1. Delirium Danielle Hansen, DO August 16, 2006

2. Objectives 1.The physician will identify common causes of delirium. 2.The physician will know how to evaluate patients with delirium. 3.The physician will know how to treat delirium.

3. Definition 1.Disturbance of consciousness and attention difficulties. 2.Change in cognition or development of perceptual disturbance. 3.Onset over short time and fluctuates during the course of the day. 4.Caused by medical condition, substance intoxication, or medication side effect. DSM-IV

4. Epidemiology

5. Epidemiology Prolonged Hospitalizations Functional Decline High Risk of Institutionalization Mortality 14% and 22% at one month and at six months, respectively Cole and Primeau, 1993

6. Pathogenesis Structural Brain Lesions Global Cortical Functional Impairment Neurotransmitter Dysfunction Cytokine Activation

7. Structural Brain Lesions Ascending Reticular Activating System Arousal and Attention Arousal and Attention Parietal and Frontal Lobes Attention Attention Frontal Lobe Insight and Judgment Insight and Judgment

8. Global Cortical Functional Impairment Normal EEG

9. Global Cortical Functional Impairment Slowing of dominant alpha rhythm Abnormal slow wave activity

10. Neurotransmitter Dysfunction AcetylcholineNeuropeptides (ie. Somatostatin) EndorphinsSerotoninNorepinephrineGABA

11. Risk Factors History of Dementia or Brain Disease Advanced Age Sensory Impairment PolypharmacyDehydration/MalnutritionImmobilityInfection Bladder Catheters

12. Causes Toxins Metabolic Derangements Brain Disorders Systemic Organ Failure Physical Disorders

13. Toxins Drugs Prescription Medications Prescription Medications Drugs of Abuse Drugs of AbuseInfectionPoisons

14. Metabolic Derangements Electrolyte Disturbance Endocrine Disturbance Hyper/HypoglycemiaHypercarbia/Hypoxemia Inborn Errors of Metabolism Nutritional Deficiencies

15. Brain Disorders CNS Infections Seizures Head Injury Hypertensive Encephalopathy Psychiatric Disorders

16. Systemic Organ Failure CardiacHematologicLiverPulmonaryRenal Icteric sclera Cyanosis

17. Physical Disorders BurnsElectrocutionHyper/HypothermiaTrauma

18. Evaluation History Physical Exam Neurologic Exam Diagnostic Instruments Medication Review Laboratory Testing Neuroimaging Lumbar Puncture EEG

19. Confusion Assessment Method FeatureAssessment 1. Acute onset and fluctuating course Usually obtained from a family member or nurse and shown by positive responses to the following questions: “Is there evidence of an acute change in mental status form the patient’s baseline?” “Did the abnormal behavior fluctuate during the day, that is, tend to come and go, or increase and decrease in severity? 2. Inattention Shown by positive response to the following: “Did the patient have difficulty focusing attention, for example, being easily distractible or having difficulty keeping track of what was being said?” 3. Disorganized thinking Shown by positive response to the following: “Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?” 4. Altered level of consciousness Shown by any answer other than “alert” to the following: “Overall, how would you rate this patient’s level of consciousness?” Alert/vigilant/lethargic/stupor/coma. The diagnosis of Delirium requires the presence of features 1 AND 2 plus 3 OR 4.

20. Principles of Prevention and Treatment 1.Avoid aggravating or causative factors. 2.Identify and treat underlying acute illness. 3.Provide supportive and restorative care to prevent further physical and cognitive decline. 4.Control dangerous and disruptive behaviors.

21. Supportive Care Limit number of room changes Glasses, hearing devices Orienting stimuli Hydration/nutritionMobility Pain management

22. Behavior Management Constant observation Frequent reassurance and reorientation Physical restraints

23. Psychotropic Medications Haloperidol 0.5-1mg PO/IV/IM Low incidence of hypotension or sedation Low incidence of hypotension or sedation Onset of action 30-60 minutes (IM/IV) Onset of action 30-60 minutes (IM/IV) Extra pyramidal side effects Extra pyramidal side effects Lorazepam 0.5-1mg Onset of action 5 minutes (IV) Onset of action 5 minutes (IV) Worsen confusion and sedation Worsen confusion and sedation Atypical Antipsychotics Increase risk of CV events and mortality Increase risk of CV events and mortality

24. Competency Exam 78 y/o white male is brought to the ER from an ECF via EMS for reports of mental status change. Upon arrival in the ER, the patient is found to be pleasantly confused, A&O x 1. His vital signs are: BP 106/70, P 96, R 16, T 96.0. The patient is unable to provide a full history but records from the ECF accompany him and his daughter arrives at the ER shortly after the patient. His PMHx is significant for HTN, Afib, DM, OA.

25. 1.All of the following are included in your initial work up of this patient except: A.CBC, CMP B.U/A C&S C.Chest X-ray D.Accucheck E.Psych Eval

27. 2.Which of the following could be the etiology of this patient’s “mental status change?” A.Opiate analgesics B.Parietal lobe CVA C.Urinary Tract Infection D.Electrolyte Abnormalities E.All of the Above

29. 3. Your workup reveals a urinary tract infection. The patient is admitted to the general medical floor. At 11:00PM, the nurse calls you stating the patient is combative and has pulled out his IV. After the behavior modification failed, you order: A. Ativan 0.5mg B. Haldol 0.5mg C. Risperdal 1mg D. Soft Wrist Restraints E. Pysch Consult

30. B. Haldol