1. Delirium
Mini-Lecture June 2013

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

3. 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?

4. 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.

5. 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.

6. 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?

7. 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

8. 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

9. 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

10. 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