DELIRIUM

DR A.VIJAYA CHANDRA REDDY

ASSOCIATE PROFESSOR OF PSYCHAITRY
DEPT. OF PSYCHIATRY
RIMS , KADAPA
Epidemiology
• Common in older population , highest incidence and prevalence in older
• 13% in population aged 85 and more
• Emergency ward admission prevalence rates 5-10%
• Under recognition of delirium in up to 60%
• 15% of general surgical patients
• 30% open heart surgery patients
• 50% patients with hip surgeries
• Mortality can range up to 22 to 76%
• 1 year mortality associated with cases of delirium 35-40%
RISK FACTORS-PROTECTIVE FACTORS

• Good premorbid functioning

• Regular educational programs to that target clinicians and
placement of liaison psychiatrist in orthopedic ward
• Training of nursing staff helps to improve outcome, decreases the
time of placement in haopsital
• Young age
 Sensory impairment
PREDISPOSING FACTORS Hearing
• Demographics
Vision
• Age 65 and older Decreased oral intake
• Male sex Dehydration
• Coginitve status Malnutriiton
Drugs
• Dementia Treatment with psychotropic drugs
• Cognitive impairment Treatment with anitcholinergic drugs
Alchohol abuse
• History of delirium
Co exisiting medical conditions
• Functional status Severe medical disease
• Funtional dependence Chronic renal or hepatic disease
Stroke
• Immobility
Neurological disease
• History of falls Metabolic abnormalities
• Low level of activity HIV
Fractures or trauma
PRECIPITATING FACTORS
• Drugs
• Sedatives and hypnotics
• Narcotics
• Anticholinergic drugs
• Poly pharmacy
• Alcohol or drug withdrawal
• Primary neurological disease
• Stroke , non dominant hemisphere
• Interracial bleeding
• Meningitis or encephalitis
• Infections Iatrogenic complications Severe acute illness
• Hypoxia Hypo natermia Shcock ,Anaemia
• Fever or hyponatermia
• Dehydrations Poor nutrition status Low serum albumin levels
• Metabolic derangements
• Surgery
• Orthopeadic surgery , cardiac surgery , prolonged cardiopulmonary
bypass Non cardiac surgery
• Environmental : admission to ICU, Use of physical restraints , use
of bladdder catheter , use of multiple surgeries , pain, emotional
stress, prolonged sleep depriavation
PATHOPHYSIOLOGY
• Two important hypothesis
• Neurochemical imbalances that effect transmission
• The second on inflammation specifically the role of cytokines on
the blood brain barrier and the impact of chronic stress on
cytokines and cortisol leveles
• Cholinergice defiecncy play important role in induction of delirium
• Dopaminergic drugs excesses contribute to delirium
• Glutaamte excess
• Increased GABA levels
• Increased ammonia in hepatic failure
INFLAMMATION IN COMPROMISED BBB
• IL-1, IL-2, IL-6, tumor necrosis factor TNF alpha and interferon may
contribute the permeability of the blood brain and alter
neurotramision
• Chronic stress brought by illness or trauma activates the
sympothateitc nervous system and hyptothalamic-pitutary-
adernococrtical axis resulting in increased cytokine levels and
chronic hypercotisolism
• Chronic hypercortisolism has deleterious effects on hippocampal
stratium
• Multiple factors contribute to pathology delirium
CLINICAL FEAUTRES
• Onset of delirium is rapid over few hours to days
• Symptoms are highly variable and intermittent.
• Manic like symptoms –Poor sleep, Pressured speech high energy,
agitation
• Depression like symptoms : withdrawn behavior, isolative , poor
sleep, restlessness , agitation
• Sleep like disturbance- reversed sleep wake cycle
• Schizophrenia like symptoms : hallucinations, delusions , parania
and thought disorganization
A cardinal feature of delirium is reduced alertness, manifested by difficulty
maintaining attention and focusing concentration.
The confused patient cannot ignore irrelevant stimuli and is easily distractable.
The frequent finding of impaired memory usually represents an inability to
register recent information because of inattentiveness, but retrieval of older
information can also be disturbed.
Higher integrative functions are similarly affected; the result is a reduced ability
to plan, solve problems, or guide actions.
These disturbances in attention often increase toward evening, a characteristic
known as sundowning, which may result from fatigue and reduced sensory
input. The confused patient cannot plan cognitive functions appropriately.
Consequently, subjects demonstrate incoherent speech and
a diminished ability to sequence actions properly
(e.g., rising from a bed or walking), which can lead to injury.
Typically, sleep becomes brief and fragmented, and fatigue
tends to aggravate these symptoms of delirium. Subjects
often demonstrate a reversal of sleep patterns, with daytime
napping and nocturnal wakefulness
The hyperactive (increased psychomotor activity) variant of delirium is most
commonly recognized and tends to be readily apparent even to the casual
observer. It is often associated with the adverse effects of anticholinergic
drugs, drug intoxication and withdrawal states.
Characteristically, patients may exhibit agitation,psychosis and mood lability
and may refuse to cooperate with medical care, may demonstrate disruptive
behaviors (such as shouting or resisting) or may sustain injuries from falling,
combativeness, or pulling out catheters and intravascular lines.
The hypoactive (decreased psychomotor activity) is more common than
hyperactive delirium in elderly patients, but it is less frequently recognized.
Metabolic conditions such as hepatic or renal encephalopathy are frequently
associated with hypoactive delirium, but other causes are also common.

