A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC DR. DAVID R. FARRIS, DO, ABPN- C NOVEMBER 19, 2014

Transcription

1 A DISCUSSION ON DELIRIUM MEDICAL & PSYCHIATRIC DR. DAVID R. FARRIS, DO, ABPN- C NOVEMBER 19, 2014

2 OBJECTIVES Participants will understand criteria for delirium Participants will relate characteristics and common features in the course of delirium Participants will review strategies to enhance management of delirium 2

3 DELIRIUM From the Latin word... delirare out of the furrow as in plowing First recognized and described by Hippocrates 3

4 DELIRIUM OTHER NAMES Encephalopathy hepatic/metabolic Acute Mental Status Change ICU Psychosis/ICU Syndrome Acute Organic Brain Syndrome Toxic Psychosis Febrile Insanity Acute Confusional State 4

5 DELIRIUM Diffuse Cerebral Dysfunction 5

6 MORBIDITY AND MORTALITY Morbidity and Mortality of any serious disease is doubled in delirium Three months mortality rate 28% One year mortality rate 50% In hospital patients 10% have delirium at any given time 6

7 IMPACT OF DELIRIUM Greater utilization of hospital resources Increased rate of placement in extended care facilities Increased length of hospital stay Frequent complications in medical/post-op conditions Poor functional recovery 7

8 INCREASED RISK FOR DELIRIUM IN PATIENTS WITH: CNS Disorders Post-Op States Alcohol and Sedative Hypnotic Dependence Underlying Dementia Mental Retardation Severe Burns Sensory Deprivation Polypharmacy Very young or very old 8

9 PREVALENCE IN SPECIFIC POPULATIONS ER Patients 10-14% Hospitalized 10-30% Elderly Hospitalized 10-40% Burn Patients 20% Cancer Patients 25% ICU Patients 30% Post CABG 30% Post-Op Patients 10-51% AIDS Patients 30-40% Cardiac Surgery Patients <74% Terminally Ill Patients <80% Brain Disease Patients <81% 9

10 DSM-5 CRITERIA Delirium (596) Substance intoxication delirium Substance withdrawal delirium Medication-induced delirium Delirium due to another medical condition; Delirium due to multiple etiologies Other Specified Delirium Unspecified Delirium 10

11 DSM-5 DEFINITIONS Substance withdrawal delirium: This diagnosis should be made instead of substance withdrawal when the symptoms in criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention. Medication induced delirium: This diagnosis applies when the symptoms in criteria A and C arise as a side effect of a medication taken as prescribed. Delirium due to another medical condition: There is evidence from the history, physical examination, or laboratory findings that the disturbance is attributable to the physiological consequences of another medical condition. Delirium due to multiple etiologies: There is evidence from the history, physical examination, or laboratory findings that the delirium has more than one etiology (e.g., more than one etiological medical condition; another medical condition plus substance intoxication or medication side effect). 11

12 SPECIFY TYPE OF DELIRIUM Acute Delirium lasting a few hours or days Persistent Delirium lasting weeks or months 12

13 DELIRIUM DIAGNOSTIC CRITERIA A. A disturbance in attention (i.e. reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment). B. The disturbance develops over a short period of time (usually hours to a few days), represents a change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day. C. An additional disturbance in cognition (e.g., memory deficit, disorientation, language, visuospatial ability, or perception). D. The disturbances in criteria A and C are not better explained by another preexisting established, or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, such as coma. E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies. 13

14 CONSCIOUSNESS Awareness of immediate environment and circumstances Ability to pay attention, to shift attention, and to focus Delirium ALWAYS includes impairment of consciousness. 14

15 DIAGNOSTIC CRITERIA Substance Intoxication Delirium: This diagnosis should be made instead of substance intoxication when the symptoms in Criteria A and C predominate in the clinical picture and when they are sufficiently severe to warrant clinical attention. 15

16 DIAGNOSTIC CRITERIA Specify state of Delirium: Hyperactive: The individual has a hyperactive level of psychomotor activity that may be accompanied by mood lability, agitation, and/or refusal to cooperate with medical care. Hypoactive: The individual has a hypoactive level of psychomotor activity that may be accompanied by sluggishness and lethargy that approaches stupor. Mixed level of activity: The individual has a normal level of psychomotor activity even though attention and awareness are disturbed. Also includes individuals whose activity level rapidly fluctuates. 16

17 CONTINUUM OF CONSCIOUSNESS Coma... Stuporous... Obtunded... Hypersomnulent Somnulent... Relaxed... Alert... Attentive... Vigilant... Hypervigilant... Distractible... Hyperaroused... Extreme Excitement... Relaxed... Alert... Relaxed, Alert, Attentive - Normal Range of Consciousness 17

