Presentation is loading. Please wait.

Presentation is loading. Please wait.

Thomas Lukens, MD Evaluation of Patients with Delirium Evaluation of Patients with Delirium.

Similar presentations


Presentation on theme: "Thomas Lukens, MD Evaluation of Patients with Delirium Evaluation of Patients with Delirium."— Presentation transcript:

1 Thomas Lukens, MD Evaluation of Patients with Delirium Evaluation of Patients with Delirium

2 Thomas Lukens, MD 5 th Mediterranean Emergency Medicine Congress Valencia, Spain September 16, th Mediterranean Emergency Medicine Congress Valencia, Spain September 16, 2009

3 Thomas Lukens, MD Thomas W. Lukens MD PhD Associate Professor Department of Emergency Medicine MetroHealth Medical Center Case Western Reserve University School of Medicine Cleveland, OH

4 Thomas Lukens, MD Today’s Objectives Discuss the diagnosis of deliriumDiscuss the diagnosis of delirium Compare and contrast findings with those having acute psychosisCompare and contrast findings with those having acute psychosis

5 Thomas Lukens, MD Case study An ED patient An ED patient

6 Thomas Lukens, MD “Not feeling well” 68 year old male brought in by son68 year old male brought in by son 2 days of “not feeling well”, decreased alertness, intermittent confusion, anxious. 2 days of “not feeling well”, decreased alertness, intermittent confusion, anxious. Patient had low grade fever at home, complains of headache, myalgias PMH- BPH, HTN, former alcoholicPMH- BPH, HTN, former alcoholic No psychiatric historyNo psychiatric history Medicines: Lisinopril, Doxazosin, ASA Medicines: Lisinopril, Doxazosin, ASA

7 Thomas Lukens, MD “Not feeling well” B/P 145/90, HR 118, RR 20, T 38.5B/P 145/90, HR 118, RR 20, T 38.5 Finger stick Glucose 100Finger stick Glucose 100 Exam- Confused, slurred speech, disinterested, somewhat uncooperativeExam- Confused, slurred speech, disinterested, somewhat uncooperative Skin- no rashSkin- no rash Fundi- unable to visualize, pupils equal & reactiveFundi- unable to visualize, pupils equal & reactive Neck suppleNeck supple Abdomen – soft, nontender, Lungs- clearAbdomen – soft, nontender, Lungs- clear CN – 2-12 intact, strength- symmetrical, gait- wide basedCN – 2-12 intact, strength- symmetrical, gait- wide based

8 Thomas Lukens, MD “Not feeling well” Presentation- consistent with:Presentation- consistent with: PsychosisPsychosis Alcohol withdrawAlcohol withdraw DementiaDementia DeliriumDelirium

9 Thomas Lukens, MD Why important to differentiate? Delirium is a medical condition, not psychiatric. Delirium is a medical condition, not psychiatric. Delirare - In its Latin form, the word means to become crazy or to rave. Delirare - In its Latin form, the word means to become crazy or to rave. Normal lab exam expected in psychotic patients Normal lab exam expected in psychotic patients Delirium- has a high morbidity/ mortality. Delirium- has a high morbidity/ mortality. Psychiatric facilities have limited ability or resources to sort out causes of delirium Psychiatric facilities have limited ability or resources to sort out causes of delirium

10 Thomas Lukens, MD Delirium A: Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, awareness of the environment) with reduced ability to focus, sustain or shift attention sustain or shift attention B: Change in cognition (eg. memory deficit, disorientation, language disturbance) or development of a perceptual language disturbance) or development of a perceptual disturbance not due to pre-existing, established or disturbance not due to pre-existing, established or developing dementia developing dementia C: The disturbance develops over a short period of time (hours to days) and tends to fluctuate during the course of (hours to days) and tends to fluctuate during the course of the day. the day. D. Evidence of etiology

11 Thomas Lukens, MD Delirium Vacillating general disorientation, accompanied by cognitive impairment, mood shift, self-awareness, and inability to attend – inability to focus and maintain attention. Vacillating general disorientation, accompanied by cognitive impairment, mood shift, self-awareness, and inability to attend – inability to focus and maintain attention.