Patients with hypoactive delirium may appear sluggish and lethargic as well as
confused.
The absence of disruptive, bizarre, and injurious behaviors contributes to
the lack of recognition.
This quiet state of withdrawal, apathy, and clouded inattention differs from the
drowsiness seen in persons dozing or sleeping in that these latter subjects can
be quickly aroused to (and remain in) normal consciousness by mild stimuli.
In hypoactive delirium, however, strong stimuli (e.g., vigorous shaking or
shouting) are often needed for arousal, which is incomplete and transient at
best
many patients who experience delirium have a mixture of both hypoactive and
hyperactive variants. Such patients
are thought by some researchers to be at highest risk of substantial morbidity
and mortality.
In one recent study conducted in critically ill patients, mixed type was most
common (54.9 percent), followed by hypoactive delirium (43.5 percent), and
purely hyperactive delirium (1.6 percent).
Hallucinations, misperceptions, illusions, and delusions are reported to occur
in at least 40 percent of cases of delirium and can accompany both
hypoactive and hyperactive subtypes. Hallucinations are usually visual,
ranging from dream-like experiences to terrifying visions, and may, in fact,
represent “sleep without muscle atonia.”
these sensory features tend to be less common in elderly than in
young patients. Rather, somatic features such as urinary
incontinence, gait impairment, tremor, and language disorders
(including receptive and expressive aphasias) tend to
predominate
The Yale Delirium Prevention Trial demonstrated
the effectiveness of intervention protocols targeted toward six
risk factors:
orientation and therapeutic activities for cognitive impairment,
early mobilization to avert immobilization, non pharmacologic
approaches to minimize the use of psychoactive drugs,
interventions to prevent sleep deprivation, communication
methods and adaptive equipment (particularly eyeglasses and
hearing aids) for vision and hearing impairment, and
Early intervention for volume depletion
TREATMENT
• Non pharmacological measurements:
• Assure the patient of safety, decrease the fear, provide a safe and calm
environment
• Patient should be provided with hearing aids and visual aids
• Provide a room with window to improve orientation
• Avoid over stimulus or under stimulus , don’t keep the patient in dark and
calm room or in busy ward
• Don’t keep two patients in one room
• Keep the patient near the nursing station.
• Uniform dressing of treating staff than holiday dressing
• Staff should discuss everything far from the patient
• Maintain normal sleep wake cycle.
• Strong evidence to support the pharmacologic management of delirium is Lacking
• use of psychoactive medications should be reserved for the management of behaviors
associated with delirium that pose a safety risk for the patient and others or for delirium
due to drug or alcohol withdrawal.
• Haloperidol is commonly used to treat delirium despite weak evidence to support its
efficacy and lack of U.S. Food and Drug Administration (FDA) approval for this indication
• Use of intravenous haloperidol (which also not FDA approved for treatment of delirium or
any other indication) is most commonly seen in critical care settings and is associated with
increased risk of QTc prolongation. ECG monitoring is recommended when haloperidol is
administered via the intravenous route
• benzodiazepines should be reserved for the management of agitation associated with
