PRESENTATION ON

DELIRIUM

INTRODUCTION
Organic Brain Disorders comprise a
range of mental disorders grouped
together on the basis of their common,
demonstratable aetiology in cerebral
disease, brain injury or other insult
leading to cerebral dysfunction. The
dysfunction may be primary, as inn
diseases, injuries and insults that
attack the brain directly or with
prediction or secondary as in systemic
diseases and disorders that attack the
brain only as one of the multiple organ
or system involved.

DELIRIUM
INTRODUCTION
It is a neuropsychiatric syndrome also
called acute confusional state or acute
brain failure that is common among the
medically ill and often is misdiagnosed
as a psychiatric illness which can result
in delay of appropriate medical
intervention. There is significantly
mortality associated with delirium so
identifying it is crucial.

DEFINITION
Delirium is defined by the acute onset
of fluctuating cognitive impairment
and a disturbance of consciousness

EPIDEMIOLOGY
30-40% of hospitalized patients more
than 65 years of old have an episode of
delirium

DSM-IV TR 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 taking,
PE or labs that the disturbance is caused
by the physiological consequence of a
medical condition.

CAUSES OF DELIRIUM
1.

SYSTEMIC ILLNESS :_ Infections,

Electrolyte imbalances, Endocrine
dysfunctions, Liver failure, Renal
failure, CNS pathology, Deficienciesthiamine, folic acid , B12

2.

MEDICATIONS:- Anticholinergics,
Steroids, Sedatives, Anticonvulsants,
Antihypertensive, Antidepressants

3.

RISK FACTORS

PRECIPITATING FACTORS
Metabolic
Malnutrition
Dehydration, electrolyte imbalance
Anaemia
Hypoxia
Hypercapnoea
Hypoglycaemia
Endocrine disorders (e.g.SIADH,Addisons disease,hyperthyroidism,
hypercalcaemia)
Infection
Especially respiratory and urinary tract infections
Medication
Anticholinergics, dopaminergics, opioids, steroids, recent polypharmacy
Vascular
Stroke/Transient ischaemic attack
Myocardial infarction , arrhythmias, decompensatedheart failure
Physical/psychological stress
Pain
Iatrogenic event, esp. post-operative, mechanical ventilation in ICU
Chronic/terminal illness, esp. cancer
Post-traumatic event, e.g. fall, fracture
Immobilisation/restraint

PREDISPOSING FACTORS
Older age
Cognitive impairment /dementia
Physical comorbidity (biventricular failure,
cancer, cerebrovascular disease)
Psychiatric comorbidity (e.g. depression)
Sensory impairment (vision, hearing)
Functional dependence (e.g. requiring
assistance for self-care and/or mobility)
Dehydration / Malnutrition
Drugs and drug-dependence.
Alcohol dependence

CLINICAL MANIFESTATIONS
Arousal- Abnormal arousals characterized
by hyperactivity
Orientation- Disoriented to time is often
seen
Language & Cognition-Irrelevant or
incoherent speech
Perception- Hallucinations
Mood- Anger, Rage and Unwarranted Fear
Associated Symptoms- Sleep Walk
Disturbances
Neurological Symptoms- Dysphasia, Tremor,
Incoordination and Urinary Incontinence

TREATMENT
Treatment of delirium involves two
main strategies: first, treatment of the
underlying presumed acute cause or
causes; secondly, optimising conditions
for the brain. This involves ensuring
that the patient with delirium has
adequate oxygenation, hydration,
nutrition, and normal levels of
metabolites, that drug effects are
minimised, constipation treated, pain
treated, and so on. Detection and
management of mental stress is also
very important.
The pharmacological treatment for

A.

PSYCHIATRIC MANAGEMENT
Psychiatric management involves an array
of tasks that the psychiatrist should seek to
ensure are performed for all patients with
delirium. A psychologically informed
understanding of the patient and the family
may facilitate these tasks. These tasks are
designed to facilitate the identification and
treatment of the underlying cause(s) of
delirium, improve the patients level of
functioning, and ensure the safety and
comfort of patients and others

1. Coordinate with other physicians

caring for the patient:-Delirium frequently
heralds a medical emergency, and patients
are usually managed in an acute-care
hospital setting.. The appropriate treatment
of delirium involves interventions to search
for and correct underlying causes, as well as
relieve current symptoms. Joint and
coordinated management of the patient with
delirium by the psychiatrist and internist,
neurologist, or other primary care or
specialty physicians will frequently help
ensure appropriate comprehensive
evaluation and and care

2. Identify the etiology:- An essential

principle in the psychiatric management of
delirium is the identification and correction of
the etiologic factors. Careful review of the
patients medical history and interview of
family members or others close to the
patient may provide some direction

3. Initiate interventions for acute conditions:-A

patient with delirium may have life-threatening
general medical conditions that demand therapeutic
intervention even before a specific or definitive
etiology is determined. Increased observation and
monitoring of the patients general medical condition
should include frequent monitoring of vital signs, fluid
intake and output, and levels of oxygenation.
4. Provide other disorder-specific treatment :-The
goal of diagnosis is to discover reversible causes of
delirium and prevent complications through prompt
treatment of these specific disorders. One must give a
high priority to identifying and treating such disorders
as hypoglycemia, hypoxia or anoxia, hyperthermia,
hypertension, thiamine deficiency, withdrawal states,
and anticholinergic-induced or other
substanceinduced delirium.

5. Monitor and ensure safety :-Behavioral disturbances,

cognitive deficits, and other manifestations of delirium may
endanger patients or others. Psychiatrists must assess the
suicidality and violence potential of patients and implement or
advocate interventions to minimize these risks

6. Assess and monitor psychiatric status:-The psychiatrist

must periodically assess the patients delirium symptoms,
mental status, and other psychiatric symptoms. Important
behavioral issues that must be addressed include depression,
suicidal ideation or behavior, hallucinations, delusions,
aggressive behavior, agitation, anxiety, disinhibition, affective
lability, cognitive deficits, and sleep disturbances

7. Assess individual and family psychological and

social characteristics:-Knowledge of the patients and
the familys psychodynamic issues, personality
variables, and sociocultural environment may aid in
dealing effectively with specific anxieties and reaction
patterns on the part of both the patient and the family.
This understanding may be based on prior acquaintance
with the patient, current interviews or interaction with
the patient or family, and/or history from the family.
8. Establish and maintain alliances:- It is important
for the psychiatrist who is treating the patient with
delirium to establish and maintain a supportive
therapeutic stance. Understanding the underlying affect,
concerns, and premorbid personality of the patient is
frequently helpful in maintaining a supportive alliance.

9. Educate patient and family regarding

the illness:- Educating patients and families
regarding delirium, its etiology, and its
course is an important role for psychiatrists
involved in the care of patients with delirium.
Specific educational and supportive
interventions are discussed in more detail in
the following paragraphs.
10. Provide postdelirium management:Following recovery, patients memory for the
experience and events of the delirium is
variable.. Explanations regarding delirium, its
etiology, and its course should be reiterated

POSSIBLE COMLPICATIONS
Loss of ability to function or care for
self
Loss of ability to interact
Progression tostupororcoma
Side effects of medications used to
treat the disorder