DAVE SHESKI, MD DELIRIUM

Transcription

1 DAVE SHESKI, MD DELIRIUM

2 GOALS/OUTLINE What is delirium? What are the different ways in which it can present? How do you screen for and diagnose it? What causes it? How do you treat it?

3 WHAT IS DELIRIUM?

4 WHAT IS DELIRIUM?

5 CLASSIC DELIRIUM 76yo male POD 1 s/p knee arthroplasty. Pre-operatively: Pleasant and appropriate. Post-operatively: The medical student reports that during pre-rounds, the patient appeared to be doing well, dressing was C/D/I, and vitals were WNL, but that he kept nodding off in the middle of answering my questions. I guess he was just tired. - Previous evening patient was found attempting to get out of bed. When they attempted to redirect him he took his TV remote as a weapon and screamed you can t keep me here! and I want to leave this hotel right now!

6 ACUTE onset over hours to days Depression, Bipolar Disorder, Schizophrenia, and other primary psychiatric disorders onset over WEEKS to MONTHS, not hours to days. Symptoms often WAX & WANE from hour to hour, but may be constant and unremitting.

7 TYPICAL PSYCHOTIC DISORDER 27yo male is admitted to the hospital for a lower extremity cellulitis. On admission he is noted to be irritable, agitated, occasionally yelling at staff, and is responding to internal stimuli, talking to himself. These symptoms are relatively consistent throughout the day and night. Family reports that approx 3 months ago patient was noted to be slightly more irritable and isolative. Over the past month he has become more aggressive and hostile, and approx two weeks ago they noticed he appeared to be talking to himself.

8 ACUTE onset over hours to days Depression, Bipolar Disorder, Schizophrenia, and other primary psychiatric disorders onset over WEEKS to MONTHS, not hours to days. Symptoms often WAX & WANE from hour to hour, but may be constant and unremitting. some- or ONLY ONE- of: - disorientation - poor attention - agitation For example She thinks she is at home, or in church, or in a prison. She thinks it s the year She is pulling her lines, throwing the bed pan, & swinging at the intern.

9 VISUAL HALLUCINATIONS 45yo female, history of paranoid schizophrenia, POD 3 s/p salpingo-oophorectomy for ovarian cancer. Pre-operatively: Flat affect but otherwise appropriate. - Pre-op psych consult documented that patient had been psychiatrically stable on depot anti-psychotics for many years. Post-operatively: Sitting in bed, somewhat groggy, picking through the bedsheets. - Complains that her bed is full of insects, and she wants to be allowed to leave at once. - Previous evening repeatedly pushed the call button, anxious that strangers were coming into her room.

10 ACUTE onset over hours to days Depression, Bipolar Disorder, Schizophrenia, and other primary psychiatric disorders onset over WEEKS to MONTHS, not hours to days. Symptoms often WAX & WANE from hour to hour, but may be constant and unremitting. - disorientation - agitation some- or ONLY ONE- of: - poor attention - any psychotic sxs, but especially VISUAL HALLUCINATIONS For example She thinks she is at home, or in church, or in a prison. She thinks it s the year She is pulling her lines, throwing the bed pan, & swinging at the intern. She is demanding someone clean the spiderwebs out of her room and is yelling at the IV pole. Hallucinations in primary psychiatric disorders (i.e. schizophrenia) are typically AUDITORY, not visual.

11 HYPOACTIVE DELIRIUM 48yo female s/p mastectomy for IDC, brought in for wound vac removal and to begin reconstruction. Upon removal of the wound vac abnormal tissue was found to have visibly spread into surrounding tissues and underlying bone. Now POD 2 after this discovery, she has poor PO intake, eats very little, presents with a markedly depressed affect and very slowed speech, often saying nothing at all. She was overheard at one point saying she wishes she were dead. Her mother states she believes she took the news very hard and is in shock.

