Delirium
Lea C. Watson, MD, MPH
Robert Wood Johnson Clinical Scholar
UNC Department of Psychiatry
Nurse pages med student:
“..Mr. Smith pulled out his NG tube and can’t
seem to sit still. Last night after his surgery
he was fine, reading the paper and talking to
his family…today I don’t even think he
knows where he is… can you come see
him?”
Med student says:
“…sounds like DELIRIUM- good thing you
called- I’ll be right there.”
Delirium
• A sudden and significant decline in mental
functioning not better accounted for by a
preexisting or evolving dementia
• Disturbance of consciousness with reduced
ability to focus, sustain, and shift attention
4 major causes
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Underlying medical condition
Substance intoxication
Substance withdrawal
Combination of any or all of these
Patients at highest risk
• Elderly
– >80 years
– demented
– multiple meds
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Post-cardiac surgery
Burns
Drug withdrawal
AIDS
Prevalence
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Hospitalized medically ill
Hospitalized elderly
Postoperative patients
Near-death terminal patients
10-30%
10-40%
up to 50%
up to 80%
Clinical features
Prodrome
Fluctuating course
Attentional deficits
Arousal /psychomotor disturbance
Impaired cognition
Sleep-wake disturbance
Altered perceptions
Affective disturbances
Prodrome
• Restlessness
• Anxiety
• Sleep disturbance
Fluctuating course
• Develops over a short period (hours to days)
• Symptoms fluctuate during the course of the
day (SYMPTOMS WAX AND WANE)
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Levels of consciousness
Orientation
Agitation
Short-term memory
Hallucinations
Attentional deficits
• Easily distracted by the environment
• May be able to focus initially, but will not
be able to sustain or shift attention
Arousal/psychomotor disturbance
• Hyperactive (agitated, hyperalert)
• Hypoactive (lethargic, hypoalert)
• Mixed
Impaired cognition
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Memory Deficits
Language Disturbance
Disorganized thinking
Disorientation
– Time of day, date, place, situation, others, self
Sleep-wake disturbance
• Fragmented throughout 24-hour period
• Reversal of normal cycle
Altered perceptions
• Illusions
• Hallucinations
- Visual (most common)
- Auditory
- Tactile, Gustatory, Olfactory
• Delusions
Affective disturbance
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Anxiety / fear
Depression
Irritability
Apathy
Euphoria
Lability
Duration
• Typically, symptoms resolve in 10-12 days
- may last up to 2 months
• Dependent on underlying problem and
management
Outcome
• May progress to stupor, coma, seizures or
death, particularly if untreated
• Increased risk for postoperative
complications, longer postoperative
recuperation, longer hospital stays, longterm disability
Outcome
• Elderly patients 22-76% chance of dying
during that hospitalization
• Several studies suggest that up to 25% of all
patients with delirium die within 6 months
Causes: “I WATCH DEATH”
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I nfections
W ithdrawal
A cute metabolic
T rauma
C NS pathology
H ypoxia
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D eficiencies
E ndocrinopathies
A cute vascular
T oxins or drugs
H eavy metals
“I WATCH DEATH”
• Infections: encephalitis, meningitis, sepsis
• Withdrawal: ETOH, sedative-hypnotics,
barbiturates
• Acute metabolic: acid-base, electrolytes,
liver or renal failure
• Trauma: brain injury, burns
“I WATCH DEATH”
• CNS pathology: hemorrhage, seizures,
stroke, tumor (don’t forget metastases)
• Hypoxia: CO poisoning, hypoxia,
pulmonary or cardiac failure, anemia
• Deficiencies: thiamine, niacin, B12
• Endocrinopathies: hyper- or hypoadrenocortisolism, hyper- or hypoglycemia
“I WATCH DEATH”
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Acute vascular: hypertensive
encephalopthy and shock
Toxins or drugs: pesticides, solvents,
medications, (many!) drugs of abuse
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anticholinergics, narcotic analgesics, sedatives
Heavy metals: lead, manganese, mercury
Drugs of abuse
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Alcohol
Amphetamines
Cannabis
Cocaine
Hallucinogens
Inhalants
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Opiates
Phencyclidine (PCP)
Sedatives
Hypnotics
Causes
• 44% estimated to have 2 or more etiologies
Workup
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History
Interview- also with family, if available
Physical, cognitive, and neurological exam
Vital signs, fluid status
Review of medical record
– Anesthesia and medication record review temporal correlation?
Mini-mental state exam
• Tests orientation, short-term memory,
attention, concentration, constructional
ability
• 30 points is perfect score
• < 20 points suggestive of problem
• Not helpful without knowing baseline
Workup
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Electrolytes
CBC
EKG
CXR
EEG- not usually necessary
Workup
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Arterial blood gas or Oxygen saturation
Urinalysis +/- Culture and sensitivity
Urine drug screen
Blood alcohol
Serum drug levels (digoxin, theophylline,
phenobarbital, cyclosporin, lithium, etc)
Workup
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Arterial blood gas or Oxygen saturation
Urinalysis +/- Culture and sensitivity
Urine drug screen
Blood alcohol
Serum drug levels (digoxin, theophylline,
phenobarbital, cyclosporin, lithium, etc)
Workup
• Consider:
- Heavy metals
- Lupus workup
- Urinary porphyrins
Management
• Identify and treat the underlying etiology
• Increase observation and monitoring – vital
signs, fluid intake and output, oxygenation,
safety
• Discontinue or minimize dosing of
nonessential medications
• Coordinate with other physicians and
providers
Management
• Monitor and assure safety of patient and
staff
- suicidality and violence potential
- fall & wandering risk
- need for a sitter
- remove potentially dangerous items from
the environment
- restrain when other means not effective
Management
• Assess individual and family psychosocial
characteristics
• Establish and maintain an alliance with the
family and other clinicians
• Educate the family – temporary and part of
a medical condition – not “crazy”
• Provide post-delirium education and
processing for patient
Management
• Environmental interventions
- “Timelessness”
- Sensory impairment (vision, hearing)
- Orientation cues
- Family members
- Frequent reorientation
- Nightlights
Management
• Pharmacologic management of agitation
- Low doses of high potency neuroleptics
(i.e. haloperidol) – po, im or iv
- Atypical antipsychotics (risperidone)
- Inapsine (more sedating with more rapid
onset than haloperidol – im or iv only –
monitor for hypotension)
Management
• Haloperidol and inapsine have been
associated with torsade de pointes and
sudden death by lengthening the QT
interval; avoid or monitor by telemetry if
corrected QT interval is greater than 450
msec or greater than 25% from a previous
EKG
Management
• Benzodiazepines
- Treatment of choice for delirium due to
benzodiazepine or alcohol withdrawal
Management
• Benzodiazepines
- May worsen confusion in delirium
- Behavioral disinhibition, amnesia, ataxia,
respiratory depression
- Contraindicated in delirium due to hepatic
encephalopathy
What we see…common cases
• Homeless male, hx. ETOH abuse, 2 days
post-op
• 82 year-old women with UTI
• Burn victim after multiple med changes
• Mildly demented 71 year-old after hip
replacement
Summary
• Delirium is common and is often a harbinger of
death- especially in vulnerable populations
• It is a sudden change in mental status, with a
fluctuating course, marked by decreased attention
• It is caused by underlying medical problems, drug
intoxication/withdrawal, or a combination
• Recognizing delirium and searching for the cause
can save the patient’s life