “..Mr. Smith pulled out his NG tube and can’t seem to sit still. Last night after his surgery he was fine, reading the paper and talking to his family…today I don’t even think he knows where he is… can you come see him?” Med student says: “…sounds like DELIRIUM- good thing you called- I’ll be right there.”

Delirium A sudden and significant decline in mental functioning not better accounted for by a preexisting or evolving dementia Disturbance of consciousness with reduced ability to focus, sustain, and shift attention

4 major causes Underlying medical condition Substance intoxication Substance withdrawal Combination of any or all of these

Patients at highest risk Elderly –>80 years –demented –multiple meds Post-cardiac surgery Burns Drug withdrawal AIDS

Prevalence Hospitalized medically ill 10-30% Hospitalized elderly10-40% Postoperative patientsup to 50% Near-death terminal patientsup to 80%

Clinical features Prodrome Fluctuating course Attentional deficits Arousal /psychomotor disturbance Impaired cognition Sleep-wake disturbance Altered perceptions Affective disturbances

Prodrome Restlessness Anxiety Sleep disturbance

Fluctuating course Develops over a short period (hours to days) Symptoms fluctuate during the course of the day (SYMPTOMS WAX AND WANE) –Levels of consciousness –Orientation –Agitation –Short-term memory –Hallucinations

Attentional deficits Easily distracted by the environment May be able to focus initially, but will not be able to sustain or shift attention

Arousal/psychomotor disturbance Hyperactive (agitated, hyperalert) Hypoactive (lethargic, hypoalert) Mixed

Impaired cognition Memory Deficits Language Disturbance Disorganized thinking Disorientation –Time of day, date, place, situation, others, self

Sleep-wake disturbance Fragmented throughout 24-hour period Reversal of normal cycle

Altered perceptions Illusions Hallucinations - Visual (most common) - Auditory - Tactile, Gustatory, Olfactory Delusions

Affective disturbance Anxiety / fear Depression Irritability Apathy Euphoria Lability

Duration Typically, symptoms resolve in days - may last up to 2 months Dependent on underlying problem and management

Outcome May progress to stupor, coma, seizures or death, particularly if untreated Increased risk for postoperative complications, longer postoperative recuperation, longer hospital stays, long- term disability

Outcome Elderly patients 22-76% chance of dying during that hospitalization Several studies suggest that up to 25% of all patients with delirium die within 6 months

Causes: “I WATCH DEATH” I nfections W ithdrawal A cute metabolic T rauma C NS pathology H ypoxia D eficiencies E ndocrinopathies A cute vascular T oxins or drugs H eavy metals

“I WATCH DEATH” Infections: encephalitis, meningitis, sepsis Withdrawal: ETOH, sedative-hypnotics, barbiturates Acute metabolic: acid-base, electrolytes, liver or renal failure Trauma: brain injury, burns

“I WATCH DEATH” CNS pathology: hemorrhage, seizures, stroke, tumor (don’t forget metastases) Hypoxia: CO poisoning, hypoxia, pulmonary or cardiac failure, anemia Deficiencies: thiamine, niacin, B12 Endocrinopathies: hyper- or hypo- adrenocortisolism, hyper- or hypoglycemia

“I WATCH DEATH” Acute vascular: hypertensive encephalopthy and shock Toxins or drugs: pesticides, solvents, medications, (many!) drugs of abuse –anticholinergics, narcotic analgesics, sedatives Heavy metals: lead, manganese, mercury

Drugs of abuse Alcohol Amphetamines Cannabis Cocaine Hallucinogens Inhalants Opiates Phencyclidine (PCP) Sedatives Hypnotics

Causes 44% estimated to have 2 or more etiologies

Workup History Interview- also with family, if available Physical, cognitive, and neurological exam Vital signs, fluid status Review of medical record –Anesthesia and medication record review - temporal correlation?

Mini-mental state exam Tests orientation, short-term memory, attention, concentration, constructional ability 30 points is perfect score < 20 points suggestive of problem Not helpful without knowing baseline

Workup Electrolytes CBC EKG CXR EEG- not usually necessary

Workup Arterial blood gas or Oxygen saturation Urinalysis +/- Culture and sensitivity Urine drug screen Blood alcohol Serum drug levels (digoxin, theophylline, phenobarbital, cyclosporin, lithium, etc)

Workup Arterial blood gas or Oxygen saturation Urinalysis +/- Culture and sensitivity Urine drug screen Blood alcohol Serum drug levels (digoxin, theophylline, phenobarbital, cyclosporin, lithium, etc)

Workup Consider: - Heavy metals - Lupus workup - Urinary porphyrins

Management Identify and treat the underlying etiology Increase observation and monitoring – vital signs, fluid intake and output, oxygenation, safety Discontinue or minimize dosing of nonessential medications Coordinate with other physicians and providers

Management Monitor and assure safety of patient and staff - suicidality and violence potential - fall & wandering risk - need for a sitter - remove potentially dangerous items from the environment - restrain when other means not effective

Management Assess individual and family psychosocial characteristics Establish and maintain an alliance with the family and other clinicians Educate the family – temporary and part of a medical condition – not “crazy” Provide post-delirium education and processing for patient

Management Environmental interventions - “Timelessness” - Sensory impairment (vision, hearing) - Orientation cues - Family members - Frequent reorientation - Nightlights

Management Pharmacologic management of agitation - Low doses of high potency neuroleptics (i.e. haloperidol) – po, im or iv - Atypical antipsychotics (risperidone) - Inapsine (more sedating with more rapid onset than haloperidol – im or iv only – monitor for hypotension)

Management Haloperidol and inapsine have been associated with torsade de pointes and sudden death by lengthening the QT interval; avoid or monitor by telemetry if corrected QT interval is greater than 450 msec or greater than 25% from a previous EKG

Management Benzodiazepines - Treatment of choice for delirium due to benzodiazepine or alcohol withdrawal

Management Benzodiazepines - May worsen confusion in delirium - Behavioral disinhibition, amnesia, ataxia, respiratory depression - Contraindicated in delirium due to hepatic encephalopathy

What we see…common cases Homeless male, hx. ETOH abuse, 2 days post-op 82 year-old women with UTI Burn victim after multiple med changes Mildly demented 71 year-old after hip replacement

Summary Delirium is common and is often a harbinger of death- especially in vulnerable populations It is a sudden change in mental status, with a fluctuating course, marked by decreased attention It is caused by underlying medical problems, drug intoxication/withdrawal, or a combination Recognizing delirium and searching for the cause can save the patient’s life