DELIRIUM

N. Pandya M.D., CMD

Associate Professor and Chair
Department of Geriatrics
NSU COM

CASE # 1 (1 of 4)
A 75-year-old man is intubated and receiving
mechanical ventilation. Medications are
nitroglycerin paste, ranitidine, and digoxin. He
has no history of psychiatric illness or recent use
of alcohol or sedative drugs.

Two days postoperatively, he becomes agitated

and attempts to remove the endotracheal tube
and other catheters. He is awake and fearful. He
is unable to respond to yes/no questions
consistently or to follow simple commands.

OBJECTIVES
Know and understand:

The predisposing or precipitating risk factors

for delirium in elderly patients
How to recognize and diagnose delirium
Interventions to prevent delirium

How to evaluate and treat elderly patients with

delirium

TOPICS COVERED
Incidence and morbidity

Recognition and diagnosis

Neuropathophysiology
Predisposing factors

Evaluation, management, and

prevention
Case studies

DELIRIUM IS ALSO KNOWN AS.

acute confusional state
acute mental status change
altered mental status
organic brain syndrome
reversible dementia
toxic or metabolic
encephalopathy

DEFINITION
An acute alteration in attention and
cognition

What is delirium?

Disturbance of consciousness
A change in cognition
Develops over a short period of time
Fluctuates during the course of the
day
Not explained by dementia
DSM-IV 1999

EPIDEMIOLOGY
affects 14-56% of hospitalized elders (2-3M
people)
10% mortality rate in hospital (25-33% in some
studies)
65% longer and costlier hospitalization ($4
billion in 1994)
involves >17.5M inpatient days
increased likelihood of nursing home placement
Inouye SK: Am J Med,1994

INCIDENCE OF DELIRIUM AMONG

ELDERLY PATIENTS IS HIGH

1/3 of older patients presenting to the

ER
Complicates 30-60% of elderly
patients after hip surgery
1/3 of inpatients aged 70+ on general
medical units, half of whom are
delirious on admission

MORBIDITY ASSOCIATED WITH

DELIRIUM
A 10-fold risk of death in hospital (Inouye AJM 1999)
A 3- to 5-fold risk of nosocomial
complications, prolonged stay, nursing-home
placement
Poor functional recovery and risk of death up
to 2 years following discharge
Persistence of delirium poor long-term
outcomes

DIAGNOSING DELIRIUM
Underecognition is a major problem
nurses recognize and document < 50%
physicians recognize and document only
20%
DSM-IV criteria precise but difficult to apply

Confusion Assessment Method (CAM)

clinically more useful
>95% sensitivity and specificity

DSM-IV DIAGNOSTIC CRITERIA

Disturbance of consciousness with reduced ability to
focus, sustain, or shift attention
Change in cognition (e.g., memory deficit,
disorientation, language disturbance) or a perceptual
disturbance not better accounted for by existing
dementia
Development over a short time (hours to days) and
fluctuation during the day
Evidence from history, physical, or labs that
disturbance is direct physiologic consequence of a
medical condition

CONFUSION ASSESSMENT
METHOD
Requires features 1 and 2 and either 3 or 4:
1. Acute change in mental status and
fluctuating course
2. Inattention
3. Disorganized thinking
4. Altered level of consciousness

Acute Onset and Fluctuating

course

Usually obtained from a family member,

nursing home staff
Is there evidence of an acute change in
mental status from the patients baseline?
Did the behavior fluctuate during the day,
that is, tend to come and go, or increase and
decrease n severity

Inattention

Did the patient have difficulty

focusing attention?
For example:
- Being easily distractible
- Having difficulty keeping track of what
was being said

Disorganized Thinking

Was the patients thinking

disorganized or incoherent?
Examples:
-Rambling or irrelevant conversation
- Unclear or illogical flow of ideas
- Unpredictable switching from
subject to subject

Altered Level of Consciousness

Anything other than alert (normal):

Vigilant
Hyperalert
Drowsy
Lethargic
Easily aroused
Stupor
Coma
Difficult to arouse

DELIRIUM vs DEMENTIA
Delirium and dementia often occur
together in older hospitalized patients;
the distinguishing signs of delirium are:
Acute onset

Cognitive fluctuations over hours or

days
Impaired consciousness and attention
Altered sleep cycles

DELIRIUM TAKES VARIOUS

FORMS
Hyperactive or agitated delirium
25% of all cases

Hypoactive delirium
less recognized or appropriately treated

Mixed

Additional features include emotional

symptoms, psychotic symptoms,
sundowning

NEUROPATHOPHYSIOLOGY
Cholinergic deficiency
Delirium is associated with serum anticholinergic
activity
Physostigmine and cholinesterase inhibitors are
beneficial
Serotonin excess or deficiency
Dopamine excess (regulates release of acetylcholine)
Cytokines (interleukin-1,and 2, tumor necrosis factor)
As seen in patients with cancer or infections
Increases permeability of the BBB
Chronic stress and hypercorticolism
Other neurotransmitters: GABA, glutamate, melatonin

PREDISPOSING FACTORS

Advanced age
Dementia
Functional impairment in ADLs
Medical comorbidity
History of alcohol abuse
Male sex
Sensory impairment (vision, hearing)
High Bun/creat ratio (dehydration)

Not a psychiatric diagnosis!

