Dr Annette DowneyConsultant Psychiatrist, Exeter

& cognitive analytic therapistMRCPsych Course, Derriford

June 2011

Definition• F05 Delirium, not induced by alcohol and other psychoactive

substances • An etiologically nonspecific organic cerebral syndrome characterized by

concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to very severe. Includes: acute or subacute: · brain syndrome · confusional state (nonalcoholic) · infective psychosis · organic reaction · psycho-organic syndrome

• Excludes: delirium tremens, alcohol-induced or unspecified ( F10.4 ) F05.0 Delirium not superimposed on dementia, so described F05.1 Delirium superimposed on dementia Conditions meeting the above criteria but developing in the course of a dementia (F00-F03). F05.8 Other delirium Delirium of mixed origin F05.9 Delirium, unspecified

Rates of Delirium

• 30% of hospital inpatients over the age of 65.

• At least 10% of unselected acute medical admissions in a typical UK hospital.

• Community prevalence of 1-2% – but 14% in the over 85s

• Usually under diagnosed and unrecognized by clinical staff

Features for Diagnosis of Delirium

1 Disturbance of consciousness, with reduced ability to focus, sustain or shift attention

2 A change in cognition (memory/orientation/language) or the development of a perceptual disturbance that is not better accounted for by a pre existing /evolving dementia

3 The disturbance is over a short time (usually hours to days) & tends to fluctuate during the course of the day

4 There is evidence from the history, physical examination or lab findings of a direct physiological consequence of a general medical condition, substance intoxication or substance withdrawal.

Historical Perspective

• Latin: ‘de’ – ‘out of’; lira – ‘the furrow’.• Old English – delire – to go astray, go wrong,

rave, to wander in mind or to go mad• Hippocrates 2500 years ago recognized a

clinical syndrome of symptomatic acute mental disorder associated with fever, which features cognitive & behavioural disturbance as well as sleep disruption, which improved when the fever improved.

Clinical Types of Delirium

• Hyperactive (classical) or florid type – increased sympathetic activity – increased HR, sweating, dilated pupils flushed, increased BP; restless & seek reassurance. Keep other patients awake & high falls risk

• Hypoactive - poor oral intake, slumped over their tray, fall asleep mid-conversation – high risk of pressure sores, malnutrition & dehydration

• Mixed – fluctuates between the two – behaviour & sleep charts helpful – are often discharged too early

Predisposing & precipitating Factors

• Usually multi-factorial (isn’t all of psychiatry?!)• The more factors the higher the risk

• Increased vulnerability mentally & physically• Age related• Dementia/cognitive impairment• Severity of illness• Metabolic/electrolyte imbalance eg dehydration,malnutrition.• Psychoactive medications – neuroleptics/narcotics/anticholinergics, more

than 3 medications added• Use of a bladder catheter• Previous delirium• Visual impairment• Male• Fractures on admission• Use of physical restraint

Neuropathophysiology

• Neurotransmitters– Hypothesis of acetylcholine deficiency

• BUT – No cholinergic medication can prevent delirium - Is this a causal relationship?

• ALSO – other neurotransmitters have been implicated eg dopaminergic medications of Parkinsons, as well as dopamine antagonists eg haloperidol treating delirium

• WHAT about the role of serotonin – ‘The serotonin syndrome’? –seems the same as hyperkinetic delirium.

• OTHER neurotransmitters – Noradrenalin/ GABA/glutamate/Melatonin; or a neurotransmitter balance?

Glucocorticoids

• Hypothalamo-pituitary Axis• The bodies reaction to physical illness is to

produce glucocorticosteroids• The hippocampus has high numbers of

receptors• Hypercortisolism is demonstrated in delirium

assoc with LRTI/ Post op delirium/post stroke delirium

• BUT most patients with delirium have normal not supressed cortisol levels.

Cytokines

• Interleukin-2 therapy causes delirium & this is dose dependent

• Mechanism?

Christ in the Storm, Rembrandt

Other Types of Delirium

• Delirium tremens

• Benzodiazepine withdrawal

Patient Experience

• ‘I was certainly paranoid in the ICU [delirious I suppose], I was absolutely sure [still am] that an ICU nurse tried to kill me to sell my organs on ebay - heard the whole conversation whilst he was sedating me with serious drugs as I kept ripping ouy my central and trach...’

• ‘When I was in ICU, after waking-up from a drug-induced coma, I thought I was being held hostage in some kind of medical lab! I had soft restraints on my hands and I remember using my foot to try to pull a machine closer to the bed because I thought I would be able to send out an "email S.O.S." - I am sure it was an ultrasound machine or ECG machine.’

