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Delirium
is life-threatening medical emergency, it is complex neuropsychiatric syndrome
which is acute in onset and presents with disturbance in consciousness,
attention, orientation, cognition, perception caused by physiological
consequence of a general medical condition. It is 1 in 5 hospitalized patients
experience delirium and high prevalence in hospital settings - 14-24%. It also
increases incidence during hospital stay - 6-56%. Delirium in hospitalized
older adults can be associated with increased complications and mortality
rates, increased need for nursing surveillance, increased healthcare
expenditure, greater levels of functional impairment and higher nursing homes.
Despite its prevalence and profound impact on
healthcare, delirium has a propensity to be under recognized by clinicians, as
evidenced from studies by a lesser than 5% documentation rates. Recognition of
delirium can be inherently difficult in part to its fluctuating nature,
clinical overlap with dementia, multi-factorial etiology and the increased
frequency of hypoactive subtype of delirium among older adults. In Qatar, the
prevalence of delirium is high in elderly, it was found 15.3% aged above 65,
which is alarming. So, it is important to early detect delirium among the
patients presenting to the floor, to ensure avoid unnecessary consultation and
investigations that delay disposition.
Keywords:
Delirium, Medical
emergency, Neuropsychiatric syndrome
INTRODUCTION
Delirium is estimated to occur in 10-15% of
medical-surgical inpatients [1,2]. It occurrence rate is 11-42% in medical
wards and one third of the patient with acute stroke develops delirium.
Clinical features of delirium
Acute onset: Within hours to one or two days
depending on the cause.
Fluctuation in
presentation:
Worse at night with periods of lucid intervals.
Altered cognition: Deficits in short term, immediate
and working memory. Disorientation in time and place usually seen. Word finding
difficulties, slurred speech.
Altered level of
consciousness:
Alert, hyper vigilant, drowsy, comatose. Level of consciousness may fluctuate.
Inattention: Inability to focus, sustain or
shift attention, inability to follow commands, easily distractible.
Perceptual
abnormalities:
Macropsia, micropsia, illusions, hallucinations- visual more common (plucking
the sheet) Auditory hallucinations also seen Purposeless behavior like picking
with stereotyped behavior seen. Delusions may be present. 30% present with
hallucinations.
Disturbed sleep wake
cycle: Disturbed
sleep, somnolence or complete reversal of sleep wake cycle.
Disorganized
thinking: Irrelevant
conversation, incoherent speech, altered rate of speech.
Fluctuation in mood: Labile mood, anxiety, agitation.
DSM-IV CRITERIA FOR
DELIRIUM
·
Disturbance
of consciousness with reduced ability to focus, sustain or shift attention
·
Change in cognition or development of a
perceptual disturbance not accountable by the preexisting, established or
existing dementia
·
Disturbance that develops over a short
period of time and tends to fluctuate during the course of the day.
·
Evidence from history, physical
examination or laboratory findings that the disturbance is caused by the direct
physiologic consequence of a general medical condition.
WHY IS DELIRIUM IMPORTANT?
Is a common
problem in hospitalized patients in medical and surgical units?
It is an
independent prognostic factor for longer-term outcomes, including high
mortality rates, nursing home placement, cognitive and functional decline [1].
Delirium in ICU
associated with an increase in the ventilator dependent days and significant
burden on health care system [2].
Patient
admitted with delirium, mortality rates- 10%-26% [3].
CHALLENGES
Poor detection
rate (12-43%) leading to poor management of patients with delirium up to 80%
[4].
Delirium in
people with dementia unrecognized and undiagnosed, often lack of ownership and
recognition of the delirium symptoms.
SUBTYPES OF DELIRIUM [5]
Hyperactive delirium
Patient
restless, agitated, least common type.
Hypoactive delirium
Patients are
drowsy, sleepy, quiet, apathy. They are underdiagnosed or misdiagnosed as
depression. Highest mortality rates and longer hospital stay. Most common type.
Mixed type
Patients
fluctuate between hypoactive and hyperactive.
RISK FACTORS OF DELIRIUM
Increasing
age-1.1% in over 55’s, 13.6% in 85 years above, dementia, severe medical
illness, sensory impairment, frailty, polypharmacy.