12 ACUTE onset over hours to days Depression, Bipolar Disorder, Schizophrenia, and other primary psychiatric disorders onset over WEEKS to MONTHS, not hours to days. Symptoms often WAX & WANE from hour to hour, but may be constant and unremitting. - disorientation - agitation some- or ONLY ONE- of: - poor attention - any psychotic sxs, but especially VISUAL HALLUCINATIONS - any depressive sxs, but especially APATHY & even SUICIDAL IDEATION For example She thinks she is at home, or in church, or in a prison. She thinks it s the year She is pulling her lines, throwing the bed pan, & swinging at the intern. She is demanding someone clean the spiderwebs out of her room and is yelling at the IV pole. She is refusing to do PT, won t eat bc food doesn t taste good, and says she wishes God would let me die. Hallucinations in primary psychiatric disorders (i.e. schizophrenia) are typically AUDITORY, not visual. Hypoactive Delirium is in fact the MOST COMMON type of delirium.

13 At risk patients - the elderly, even if they don t have dementia, but especially if they do - TBI, stroke patients, and anyone else with an injured brain - anyone in the ICU Draw a clock, put all the numbers on it, and set the time to 10 past 11. Not sure if they are delirious? Clock Drawing is a fast, sensitive screening tool. Delirious Delirious Not Delirious

14 We must FIND & TREAT THE CAUSE if we wish symptoms to resolve. Eliminate all BENZOS, OPIATES, and ANTI-CHOLINERGICS - Includes hypnotics (ambien, lunesta), tricyclics (amy- & nortriptyline), and lesser-known anti-chol s (oxybutinin, meclazine). Seek out OCCULT INFECTIONS - - Repeat UA, Chest X-Ray, & CBC. - - Other sources (i.e. central lines, foot or decub ulcers.

15 ETOH WITHDRAWAL 55yo male admitted for operative repair of a wrist fracture. On day 1 of hospitalization he is tired, moderately irritable, but appropriate. On day 2 of hospitalization he becomes tachycardic, hypertensive, and diaphoretic. That evening he becomes extremely agitated, yelling incoherently at staff and constantly muttering to himself. He appears to be picking at the bedsheets saying get them off of me! and at other times appears to be yelling at unseen individuals in the room. He is started on IV haldol. On day 3 of hospitalization he has a seizure.

16 NON-CONVULSANT STATUS 92yo female s/p laminectomy. She is clearly delirious, disoriented, agitated, and having visual hallucinations, but CBC, CMP, UA, Chest-X-Ray are all nl, and her MAR has been purged of all deliriogenic medications. She is started on risperdal. On day 1 she continues to be clearly delirious. On day 2 she is markedly less interactive and is often extremely difficult to arouse. Risperdal is switched to abilify in an effort to perk her up. On day 3 she is unarousable. Head CT is unremarkable. EEG reveals she is in non-convulsant status epileptics.

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18 We must FIND & TREAT THE CAUSE if we wish symptoms to resolve. Eliminate all BENZOS, OPIATES, and ANTI-CHOLINERGICS Seek out OCCULT INFECTIONS - Includes hypnotics (ambien, lunesta), tricyclics (amy- & nortriptyline), and lesser-known anti-chol s (oxybutinin, meclazine). - Electrolyte abnormalities - B12, Folate - TSH - HIV, rpr Consider other causes - CVAs - Auto-immune encephalitis - Seizures (unwitnessed, the postictal periods causing delirium) - - Repeat UA, Chest X-Ray, & CBC. - - Other sources (i.e. central lines, foot or decub ulcers. - Steroids - PE - ETOH withdrawal (peaks at hours)

19 IATROGENIC DELIRIUM 64yo male 2 days s/p glossectomy with extending margins to maxilla for SCC. He is on PRN dilaudid for pain control. Night float is paged around 1am as he is reporting insomnia. Night float gives him: 50mg IV benadryl is given for sleep. At 2am he is found wandering out of his room. When nurses redirect him, he becomes agitated. 1mg IV ativan is given for agitation. He calms initially, but a short time later night float is paged again bc he threw his bed-pan and started yelling aggressively when his vitals were being taken. 2mg IV ativan is given for agitation, and a PRN order for ativan is placed in the MAR. He doesn t disturb night float for the next several hours. The next morning during pre-rounds he is floridly hallucinating, pointing at unseen objects on the ceiling and shortly later pulls out his IV and has a fall trying to get out of bed.

