1. (COGNITIVE DISORDER) DELIRIUM Chapter 20

2. Definition Delirium is defined as an acute organic brain syndrome. Characterized by global cognitive impairmant of abrupt onset and relatively brief duration and by concurrent disturbance of attention, sleep awake cycle and psychomotor behavior. Criteria for delirium according to DSM-IV A.Disturbance of consciousness (i.e. reduced clarity of awarness of the environment) with reduced ability to focus, sustain or shift attention B.A change in cognition (such as memory deficit, disorientation, language disturbance) or the development of a perceptual disturbance that is not better accounted for by a pre existing, established or evolving dementia C.The disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the

3. Course of the day D. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a GMC Clinical presentation and assessment 1.Common symptoms # wandering attention # distractibility # disorientation # misinterpretations, illusions, hallucinations #speech/ language disturbances (dysarthria, dysnomia, dysgraphia) #affective symptoms (anxiety, fear, depression, irritability, anger, euphoria)

4. # shifts in psychomotor activity ( groping/ picking at cloths, attempts to get out of bed when unsafe, sudden movements, sluggishness, lethargy) 2. folstein mini mental status exam should be done Risk factors 1.Hospitalizations (incidence 10-40%) 2.Nursing home residents (incidence 60%) 3.Childhood (e.g. febrile illness, anticholinergic use) 4.Old age (especially male) 5.Severe illness (e.g. cancer, AIDS) 6.Pre existing cognitive impairment or brain pathology 7.Recent anaesthesia 8.Substance abuse

5. Etiology 1.Infections (encephalitis, meningitis, UTI, pneumonia) 2.Withdrawal (alcohol, barbiturates, benzodiazepines) 3.Acute metabolic disorder (electrolyte imbalance, hepatic or renal failure) 4.Trauma (head injury, post operative) 5.CNS pathology (stroke, hemorrage, tumour, seizure disorder, parkinsons) 6.Hypoxia (anemia, cardiac failure, pulmonary embolus) 7.Deficiencies (vitamin B12, folic acid, thiamine) 8.Endocrinopathies (thyroid, glucose, parathyroid, adrenal) 9.Acute vascular ( shock, vasculitis, hypertensive encephalopathy) 10.Toxins : substance use, alcohol withdrawal, sedatives or sedative withdrawal, opioids, anesthetics, anticholinegics,

6. Dopaminergic agents, steroids, insulin, glyburide, antibiotics (especially quinolones), NSAIDS 11. Heavy metals (arsenic, lead, mercury) Investigations 1.standard: CBC and differential, electrolytes, ca, po4, Mg, glucose, ESR, LFTs, Cr, BUN, TSH, vitamin B12, folate, albumin, urine C&S, R&M 2.As indicated: ECG, CXR, CT head, toxicology/ heavy metal screen, VDRL, HIIV, LP, EEG, blood cultures 3.Indications for CT head: focal neurological deficit, acute change in status, antocoagulant use, acute incontinance, gait abnormality, history of cancer

7. Management 1.Intrinsic # identify and treat underlying cause immediately # stop all non essential medications # maintain nutrition, hydration, electrolyte balance and monitor vitals 2. Extrinsic # environment should be quiet and well lit # optimize hearing and vision # room near nursing station for closer observation; constant care if patient jumping out of bed, pulling out lines # family members present for reassurance and re orientation # calender, clock for orientation cues

8. 3. Biological # haloperidol or risperidone (low dose) # lorazepam 4. Physical restraints if patient becomes violant Prognosis Up to 50% 1 yr mortality rate after episode of delirium

9. The End