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3. Delirium Definition Acute onset of fluctuating cognitive impairment and disturbance of consciousness.

4. www.company.com DSM IV Criteria  Disturbance of consciousness with reduced ability to focus, sustain or shift attention.  A change in cognition or development of perceptual disturbances that is not better accounted for a preexisting, existed or evolving dementia.  The disturbance develops over a short period of time and tends to fluctuate during the course of the day  There is evidence from this history,physical examination or labs that the disturbance is caused by the physiological consequence of a medical condition, substance intoxication, substance withdrawal, or multiple etiologies.

5. www.company.com Clinical characteristics Altered consciousness: such as decreased level of coconsciousness. Altered attention: diminished ability to focus, sustain, or shift attention. Disorientation: especially to time & place. Decreased memory. Rapid onset. Brief duration: usually days to weeks. fluctuations

6. www.company.com Sometimes worse at night (sun downing) Disorganization of thoughts. Perceptual disturbances: such as illusion and hallucinations. Disruption of sleep-wake cycle: fragmented sleep at night, with or without daytime drowsiness. Mood alterations: irritability, dysphoria, anxiety, euphoria. Altered neurological function: as autonomic hyperactivity or instability. Clinical characteristics

7. www.company.com Types of delirium Hypoactive confusion, somnolence,  alertness Hyperactive agitation, hallucinations, aggression Mixed (>60%) features of both

8. www.company.com Epidemiology approximately 0.4% of people > 17y. approximately 1.1% of people > 55y. approximately 10-30% of hospitalized patients approximately 40-50% of patients recovering from hip fracture surgery.

9. www.company.com Etiology It is usually multifactorial A.General medical condition B.Substance related C.Presence of risk factors

10. www.company.com Etiology: Medical condition CNS pathology: tumors, trauma, strokes, seizures Infections Electrolyte abnormalities Endocrine dysfunctions (hypo or hyper) Liver failure  hepatic encephalopathy Renal failure  uremic encephalopathy Pulmonary disease with hypoxemia Cardiovascular disease: CHF, arrhythmias, MI Deficiency states: Thiamine, nicotinic or folic acid, B12

11. www.company.com Etiology: Substance-related  Intoxication –Alcohol –Hallucinogens –Opioids –Marjuana –Stimulants –sedatives

12. www.company.com  Withdrawal –Alcohol –Benzodiazepines –barbiturates Etiology: Substance-related

13. www.company.com  Medication-induced –Anticholinergics (furosemide, digoxin, theophylline, cimetidine, prednisolone, TCA’s, captopril) –Analgesics (morphine, codeine..) –Steroids –Antiparkinson (anticholinergic and dopaminergic) –Sedatives (benzodiazepines, barbiturates) –Anticonvulsants –Antimicrobials (penicillin, cephalosporins, quinolones) –Antidepressants Etiology: Substance-related

14. www.company.com  Toxins –Carbon monoxide –organophosphates Etiology: Substance-related

15. www.company.com Predisposing risk factors >60 years of age Male gender Visual impairment Underlying brain pathology such as stroke, tumor, vasculitis, trauma, dementia Major medical illness Recent major surgery Depression Functional dependence Dehydration Substance abuse/dependence Hip fx Metabolic abnormalities Polypharmacy

16. www.company.com Precipitating risk factors Medications Severe acute illness UTI Hyponatremia Hypoxemia Shock Anemia Pain Orthopedic surgery Cardiac surgery ICU admission High number of hospital procedures

17. www.company.com The pathophysiology of delirium Many hypotheses exist including:  Neurotransmitter abnormalities  Inflammatory response with increased cytokines  Changes in the blood-brain barrier permeability  Widespread reduction of cerebral oxidative metabolism  Increased activity of the hypothalamic- pituitary adrenal axis

18. www.company.com How to evaluate a patient with suspected delirium Look with particular attention to level of consciousness, behavior and level of cooperativeness Look at the overall time course Review medication list including scheduled, doses, recent medications discontinued or started Evaluate for recent medical illness and interventions Screen for history of substance dependence to determine risk of withdrawal

19. www.company.com Review diagnostic studies including labs, imaging, vital signs Interview patient paying close attention to concentration, level of somnolence, mood lability, executive function, short term memory deficits, kinetics. Use MMSE. Gather collateral information from family/friends regarding baseline function, personality, psych history How to evaluate a patient with suspected delirium

20. www.company.com Treatment First and foremost treat the underlying cause. Physical Support : for orientation (calendar, clock, family pictures, windows), –have family or friends visit frequently making sure they introduce themselves, minimize staff switching. –Patient shoud be neither sensory deprived nor stimulated by the environment.

21. www.company.com Treatment Pharmacotherapy: two major symptoms should be treated are psychosis & insomnia. –For psychosis: Typical antipsychotics (haloperidol) initial dose 2- 6mg IM, repeated if the patient remains agitated. Atypical antipsychotics (risperidone) are also used but limited.

22. www.company.com –For insomnia: Benzodiazepine short or intermediate half-life (lorazepam) 1-2mg at bed time Treatment

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24. Cast Muhammed Ismail Ahmed Tarek Mo 'amen Gomaa Marwan Saber Karim Maaroof Ramy Waleed Muhammed Adel Mahmoud Khedr