Medication-related is most common

Medication withdrawal
Poly-pharmacy
Excessive dose

Medications and Delirium

30% of elderly (>75 yrs) admissions are
due to adverse drug events
15% present as delirium
Chan et al; Internal Medicine Journal; 2001 May-June

Other causes of delirium

Pneumonia -elderly may not have
cough/fever
Sepsis - fever often absent
Myocardial infaction -often no chest
pain or dyspnea
Abdominal infections - pain may be
minimal

Precipitating Factors or Insults that

can contribute to Delirium
Drugs

Sedating hypnotics
Narcotics
Anticholinergic drugs
Treatment with multiple drugs
Alcohol or drug withdrawal

Primary Neurologic Diseases

Stroke particularly nondominant hemisphere
Intracranial bleeding
Meningitis or encephalitis

Precipitating Factors or Insults that can

contribute to Delirium
Intercurrent illnesses
Infections
Iatrogenic complications
Severe acute illness
Hypoxia
Shock
Fever or hypothermia
Anemia
Dehydration
Poor nutritional status
Low serum albumin
Metabolic disturbance (electrolyte, glucose, acidbase)

Precipitating Factors or Insults that can

contribute to Delirium
Surgery
Orthopedic surgery
Cardiac surgery
Prolonged cardiopulmonary bypass
Non-cardiac surgery
Environmental
Admission to an ICU
Use of physical restraints
Use of bladder catheters
Use of multiple procedures
Pain
Emotional stress or social isolation
Prolonged sleep deprivation

Multifactorial Model of Delirium

Inouye SK, Charpentier PA: JAMA,1996

INCIDENCE & RISKS FOR

POSTOPERATIVE DELIRIUM
Occurs in 10%-15% after elective noncardiac surgery
May exceed 50% after emergent hip-fracture repair

Increased risk with preoperative risk factors

age, cognitive impairment, physical functional
impairment, hx of alcohol abuse, abnormal serum
chemistries, intrathoracic and aortic aneurysm surgery
1 or 2 factors = 10% risk of delirium
3 or more factors = 50% risk of delirium

KEYS TO PREVENTING
POSTOPERATIVE DELIRIUM
Peak onset is on 2nd postoperative day
Associated with postoperative pain,
postoperative anemia, use of benzodiazepines
and opioids
Recommended:
limit sedation
provide adequate analgesia
transfuse high-risk patients

How does delirium present?

Infection/sepsis
-30% will have delirium as well
Falls
- Delirium contributes
- Often no significant injury
Not acting right
- Vague complaints per family

EVALUATION: HISTORY &

PHYSICAL
History
Focus on time course of cognitive changes,
esp. their association with other symptoms or
events
Medication review, including OTC drugs,
alcohol
Physical examination
Vital signs
Oxygen saturation
General medical evaluation
Neurologic and mental status examination

EVALUATION: LABORATORY
TESTING
Base on history and physical
Include CBC, electrolytes, renal function tests
Also helpful: UA , LFTs, serum drug levels, arterial
blood gases, chest x-ray, ECG, cultures
Cerebral imaging rarely helpful, except with head
trauma or new focal neurologic findings
EEG and CSF rarely yield helpful results, except with
associated seizure activity or signs of meningitis

MANAGEMENT: GENERAL
PRINCIPLES
Requires interdisciplinary effort by
physicians, nurses, family, others
Multifactorial approach is most successful
because multiple factors contribute to
delirium
Failure to diagnose and manage delirium
costly, life-threatening complications, loss of
function

KEYS TO EFFECTIVE
MANAGEMENT
Treat the underlying disease

Address contributing factors

Avoid the complications of delirium by:
- removing indwelling devices ASAP
- preventing or treating constipation and
urinary retention
- encouraging proper sleep hygiene,
avoiding sedatives
Optimize medication regimen (see next slide)

MANAGEMENT:
DRUGS TO REDUCE OR ELIMINATE
Almost any medication if time course is
appropriate

Alcohol
Antibiotics
Anticholinergics
Anticonvulsants
Antidepressants
Antihistamines
Antiparkinsonian
agents
Antipsychotics

Barbiturates
Benzodiazepines
Chloral hydrate
H2-blocking agents
Lithium
Opioid analgesics
(esp. meperidine)

MANAGEMENT:
BEHAVIORAL PROBLEMS

Provide social restraints

Consider a sitter or allow family to stay in
room
Avoid physical or pharmacologic restraints
Pharmacological therapy (next slide)

Pharmacological therapy for delirium

Antipsychotic haloperidol
- 0.5 to 1 mg po twice daily (add every 4h
PRN)
- 0.5- 1 mg IM (repeat in 30-60 min if needed
- assess for akathisia and extrapyramidal
effects
- avoid in older persons with parkinsonism
- in ICU, monitor for QT interval
prolongation, torsade de pointes,
neuroleptic malignant syndrome,
withdrawal dyskinesias