CAUSES OF DELIRIUM
·
Infections:
UTI, pneumonia, encephalitis
·
Withdrawal:
Alcohol, BZD
·
Acute
cause: Dehydration, electrolyte
disturbance, hepatic/renal metabolic failure (Figure 1)
·
Toxins/drugs:
Opiates, salicylates
·
CNS
pathology: Stroke, hemorrhage, TIA, tumors,
seizures, infection
·
Hypoxia:
Pulmonary/cardiac failure
·
Deficiency:
Thiamine, vitamin B12
·
Endocrine:
Hypo/hyperglycemia, hyperparathyroidism
·
Acute
vascular shock: Hypertensive encephalopathy
·
Trauma:
Head injury
·
Heavy
metals poisoning: Lead, mercury
ASSESSMENT [6]
·
History
including presenting complaints, duration of onset collateral history
·
Vital signs-HR,
BP, temperature, BM, look for signs of pain
·
Thorough
physical examination-cardiac, pulmonary and neurological examination
·
Check the
hydration status
·
Rule out
infected pressure sores, fecal impaction, urinary retention
·
Complete blood
count, CMP, TFT, vitamin B12, drug levels if indicated, toxicology, urine
culture and sensitivity, ECG, CXR, EEG, CT/MRI brain scan, CSF analysis (if
warranted)
·
Assessment
tools: 4AT (rapid assessment tools), CAM ICU (confusion assessment method),
delirium rating scale (DRS), single question in delirium (SQiD)
MANAGEMENT [7]
·
Identify the underlying
cause and treat it.
·
Review the
medications and drug interactions
·
Monitor the
vital signs and intake and output
·
Non-pharmacological
interventions
·
Pharmacological
interventions where ever indicated
NON PHARMACOLOGICAL MANAGEMENT
·
Engage family
and care givers
·
Avoid physical
restrain if possible
·
Reorientation
using calendars, clocks, one to one interaction
·
Correct sensory
impairment e.g. using specs, hearing aid
·
Maintain
continuity of care
·
Maintain
mobility following falls risk assessment
·
Ensure adequate
analgesia
·
Maintain good
sleep pattern and adequate hydration
PHARMACOLOGICAL MANAGEMENT
·
Treat underlying
physical health cause-pneumonia, AKI, constipation, other causes
·
Antipsychotics
used cautiously at the lowest possible dose and for a short duration in
treating agitation and psychotic symptoms in delirium
·
Haloperidol
commonly prescribed. Second generation antipsychotics like quetiapine,
olanzapine, risperidone could be used. Baseline ECG mandatory.
·
Agitation
associated with alcohol withdrawal or sedative hypnotic withdrawal-BZD
treatment of choice. Follow local guidelines for BZD sliding scale.
·
Review of 7
trials of acetyl cholinesterase inhibitors-5 studies showed it is not
beneficial in preventing or managing delirium.
·
Melatonin may be
useful in prevention and management of Delirium.
PREDICTORS OF POOR OUTCOME IN DELIRIUM [8]
·
Longer duration
of the delirium episode
·
Severity of
delirium
·
Subtype of
delirium-hypoactive
·
Pre-existing
psychiatric morbidity like dementia, depression
CONCLUSION
Delirium is a
medical emergency, it is a complex neuropsychiatric syndrome caused by
physiological cause of an underlying medical condition. It is associated with
high morbidity and mortality. Recognizing delirium and treating the underlying
cause is imperative in the management of the condition.
1. Inouye SK (1998) Delirium in
hospitalized older patients: Recognition and risk factors. J Geriatr Psychiatry
Neurol 11: 118-125.
2. Leslie DL, Marc Antonio ER, Zhang
Y, Leo-Summers L, Inouye SK (2008) One-year health care costs associated with
delirium in the elderly population. Arch Intern Med 168: 27-32.
3. McCusker J, Cole M, Abrahamowicz M,
Primeau F, Belzile E (2002) Delirium predicts 12 month mortality. Arch Intern
Med 162: 457-463.
4. Hamad HA, Nadukkandiyil N (2017)
Geriatric consultation team in emergency department: A business case report
analysis. OAJ Gerontol Geriatr Med 1.
5. Lipowski ZJ (1987) Delirium (acute
confusional states). JAMA 258: 1789-1792.
6. Steis MR, Evans L, Hirschman KB,
Hanlon A, Fick DM, et al. (2012) Screening for delirium using family caregivers:
Convergent validity of the family confusion assessment method and
interviewer-rated confusion assessment method. J Am Geriatr Soc 60: 2121-2126.
7. Bellelli G, Morandi A, Di Santo SG,
Mazzone A, Cherubini A, et al. (2016) “Delirium Day”: A nationwide point
prevalence study of delirium in older hospitalized patients using an easy
standardized diagnostic tool. BMC Med 14: 106.
8. Zaraa A, Radwan A (2016) The impact
of delirium screening on admission to general hospital using stanford proxy
test for delirium SPTD: A quality improvement project. J Psychol Clin
Psychiatry 6: 00370.
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