DELIRIUM:
Delirium is an acute, fluctuating disturbance in consciousness and change in cognition, not better accounted for by a preexisting or evolving dementia. Other commonly
associated features include disturbances of sleep, psychomotor activity and emotion. Some pts manifest prodromal symptoms such as restlessness, anxiety, irritability, distractibility, or sleep disturbances
in the days before onset of overt delirium. The prevalence of delirium is 10 to 30% in the hospitalized medically ill, 10-40% in the hospitalized elderly, up to 25% of hospitalized cancer pts, 30-40% of
hospitalized AIDS pts, up to 51% of postop pts and up to 80% of near death, terminally ill pts. Symptoms can last from 1 wk to 2 mos, but typically resolve in 10-12 days if treated. Delirium in the
medically ill is associated with significant morbidity and increased mortality rates, particularly in the elderly, and can lead to complications such as pna, decubitus ulcers, etc. and may progress to stupor,
coma and even death if untreated. Post surgery pts and pts with burns, dialysis, and/or CNS lesions are at an increase risk for developing delirium.
DSM IV criteria for Delirium:
A) Disturbance in consciousness, manifested
by a reduced clarity of awareness of
environment with decreased ability to focus,
sustain or shift attention
B) Change in cognition (i.e. memory,
disorientation, speech/language
disturbance) or perceptual disturbances (i.e.
misinterpretations, delusions,
hallucinations)
C) Disturbance develops over a short period of
time and tends to fluctuate throughout the
day.
* can be due to general medical condition, substance
intoxication/withdrawal, medications, toxins, or a
combination of these. Disturbance is not accounted
for by preexisting or evolving dementia.
Potential Etiologies of Delirium: “I WATCH DEATH”
Testing to consider by Etiology:
Infection
Withdrawal
HIV, sepsis, pneumonia
Alcohol, barbiturate, sedative-hypnotic
Etiology
Acute metabolic
Acidosis, alkalosis, electrolyte disturbance, hepatic
failure, renal failure
Infection
Trauma
Closed-head injury, heat stroke, postoperative,
severe burns
CNS pathology
Abscess, hemorrhage, hydrocephalus, subdural
hematoma, Infection, seizures, stroke, tumors,
metastases, vasculitis, encephalitis, meningitis,
syphilis
Hypoxia
Anemia, carbon monoxide poisoning, hypotension,
pulmonary or cardiac failure
Deficiencies
Vitamin B12, folate, niacin, thiamine
Endocrinopathies Hyper/hypoadrenocorticism, hyper/hypoglycemia,
myxedema, hyperparathyroidism
Acute vascular
Hypertensive encephalopathy, stroke, arrhythmia,
shock
Toxins or drugs
Prescription drugs, illicit drugs, pesticides, solvents
Heavy Metals
Lead, manganese, mercury
Withdrawal,
toxins, drugs,
heavy metals
Acute metabolic,
endocrinopathies
Trauma, CNS
pathology
Acute Vascular
Other
Tests
CBC with diff, UA and cx, blood
cultures, CXR, LP, HIV, RPR,
LFTs
Etoh level, UDS, serum
osmolality, med levels (i.e.
anticonvulsants, digoxin, etc.)
Rapid glucose, LFTs, serum
osmolality, serum electrolytes,
ABG, BUN/Creatinine, TSH, T4,
T3, serum cortisol level
Head CT, Xrays, MRI, EEG, LP
PT, PTT, carotid/vertebral a. u/s
EKG, cardiac enzymes (silent MI),
cardiac echo
Delirium Management: Note that delirium management includes psychiatric, environmental/supportive interventions and somatic interventions. Somatic Interventions are as follows:
ANTIPSYCHOTIC MEDICATION: High- potency antipsychotics, such as haloperidol, are the pharmacological DOC for delirium symptoms. ! Caution ! Torsades de pointes and QT prolongation has
been observed in pts receiving haloperidol. Must obtain baseline ECG (Qtc > 450 msec or greater than 25% above baseline, consider cardiology consult and antipsychotic med discontinuation), and
monitor ECG when administering these medications.
Haloperidol: (oral, IM, IV: (IV is not FDA approved): initial dosage 1 to 2 mg every 2 to 4 hours, lower dosages for elderly (i.e. 0.25 to 0.50 mg every 4 hours). Newer antipsychotics (i.e. risperidone,
olanzapine, quetiapine) have increasingly been used (case reports, case series, open label trials). Cochrane review found doses HLP ≤ 3 mg/day equally tolerable to newer agents.
OTHER INTERVENTIONS:
Benzodiazepines: benzos as monotherapy reserved for pts with delirium 2/2 seizures or withdrawal from etoh/sedative-hypnotics.
Cholinergic: cholinergic medications (i.e. physostigmine and donepezil), may be useful in delirium 2/2 anticholinergic agents
Paralysis, sedation and ventilation: may be necessary in delirium 2/2 severe hypercatabolic conditions
Opioids: consider in delirium with pain as an aggravating factor
Vitamins: may be useful in delirium in pts at risk for vitamin B deficiency
ECT: consider if delirium caused by NMS. Weigh risks/benefits.
APA Guidelines