sedative–hypnotic withdrawal (e.g., alcohol, benzodiazepines, barbiturates, meprobamate,
and carisoprodol).
• Patients experiencing alcohol withdrawal should be given high dose thiamine via the
intramuscular or intravenous route as oral absorption is very poor to prevent progression to
Korsakoff syndrome
• Current evidence suggests that dexmedetomidine (Precedex) may be effective in
preventing and treating delirium in the ICU setting
• Electroconvulsive Therapy. Electroconvulsive therapy (ECT) is also a treatment of
delirium when other approaches have failed. It has been used as a last resort for
delirious patients with severe agitation who are not responsive to pharmacotherapy,
such as high doses of intravenous haloperidol. The ECT is usually given en bloc or
daily for several days, sometimes with multiple treatments per day. ECT use in
delirium should be monitored closely as ECT can cause delirium on its own.
• Sleep–Wake Cycle. Delirium is frequently complicated by changes in the sleep–wake
cycle. Attempts to restore sleep integrity may include moving the schedule of existing
sedating medications to the hour of sleep or reducing or moving activating
medications and stimulants such as caffeine to the morning. Brief, judicious use of
sedating agents, such as zolpidem (Ambien) or trazodone (Desyrel), to reset the
sleep–wake cycle may be appropriate. Care should be taken to avoid excess sedation
because of risk of falls, aspiration, and inability to perform or assist with activitiesof
daily living.
• Anticholinergic medications are associated with delirium. There may be a cumulative effect
of the anticholinergic load from multiple medications. Anticholinergic poisoning almost
always results in delirium and is often accompanied by physical agitation and visual
hallucinations.
• Physical signs resulting from antimuscarinic action include widely dilated, poorly reactive
pupils; warm, dry skin; dry mouth; fever; tachycardia; elevated blood pressure;
constipation; and urinary retention.
• Use of cholinesterase inhibitors, such as physostigmine, has been shown to reduce the
severity of the delirium but requires repeated dosing because of a short half-life.
• Wernicke encephalopathy is a medical emergency, and in patients in whom the disorder is
suspected, thiamine should be initiated immediately, either intravenously or
intramuscularly, to ensure adequate absorption
• The primary concern in managing a patient with substance intoxication is supportive, that
is, ensuring that the patient does not have significant respiratory depression and that there
are no cardiovascular abnormalities. For benzodiazepine ingestions, the benzodiazepine
receptor antagonist flumazenil (Romazicon) may be helpful; however, repeated
administrations might be required.
• Naloxone acts through competitive binding at opioid receptors,
can reverse all the receptor-mediated actions of opioids, and is
indicated for patients who have significant CNS or respiratory
depression. Naloxone must be administered intramuscularly or
intravenously, has a short half-life, and may require repeated
administration as the effects wear off
• Long acting benzodiazepines have favor reducing delirium
caused by alcohol withdrawal syndrome
• In Parkinson's disease reduction of dose anti Parkinson's drugs
should be done if these action don’t produce any effect than
clozapine should be the drug of choice with best evidence.
Quetiapine can be used but there is not sufficient evidence
• The focus may change from an aggressive search for the etiology
of the delirium to one of palliation, comfort, and assistance with
dying.