12 Thomas Lukens, MD Delirium Etiology D:Drugsanticholinergics, ETOH E:Endocrinesugars, Na, Ca, Mg, cortisol, etc. M:Metabolicorgan failure, hypoxia, etc. E:Epilepsy or seizurespostictal status N:Neoplasmespecially SIADH, CNS T:Traumaconcussion, surgery I:Infectionany I:Infectionany A: “Apoplexy” any vascular event MI, PE, CVA

13 Thomas Lukens, MD Psychosis A mental illness that markedly interferes with a person's capacity to meet life's everyday demands. A mental illness that markedly interferes with a person's capacity to meet life's everyday demands. Impaired reality testing; that is, they are unable to distinguish personal, subjective experience from the reality of the external world. Impaired reality testing; that is, they are unable to distinguish personal, subjective experience from the reality of the external world. It is a thought disorder in which reality testing is grossly impaired. It is a thought disorder in which reality testing is grossly impaired. Hallucinations characteristic Hallucinations characteristic

14 Thomas Lukens, MD Psychosis Characteristics Hallucinations Hallucinations Typically auditory Typically auditory May be visual May be visual Delusions Delusions Unreasonable beliefs- may be paranoid in nature Unreasonable beliefs- may be paranoid in nature Sudden appearing, make no sense to normal individuals Sudden appearing, make no sense to normal individuals Thought disorder Thought disorder Loose associations Loose associations Distractible but oriented when quizzed Distractible but oriented when quizzed

15 Thomas Lukens, MD Psychosis Normal lab exam expected in psychotic patients Normal lab exam expected in psychotic patients Past history of psychiatric illness is expected Past history of psychiatric illness is expected Patients with psychiatric disorders can have co-existing medical conditions

16 Thomas Lukens, MD Delirium vs. Psychosis OnsetCourseSpeechOrientationAttentionMemoryAgitation Halluc- inations DelusionsAcuteFluctuating Variable (normal) ImpairedFleeting Usually impaired Present Visual> auditory Tactile Simple, paranoid Gradually progressive Continuous Tangential, loose associations Usually intact - if patient cooperates Maintained for periods Usually intact- needs cooperation Usually absent Auditory > visual Complex, systematized

17 Thomas Lukens, MD Impression Elderly patient with acute delirium Think infection – a common cause Think infection – a common cause 35% in one series 35% in one series Drug interactions- also common Drug interactions- also common Anticholenergic effects Anticholenergic effects Delirium - common in elderly patients in the ED Delirium - common in elderly patients in the ED Younger patient- think ingestion

18 Thomas Lukens, MD Delirium Some uncommon etiologies Isolated ↑ammonia with normal LFT’s Subclinical status epilepticus/recurrent seizures NMS with no documented neuroleptic ingestion Central pontine myelinolysis Bilateral anterior artery stroke

19 Thomas Lukens, MD Delirium treatment Benzodiazepines are as effective as haloperidol in controlling agitationBenzodiazepines are as effective as haloperidol in controlling agitation IM Midazolam, IM LorazepamIM Midazolam, IM Lorazepam Haloperidol less rapid effect than droperidolHaloperidol less rapid effect than droperidol Combination therapy also effective- lower dose of each neededCombination therapy also effective- lower dose of each needed Atypical antipsychotics- not proven more effective than benzodiazepines or haloperidol in deliriumAtypical antipsychotics- not proven more effective than benzodiazepines or haloperidol in delirium ACEP Clinical Policy. Ann Emerg Med (2006);47:79

20 Thomas Lukens, MDConclusions Delirium is a medical emergencyDelirium is a medical emergency Psychosis may not bePsychosis may not be Rapid determination of etiology is fundamentalRapid determination of etiology is fundamental Infections are a common cause of delirium in the elderlyInfections are a common cause of delirium in the elderly Transfer to a psychiatric facility isn’t the treatment.Transfer to a psychiatric facility isn’t the treatment.

21 Thomas Lukens, MD Questions? /16/2009

22 Thomas Lukens, MD Greetings from Cleveland, Ohio


Download ppt "Thomas Lukens, MD Evaluation of Patients with Delirium Evaluation of Patients with Delirium."

Similar presentations


Ads by Google