Delirium
Mini-Lecture June 2013
Objectives
• Discuss various causes of delirium
• Review diagnostic tests in the work-up of
delirium
Case
• 75 y/o M with DMII, COPD, and obesity is
hospitalized for a hip fracture. Patient was doing
well post-operatively with adequate pain
management and rehabilitation. On POD #3, he
forgets where he is, becomes more lethargic, and
refuses to eat. Patient’s temperature is 38.5, HR
105, RR 12, 90% on 2L NC.
• What are the possible causes of this change in
mental status?
Definition of Delirium
• Altered consciousness and cognition with the following
characteristics:
– Poor attention
– Develops over hours to days and fluctuating course during
the day.
– Disturbance is likely from medical condition, substance
intoxication, or medication side effect.
– Unlikely due to preexisting, established, or evolving
dementia.
Delirium
• 10-20% of all hospitalized adults
• 30-40% of elderly hospitalized patients
• 60% to 80% of mechanically ventilated
ICU patients
• 50% to 70% of non-ventilated ICU
patients
Delirium in older patients, Francis et al., Journal of the American Geriatrics Society.
1992;40(8):829
Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study.
Inouye SK et al., J Gen Intern Med. 1998;13(4):234.
Pointers on Assessment
• ABCs and vitals first! Check GCS.
• Try to obtain collateral information from family or
hospital staff
• Get an understanding of patient’s baseline
mental status
• What were the circumstances around the time
of change in mental status?
• What is the duration of change?
• Has it happened before?
• What does the family think is going on?
AEIOU-TIPS mnemonic
A Alcohol, Ammonia
Examples
Possible Diagnostic Tests
•
•
•
•
alcohol intoxication/withdrawal
elevated ammonia (hepatic
encephalopathy)
•
alcohol level
serum osmolality (toxic
alcohols)
ammonia
E
Electrolytes/
Endocrine
•
•
•
•
•
•
hypoglycemia
hypo/hypernatremia
hypercalcemia
hypo/hyperthyroidism
addisonian crisis
DKA/HHNS
•
•
•
•
•
glucose
serum osmolality (HHNK)
serum electrolytes (esp Na, Ca)
thyroid function tests
serum cortisol level
I
Iatrogenic
•
•
•
steroid psychosis
anticholinergics in elderly,
opiates, benzos
•
levels of medications
(anticonvulsants, digoxin,
theophylline,etc)
drug screen (street drugs,
sedatives, narcotics)
•
O Oxygen, opiates,
obstruction
U Uremia
•
•
•
•
pneumonia,
PE
carbon monoxide
opiate narcosis
•
•
•
oxygen
ABG
CXR
•
BUN
AEIOU-TIPS mnemonic
Examples
Possible Diagnostic Tests
•
•
•
•
•
•
Head CT/ cervical spine CT
X-ray of any areas with trauma or deformity
MRI/MRA if indicated
concussion
TIA/CVA
Hematoma
T
Trauma
I
Infection
•
•
•
•
•
CBC with differential
Urinalysis and culture (UCG if appropriate)
Blood cultures and gram stain
Chest X-ray
Lumbar puncture (with opening pressure) - CT first if you
suspect increased ICP
P
Poisoning
•
•
•
•
Levels of medications (anticonvulsants, digoxin,
theophylline,etc)
Drug screen (street drugs, sedatives, narcotics)
Alcohol level
Serum osmolality (toxic alcohols)
•
•
Check anticonvulsant level
EEG/ MRI if indicated
S
Seizures
Case
• Patient could have multiple causes of his
delirium. A few of the possibilities include:
– Infection given patient’s temperature and HR
(common post-op infections such as UTI and PNA)
– Opiate toxicity given RR and O2 sat
– Electrolyte imbalance
– Hypoglycemia is possible if pt is on insulin and has
decreased po intake
Summary
• Delirium is common in hospitalized
patients and portends a poor
prognosis.
• Try to obtain collateral information
• Use mnemonic AEIOU-TIPS to help
determine etiology and useful
diagnostic tests