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Delirium an Overview

Delirium an Overview. Dr. Shailendra Mohan Tripathi Assistant Professor Department of Geriatric Mental Health K. G. Medical University, Lucknow. Doctor, can you please come and see Mrs. Pandey ….. She’s a bit confused….. and she pulled her IV out.. And she won’t stay in bed..

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Delirium an Overview

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  1. Delirium an Overview Dr. Shailendra Mohan Tripathi Assistant Professor Department of Geriatric Mental Health K. G. Medical University, Lucknow

  2. Doctor, can you please come and see Mrs. Pandey….. She’s a bit confused….. and she pulled her IV out.. And she won’t stay in bed.. And she’s becoming agitated … and she won’t do what we say… She is asking someone /something to get away …… She sleeps in day and wakes up in night…… She lifts bed cover, peeps beneath the cover and cot as if she is searching something …..

  3. That is what delirium is ….. Agitation Confusion Sedation Searching & Picking Behaviour OR Combination Hallucinations Distractions

  4. Delirium ……. • Delirium is“An etiologically nonspecific syndrome characterised by concurrent disturbances of consciousness and attention, perception,thinking,memory, psychomotor behavior, emotion and the sleep-wake cycle”(ICD-10) • Why it is important ? • Common presentation; often emergency • Usually misdiagnosed; even some times by experts as well • Very common in elderly patients

  5. Delirium ….. • Why is delirium so serious ? • Delirium A DANGEROUS Diagnosis Delirium* is Associated with : - Hospital complications - Loss of function - hospital stay - nursing home placement - mortality * Compared to patients without delirium

  6. Delirium….. • Why elderly develop more ? • Compromised organ functions • Co-existence of multiple diseases • Altered pharmacodynamic and pharmacokinetic functions • Decreased intake of fluids • Frequent electrolyte imbalances • Mistakes in taking medications • Neglect by caregivers/hospital staff

  7. Clinical characteristics • Develops acutely (hours to days) • Characterized by fluctuating level of consciousness • Reduced ability to maintain attention • Agitation or hypersomnolence • Extreme emotional lability • Cognitive deficits can occur

  8. Clinical characteristics: cognitive deficits • Language difficulties: word finding difficulties, dysgraphia • Speech disturbances: slurred, mumbling, incoherent or disorganized • Memory dysfunction: marked short-term memory impairment, disorientation to person, place, time. • Perceptions: misinterpretations, illusions, delusions and/or visual (more common) or auditory hallucinations • Constructional ability: can’t copy a pentagon

  9. Types of delirium • Hyperactive or hyperalert • the patient is hyperactive, combative and uncooperative. • May appear to be responding to internal stimuli • Frequently these patients come to our attention because they are difficult to care for.

  10. Hypoactive or hypoalert • Pt appears to be napping on and off throughout the day • Unable to sustain attention when awakened, quickly falling back asleep • Misses meals, medications, appointments • Does not ask for care or attention • This type is easy to miss because caring for these patients is not problematic to staff • Mixed • a combination of both types just described

  11. Epidemiology- Delirium occurs in: • approximately 40% of hospitalized elderly pts >60 yrs • approximately 50% of pts post-hip fracture • approximately 30% of pts in surgical intensive care units • approximately 20% of pts on general medical wards • approximately 15% of pts on general surgical wards

  12. Etiology • It is usually multifactorial • Systemic illness • Medications- any psychoactive medication can cause delirium • Presence of risk factors

  13. Etiology: Systemic illnesses • Infections • Electrolyte abnormalities • Endocrine dysfunctions (hypo or hyper) • Liver failure- hepatic encephalopathy • Renal failure- uremic encephalopathy • Pulmonary disease with hypoxemia • Cardiovascular disease/events: CHF, arrhythmias, MI • CNS pathology: tumors, strokes, seizures • Deficiency states: Thiamine, nicotinic or folic acid, B12

  14. Etiology: Drugs • Anticholinergics (furosemide, digoxin, theophylline, cimetidine, prednisolone, TCA’s, captopril) • Analgesics (morphine, codeine..) • Steroids • Antiparkinson (anticholinergic and dopaminergic) • Sedatives (benzodiazepines, barbiturates) • Anticonvulsants

  15. Etiology: Drugs continued • Antihistamines • Antiarrhythmics (digitalis) • Antihypertensives • Antidepressants • Antimicrobials (penicillin, cephalosporins, quinolones) • Sympathomimetics

  16. A Model of Delirium A multifactorial syndrome that arises from an interrelationship between: • Predisposing factors a patient’s underlying vulnerability AND • Precipitating factors noxious insults

  17. >60 years of age Baseline cognitive impairment 2.5 fold increased risk of delirium in dementia patients 25-31% of delirious patients have underlying dementia Medical co-morbidities: Any medical illness Visual impairment Hearing impairment Functional impairment Depression Advanced age History of alcohol abuse Male gender Polypharmacy Dehydration Predisposing Factorsi.e. baseline underlying vulnerability

  18. Medications Bed Rest Indwelling bladder catheters Physical restraints Iatrogenic events Uncontrolled pain Fluid/electrolyte abnormalities Infections Medical illnesses Urinary retention and fecal impaction Alcohol/drug withdrawal Environmental influences Precipitating Factorsi.e. noxious insults

  19. Prevention=Good Hospital Care for the Elderly Patient (Inouye SK et al. NEJM. 1999;340:669-76)

  20. Wernicke’s Hypoxia Hypoglycemia Hypertensive encephalopathy Meningitis/encephalitis Poisoning Anticholinergic psychosis Subdural hematoma Septicemia Subacute bacterial endocarditis Hepatic or renal failure Thyrotoxicosis/myx-edema Delirium tremens Complex partial seizures Important Rule-outs

  21. How To Manage ? • Keep looking for the underlying causes • Clinical workup • Lab workup • Removal of contributing factors • Treat the underlying causes In the meanwhile….

  22. How To Manage ? Management Clues • Use of drugs ?? - Golden rules : Minimum drugs : Avoid psychotropic drugs • Use of Restrains?? : More harm than protection • Sedate With Drugs?? : Temporary : More confusion : Often get opposite result

  23. How To Manage ? Use of Close Observation room is the best setting • Avoid environmental stimuli • Restraint Free • 24-hour nursing • Adequate safety measures (illumination, instruments etc) • Ensure vitals • WAIT & WATCH

  24. Assume it is Delirium until Proven Otherwise Delirium may be the only manifestation of life-threatening illness in the elderly patient

  25. K.G. Medical University, Lucknow U.P., INDIA Thank you

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