1. Delirium: Pallavi Dham OPMHS, CHSA

2. Nurse pages duty doctor: Nurse pages duty doctor: “..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 he is acting “crazy”… can you come see him?” “..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 he is acting “crazy”… can you come see him?”

3. GP calls and asks for assistance: 82 year old lady admitted to local hospital following increasing paranoia (1-2 weeks). Suspicious that the staff is stealing her things especially at night. Fine during the day. She has a past history of depression. She has not been coping well and needed more supports since a year. 82 year old lady admitted to local hospital following increasing paranoia (1-2 weeks). Suspicious that the staff is stealing her things especially at night. Fine during the day. She has a past history of depression. She has not been coping well and needed more supports since a year. GP wonders if she has psychotic depression/dementia?

4. What is Delirium?

5. Literally speaking…… Derived from Latin Derived from Latin From dēlīrāre, de- + līra ridge, furrow From dēlīrāre, de- + līra ridge, furrow literally: to swerve from a furrow, hence be crazy literally: to swerve from a furrow, hence be crazy

6. Delirium A sudden and significant decline in mental functioning A sudden and significant decline in mental functioning Disturbance of consciousness with reduced ability to focus, sustain, and shift attention Disturbance of consciousness with reduced ability to focus, sustain, and shift attention

7. WHAT IS DELIRIUM? 4 features under DSM-IV: Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention; Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention; A change in cognition, (memory deficit, language disturbance, disorientation) or development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. A change in cognition, (memory deficit, language disturbance, disorientation) or development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia.

8. WHAT IS DELIRIUM? 4 features under DSM-IV: That the disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. That the disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. That there is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of general medical conditions. That there is evidence from the history, physical examination or laboratory findings that the disturbance is caused by the direct physiological consequences of general medical conditions.

9. Why is it important?

10. Prevalence Hospitalized medically ill 10-30% Hospitalized medically ill 10-30% Hospitalized elderly10-40% Hospitalized elderly10-40% Postoperative patients up to 50% Postoperative patients up to 50% Near-death terminal patient up to 80% Near-death terminal patient up to 80%

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

12. Neuropathogenesis Cholinergic system Cholinergic system GABAergic system/ Glutamate GABAergic system/ Glutamate Brain arousal circuits Brain arousal circuits EEG- slow wave delta activity EEG- slow wave delta activity

13. Who does it effect?

14. Patients at highest risk Elderly Elderly >80 years >80 years demented demented multiple meds multiple meds Post-cardiac surgery, hip replacement surgery Post-cardiac surgery, hip replacement surgery ICU ICU Burns Burns Drug withdrawal Drug withdrawal

15. 4 major causes Underlying medical condition Underlying medical condition Substance intoxication/Substance withdrawal Substance intoxication/Substance withdrawal Medication S/E: especially medication with high anticholinergic action Medication S/E: especially medication with high anticholinergic action Combination of any or all of these Combination of any or all of these

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

17. How do you diagnose?

18. DELIRIUM Fluctuation Attention deficit Psychomotor disturbance Impaired cognition Sleep wake cycle Altered perception Affect disturbance

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

20. COMPLEXITIES OF DIAGNOSIS Delirium is often misdiagnosed as Dementia. Delirium is often misdiagnosed as Dementia. Clinical presentation is similar to depression, psychosis and dementia (particularly Lewy Bodies) Clinical presentation is similar to depression, psychosis and dementia (particularly Lewy Bodies) It may co-exist in combination with these conditions and diagnosis is often considered secondary. It may co-exist in combination with these conditions and diagnosis is often considered secondary. Dementia Delirium Depression Psychosis

21. Is it Delirium, Dementia or Depression? DeliriumDementia Onset Rapid (hours/days); rapid decrease in MMSE score. Slow (months, years); slow decline of 2 to 3 MMSE points over a period of years. Symptoms Fluctuate over the course of the day. Relatively stable. Duration Days to weeks. Years. Orientation Disorientation and disturbed thinking are intermittent. Persistent disorientation. Level of consciousne ss Fluctuates, with inability to concentrate. Alert, stable. Sleep/wake cycle Sleep/wake cycle may be reversed. Sleep may be fragmented. Depression Subacute onset- weeks to months, pseudodementia Persistent and pervasive Weeks to months Oriented Alert, stable Early morning awakening

22. TYPES OF DELIRIUM. 1. Hyperactive Delirium: The person presents with agitated behaviour that may include delusions or hallucinations. D/D:Schizophrenia, agitated dementia or other psychotic disorders. However, visual hallucinations are more common *(May account for only 25% of total)

23. TYPES OF DELIRIUM … cont. 2. Hypoactive Delirium: The person presents with inactive, withdrawn behaviour This presentation may be confused with depression or dementia. * (over 50%) 3. Mixed Delirium: The person displays clinical signs associated with both hyperactive and hypoactive delirium, and throughout the condition’s course may fluctuate between the two types for varying lengths of time. 4. Nocturnal Delirium: The person displays signs of delirium at night or in the early evening (often called Sundown Syndrome). *(47% of symptoms in morning & 37% evening or night)

24. COMMONLY USED SCREENING TOOLS Mini Mental State Examination Mini Mental State Examination Clock diagram Clock diagram Delirium Rating Scale Delirium Rating Scale Confusion Assessment Method (CAM) *Compatible with DSM IV with ≥ 95% sensitivity & specificity Confusion Assessment Method (CAM) *Compatible with DSM IV with ≥ 95% sensitivity & specificity

27. Management Identify and treat the underlying etiology Identify and treat the underlying etiology Discontinue or minimize dosing of nonessential medications- anticholinergics and hypnotics Discontinue or minimize dosing of nonessential medications- anticholinergics and hypnotics Coordinate with other physicians and providers Coordinate with other physicians and providers Regular monitoring and ensure safety Regular monitoring and ensure safety

28. Medication management Antipsychotic medications for acute behavioural control- at a much lower dose. Haloperidol < 3mg/day, Risperidone 0.5mg, Olanzapine 2.5mg and now Quetiapine Antipsychotic medications for acute behavioural control- at a much lower dose. Haloperidol < 3mg/day, Risperidone 0.5mg, Olanzapine 2.5mg and now Quetiapine Benzodiazepines only in substance withdrawal states/Lewy Body Dementia Benzodiazepines only in substance withdrawal states/Lewy Body Dementia

30. SUMMARY If you suspect Delirium: Treat the cause first. Treat the cause first. Be supportive towards the client and family. Be supportive towards the client and family. Try non medical models to try and manage behaviours. Try non medical models to try and manage behaviours. Try medication as a last resort. Try medication as a last resort.

31. ANY QUESTIONS ???