Delirium Mini-Lecture June 2013

Objectives Discuss various causes of delirium Review diagnostic tests in the work-up of delirium

Case 75 y/o M with DMII, COPD, and obesity is hospitalized for a hip fracture. Patient was doing well post-operatively with adequate pain management and rehabilitation. On POD #3, he forgets where he is, becomes more lethargic, and refuses to eat. Patient’s temperature is 38.5, HR 105, RR 12, 90% on 2L NC. What are the possible causes of this change in mental status?

Definition of Delirium Altered consciousness and cognition with the following characteristics: Poor attention Develops over hours to days and fluctuating course during the day. Disturbance is likely from medical condition, substance intoxication, or medication side effect. Unlikely due to preexisting, established, or evolving dementia.

Delirium 10-20% of all hospitalized adults 30-40% of elderly hospitalized patients 60% to 80% of mechanically ventilated ICU patients 50% to 70% of non-ventilated ICU patients Delirium in older patients, Francis et al., Journal of the American Geriatrics Society. 1992;40(8):829 Does delirium contribute to poor hospital outcomes? A three-site epidemiologic study. Inouye SK et al., J Gen Intern Med. 1998;13(4):234.

Pointers on Assessment ABCs and vitals first! Check GCS. Try to obtain collateral information from family or hospital staff Get an understanding of patient’s baseline mental status What were the circumstances around the time of change in mental status? What is the duration of change? Has it happened before? What does the family think is going on?

AEIOU-TIPS mnemonic Examples Possible Diagnostic Tests A Alcohol, Ammonia alcohol intoxication/withdrawal elevated ammonia (hepatic encephalopathy) alcohol level serum osmolality (toxic alcohols) ammonia E Electrolytes/ Endocrine hypoglycemia hypo/hypernatremia hypercalcemia hypo/hyperthyroidism addisonian crisis DKA/HHNS glucose serum osmolality (HHNK) serum electrolytes (esp Na, Ca) thyroid function tests serum cortisol level I Iatrogenic steroid psychosis anticholinergics in elderly, opiates, benzos levels of medications (anticonvulsants, digoxin, theophylline,etc) drug screen (street drugs, sedatives, narcotics) O Oxygen, opiates, obstruction pneumonia, PE carbon monoxide opiate narcosis oxygen ABG CXR U Uremia BUN

AEIOU-TIPS mnemonic Examples Possible Diagnostic Tests T Trauma I concussion TIA/CVA Hematoma Head CT/ cervical spine CT X-ray of any areas with trauma or deformity MRI/MRA if indicated I Infection CBC with differential Urinalysis and culture (UCG if appropriate) Blood cultures and gram stain Chest X-ray Lumbar puncture (with opening pressure) - CT first if you suspect increased ICP P Poisoning Levels of medications (anticonvulsants, digoxin, theophylline,etc) Drug screen (street drugs, sedatives, narcotics) Alcohol level Serum osmolality (toxic alcohols) S Seizures Check anticonvulsant level EEG/ MRI if indicated

Case Patient could have multiple causes of his delirium. A few of the possibilities include: Infection given patient’s temperature and HR (common post-op infections such as UTI and PNA) Opiate toxicity given RR and O2 sat Electrolyte imbalance Hypoglycemia is possible if pt is on insulin and has decreased po intake

Summary Delirium is common in hospitalized patients and portends a poor prognosis. Try to obtain collateral information Use mnemonic AEIOU-TIPS to help determine etiology and useful diagnostic tests