Pharmacological therapy for

delirium
Atypical antipsychotic
Risperidone 0.5 mg twice daily
Olanzapine 2.5 to 5 mg once daily
Quetiapine 5mg once daily

Benzodiazepine
0.5 to 1mg (add every 4h as needed)

Antidepressant
Trazadone 25 to 150mg at bedtime

MANAGEMENT: REHABILITATION
Use orienting stimuli (clocks, calendar, radio)
Provide adequate socialization
Use eyeglasses and hearing aids appropriately
Mobilize patient as soon as possible

Ensure adequate intake of nutrition and fluids, if

necessary by hand feeding
Educate and support the patient and family

Delirium is an indicator of the

quality of health care
Frequently iatrogenic and linked to the
process of care
30-40% of cases may be preventable
Many aspects of hospital care contribute
to the development of delirium
Now a designated marker for the quality of
care and patient safety (NQM and AHRQ)

THE BEST MANAGEMENT IS

PREVENTION
Interventions for cognitive impairment,
sleep deprivation, immobility, sensory
impairment, dehydration

Focus on nonpharmacologic approaches

(e.g., sleep protocol involving warm milk,
back rubs, soothing music)
Limit or avoid psychoactive and other
high-risk medications

NATURAL HISTORY
May not be a transient disorder as believed
Of 325 patients with delirium in teaching
hospital, only 4% completely recovered at
discharge, 20.8% at 3 mth, and 17.7% at 6
mth
Levkoff et al:Arch Int Med, 1992

Delirium of 30 days or more is typical in

elders
Worse outcomes in those with underlying
cognitive impairment or dementia

SUMMARY (1 of 2)
Delirium is common and associated with
substantial morbidity for older persons
Delirium can be diagnosed with high
sensitivity and specificity using the CAM
A thorough history, physical, and focused labs
will lead to the underlying cause(s) of delirium

SUMMARY (2 of 2)
A careful medication review is mandatory;
discontinue any likely to contribute to delirium,
if possible
Managing delirium involves treating the
primary disease, avoiding complications,
managing behavioral problems, providing
rehabilitation
The best treatment for delirium is prevention

CASE # 1 (1 of 4)
A 75-year-old man is intubated and receiving
mechanical ventilation. Medications are
nitroglycerin paste, ranitidine, and digoxin. He
has no history of psychiatric illness or recent use
of alcohol or sedative drugs.

Two days postoperatively, he becomes agitated

and attempts to remove the endotracheal tube
and other catheters. He is awake and fearful. He
is unable to respond to yes/no questions
consistently or to follow simple commands.

CASE # 1 (2 of 4)
Temperature is 37.4C (99.3F), pulse is 112 / min,
and BP is 110/64 mm Hg. The abdomen is
nontender. All extremities move spontaneously.
Chest x-ray reveals a possible right lower lobe
infiltrate.
Laboratory studies:
Leukocyte count
Plasma glucose
Blood urea nitrogen
Serum sodium
Serum digoxin
Urinalysis

12,000/L
150 mg/dL
20 mg/dL
142 mEq/L
0.7 ng/mL
1+ bacteria

CASE # 1 (3 of 4)
Which of the following is the most appropriate initial
step to manage this patients agitation?

Orienting stimuli and reduce noise level

Ceftriaxone, 2 g IV
Haloperidol, 1 mg IV
Midazolam, 2 mg / h by continuous IV infusion
Physostigmine, 1 mg IV

CASE # 1 (4 of 4)
Which of the following is the most appropriate initial
step to manage this patients agitation?

Orienting stimuli and reduce noise level

Ceftriaxone, 2 g IV
Haloperidol, 1 mg IV
Midazolam, 2 mg / h by continuous IV infusion
Physostigmine, 1 mg IV

CASE # 2 (1 of 3)
The average length of stay in your hospitals
medical unit has been increasing. Analysis of
outliers among the most common DRGs reveals
a number of patients who had prolonged
hospitalizations secondary to acute confusional
states.
As a member of the quality improvement
committee, you have been asked to suggest
evidence-based measures to prevent this
problem.

CASE # 2 (2 of 3)
Which of the following interventions would you
recommend?

Train nursing staff to perform serial MMSE

Establish a delirium consultation service to evaluate
patients at request of their attending physicians
Implement a clinical pathway to expedite neurologic
imaging and other tests in patients with delirium
Establish interdisciplinary protocols to address sensory
impairment, immobility, dehydration, cognitive impairment,
and sleep deprivation
Implement early discharge planning so that patients can be
sent home before predicted length of stay is exceeded

CASE # 2 (3 of 3)
Which of the following interventions would you
recommend?

Train nursing staff to perform serial MMSE

Establish a delirium consultation service to evaluate
patients at request of their attending physicians
Implement a clinical pathway to expedite neurologic
imaging and other tests in patients with delirium
Establish interdisciplinary protocols to address
sensory impairment, immobility, dehydration, cognitive
impairment, and sleep deprivation
Implement early discharge planning so that patients can be
sent home before predicted length of stay is exceeded

THANK YOU!