20 Do these in EVERY delirious patient. Behavioral Make sure they have their HEARING AIDS & GLASSES. Consult PT and OT to keep them engaged and active during the day. Ask the nurses to help minimize night-time interruptions. Ask the sitter to frequently remind the patient where they are and why. Interventions But, don t forget, we must still find & treat the underlying cause. Anti-psychotics may be used to help manage agitation. less sedating more EPS better in hypoactive more sedating less EPS better in dementia, HIV, & Parkinson s Risperdal sublingual m-tab Seroquel 0.5mg QHS 0.25mg Q6 PRN 50mg QHS 25mg Q6 PRN -ORonly if can t or won t take PO Haldol IM, IV 1-3mg PRN refusal of PO IM: higher risk of NMS, EPS IV: higher risk of Qt prolong

21 ACUTE onset over hours to days Symptoms often WAX & WANE from hour to hour, but may be constant and unremitting. Dep Schi ression, zo B psy phreni ipolar WEE chiatric a, and ot Disorder, KS to h d MON isorders er prima ry THS, onse not h t ours over to da ys. some- or ONLY ONE- of: Eliminate all BENZOS, OPIATES, and ANTI-CHOLINERGICS Seek out OCCULT INFECTIONS - Includes hypnotics (ambien, lunesta), tricyclics (amy- & nortriptyline), and lesser-known anti-chol s (oxybutinin, meclazine). - - Repeat UA, Chest X-Ray, & CBC. - - Other sources (i.e. central lines, foot or decub ulcers. She thinks she is at home, or in church, or in a prison. Consider other causes She is pulling her lines, throwing the bed pan, & swinging at the intern. She is demanding someone clean the spiderwebs out of her room and is yelling at the IV pole. - Electrolyte abnormalities - B12, Folate - TSH - HIV, rpr Hallucinations in primary psychiatric disorders (i.e. schizophrenia) are typically AUDITORY, not visual. - the elderly, even if they don t have dementia, but especially if they do - Auto-immune encephalitis - Seizures (unwitnessed, the postictal periods causing delirium) Do these in EVERY delirious patient. Make sure they have their HEARING AIDS & GLASSES. Consult PT and OT to keep them engaged and active during the day. Ask the nurses to help minimize night-time interruptions. Ask the sitter to frequently remind the patient where they are and why. l t stil e. s u we m ng caus, t e g t for underlyi n o d Anti-psychotics may be used to help manage agitation. But, treat the & d fin - TBI, stroke patients, and anyone else with an injured brain - anyone in the ICU less sedating more EPS Draw a clock, put all the numbers on it, and set the time to 10 past 11. Not sure if they are delirious? better in hypoactive Risperdal sublingual m-tab 0.5mg QHS 0.25mg Q6 PRN -ORDelirious - Steroids - PE - ETOH withdrawal (peaks at hours) Delirious Interventions Hypoactive Delirium is in fact the MOST COMMON type of delirium. Clock Drawing is a fast, sensitive screening tool. - CVAs She is refusing to do PT, won t eat bc food doesn t taste good, and says she wishes God would let me die. Behavioral - agitation - any psychotic sxs, but especially VISUAL HALLUCINATIONS - any depressive sxs, but especially APATHY & even SUICIDAL IDEATION For example She thinks it s the year Not Delirious more sedating less EPS better in dementia, HIV, & Parkinson s Seroquel 50mg QHS 25mg Q6 PRN only if can t or won t take PO - disorientation - poor attention At risk patients We must FIND & TREAT THE CAUSE if we wish symptoms to resolve. Haldol IM, IV 1-3mg PRN refusal of PO IM: higher risk of NMS, EPS IV: higher risk of Qt prolong