June 201113

Delirium Presents With:Delirium Presents With:

• Sudden onset• Poor concentration/attention (WORLD)• Global impairment of time, place and person,

recent memory, and slowed thinking.• Psychomotor disturbance – either reduced or

agitated• Disturbed sleeping pattern – eg up all night• Emotional lability• Hallucinations – often visual and complex

Confusion Assessment method (CAM) for Delirium

Inouye, S. Ann Int Med 1990;113:941-948.Criteria:• 1. Acute change in mental status, • AND Observation by a family member, caregiver, or primary care physician• 2. Symptoms that fluctuate over minutes or hours, • AND Observation by nursing staff or other caregiver• 3. Inattention -Patient history, Poor digit recall, inability to recite months of

year backwards• PLUS4. Altered level of consciousness, • OR Hyper-alertness, drowsiness, stupor, or coma• 5. Disorganized thinking, Rambling or incoherent speech

• The first 3 criteria PLUS the fourth OR the fifth criterion must be present to confirm a diagnosis of delirium.

Video demonstration of the CAM method

June 201116

Delirium DifferentialDelirium Differential• Depression (pseudodementia) • Dementia (chronic confusion)• Motor slowness (Parkinsons /ism) • General physical frailty• Learning disability• Dissociative states/personality

(pseudodementia also).• Impoverished Social Environment• Iatrogenic (eg secondary to medication)• Cognitive Impairment not dementia

June 2011Annette Downey

Differentiating: Differentiating: Delirium Delirium and Dementiaand Dementia

• Acute often at night• Fluctuates with lucid

periods• Lasts hours /days• Reduced awareness• Impaired attention• Disorientated for time• Visual illusions and

hallucinations• Disrupted sleep

• Insidious onset• Stable over a day• Lasts months/years• Clear awareness• Good Attention• Disorientation in later

stages• Impoverished thinking• Sleep is usually normal

Causes of Delirium

• Infection• Stroke• Drugs• MI• Fractures• Carcinoma• Electrolytes• Heart failure• Diabetes

• Peripheral vascular disease/gangrene

• Alcohol withdrawal• GI bleed• Respiratory failure• PE• Anaemia• Perforated DU• Subdural• Brain tumour

June 2011Annette Downey

Management begins with Management begins with obtaining a full historyobtaining a full history

• Informant History – relatives & carers for baseline status

• Record chronological progression• Wide symptom variation• Length of symptoms• Insidious or rapid onset• Gradual or stepwise progression• Day to day fluctuations• Describe a typical day• Consider effect of symptoms on function

Initial Clinical management

• Establish baseline status• Medical investigations – FBC, glucose, urea,

electrolytes, Ca, LFTs, TFTs, inflammatory markers, urine dipstick, +/-MSU

• Blood cultures indicated?• ABG/ CXR/ ECG• Rectal examination?• Prompt rehydration/antibiotics & O2• SC fluids may be a good idea• Are medications being taken or discarded?• Accurate fluid & nutritional charting• Watch out for pressure sores/pneumonia/DVTs

Supportive & behavioural management

• Appropriate lighting levels for the time of day

• Regular & repeated cues to orientation

• Clocks/calandars• Hearing aids/spectacles• Continuity of care from nursing

staff• Encourage mobility & activity• Approach & handle gently• Turn off noisy alarms etc• Analgesia regularly• Warm milky drinks, relative

quiet & single cubicle if poss

• Encourage family visits• Explain the confusion to family• Fluid & food intake• Adequate CNS oxygen

delivery (sats above 95%)• Sleep hygeine• Avoid ward & hospital transfers• Avoid physical restraint• Rx constipation• Avoid anticholinergics• Avoid catheters where poss

Medication

• Review the ongoing need for repeat prescriptions

• Consider omitting respiridone, olanzapine/ quetiapine.

• Do Not Stop AChEIs such as donepezil, rivastigmine, galantamine

• Scrutinize opiates – tramadol• Follow your local hospital guidelines for the use

of prn sedative medications ie rapid tranquilization policy for mental health trusts.

June 2011Annette Downey

Medical treatmentMedical treatmentThere is not much research to support clinical There is not much research to support clinical

practicepractice• Haloperidol PO 0.5 mg

at 2 hourly intervals (max of 5 mg per day) or IM 1-2 mg

• Anxiolytics especially for lewy body dementia & patients with parkinsons

–lorazepam PO 0.5-1mg (max 3 mg per day)

-clonazepam

• Avoid polypharmacy• Side effects are

common• Titrate slowly and

monitor carefully• Dosette boxes and

blister packs very helpful in agreement with carers

Communication

• Frightening confusing experience for patients• Use lucid periods opportunistically• Warn that it might recur & advise early attendance at GP

surgery• With relatives/carers – family meetings on the ward –

again opportunistically– Initially information gathering– Then education/explanation

about deliriumHelp with orientation – photos, assist at meal times, playing card games, talking about past times.Discussing the future

Prognosis

• Delirium is a marker for physical & cognitive decline

• It is an independent risk factor for poorer outcomes following admission

• There is a trend to longer inpatient stays• Increased risk of falls, pressure sores, urinary

incontinence• Higher readmission rates• Increased long term institutionalism• Increased mortality

June 2011Annette DowneyAdopt A Person Centred Approach

June 2011Annette Downey

• Each person has a unique life history, set of relationships and preferences

• The persons actions are not under their control

• Important to avoid getting angry and frustrated; avoid challenging the person.