18 LUCIDITY Clarity of thought Using cognitive functions to interact with the environment Memory registration storage & retrieval Comprehension Reasoning and Judgment Language skills & ability to communicate 18

19 CONTINUUM OF LUCIDITY Disoriented to self Disoriented to place Disoriented to time Confused Aware Coherent Fluent Organized Oriented 19

20 IMPAIRMENT IN LUCIDITY OR CONSCIOUSNESS DOES NOT IMPLY IMPAIRMENT IN THE OTHER 20

21 DIFFERENTIALS Onset Delirium Acute Dementia Insidious/Chronic Reversible Usually Usually not Attention Impaired Not affected Level of Consciousness Fluctuates Normal Range 21

22 SUBTYPES OF DELIRIUM Hyperactive 25% Hypoactive 25% Mixed 35% 22

23 HYPERACTIVE DELIRIUM Sympathetic Nervous System Hyperactivity Psychomotor Agitation Verbal/Physical Aggression Motor Preservation Wandering Increased alertness to stimuli Mood Lability Anger Euphoria 23

24 HYPOACTIVE DELIRIUM Lethargy/Somnolence Withdrawn/Apathetic Decreased Response to Stimuli Psychomotor Retardation Inattention Clouded Consciousness Slowed Speech Any Psychiatric Symptoms - Mood symptoms lability, depression, euphoria, irritability, agitation Psychomotor agitation or retardation Nonspecific nonlocalizing neurologic abnormalities tremor myoclonus Disorientation Visual Constructional Impairment 24

25 CHARACTERISTICS AND COMMON FEATURES Sleep wake cycle disturbance Language disturbance Fluctuating course Altered consciousness Altered lucidity Inattention, easily distracted Psychotic symptoms Thought process distortions loose associations, flight of ideas Thought content distortions hallucinations, delusions 25

26 ONSET OF DELIRIUM Acute.typically hours to days Subacute can be days to weeks May be abruptly precipitated 26

27 COURSE OF DELIRIUM Fluctuating in severity of symptoms this is characteristic and suggestive of delirium Lucidity is usually better in the mornings Confusion is worse at night (sundowning) Worsening symptoms with excessive stimulation or sensory deprivation 27

28 DURATION OF DELIRIUM Typically hours to days Can be weeks or even months 28

29 OUTCOME OF DELIRIUM Many have full recovery but not usually by the time of discharge Persistent cognitive deficits are common If underlying dementia now new lower baseline of cognitive functioning 29

30 PATHOPHYSIOLOGY Limited understanding Disturbances of metabolic function of the brain Variety of different abnormalities may alter the brain metabolism therefore a large list of potential etiologies Usually causes are multiple and additive Several theories exist... Dysfunction of the reticular activating system arousal and motivation center of brainstem Dysfunction of the neurochemical systems noradrenergic, GABAergic, dopamine and serotonin systems Hypofunction of the cholinergic system anticholinergic drug toxicity 30

31 ETIOLOGY OF DELIRIUM 31

32 SYSTEMIC CHANGES Infectious febrile or afebrile, sepsis, encephalitis, meningitis, syphilis, HIV, abscess Vitamin deficiency B12, folate, thiamine, niacin Fecal impaction Urinary retention Any abdominal disorder Acute Vascular Arrhythmia, shock, hypertensive encephalopathy 32

33 METABOLIC Fluid and Electrolyte Disturbance Hyper/hyponatremia, acidosis, alkalosis, hyper/hypovolemia Renal Failure Liver Failure Anemia Thyroid Dysfunction Adrenal Dysfunction Hyper/hypoglycemia Hyper/hypocalcemia Hyper/hypomagnesemia Endocrine Disorders 33

34 CNS PATHOLOGY Hemorrhage Abscess Hydrocephalus Intracranial bleed subdural hematoma Seizures Infarction CVA Tumors Metastasis Vasculitis Sleep deprivation 34

35 HYPOXIA Anemia Carbon monoxide poisoning Hypotension Pulmonary failure Cardiac failure Hypercarbia 35

36 TRAUMA Closed head injury Heat stroke Severe burns Postoperative states 36

37 PHYSICAL & ENVIRONMENTAL Stress of any type Surgery anesthesia Pain Fever or hypothermia 37

38 HEAVY METALS Lead Mercury Manganese 38

39 DRUGS OR TOXINS Anticholinergic Anticonvulsants Antidepressants Antihypertensives Antiparkinsonians Anxiolytics Methyldopa Clonidine Beta blockers Phenytoin Digoxin Cimetidine Ranitidine Narcotics Nifedipine Muscle relaxants Hallucinogens Furosimide Inhalants Opiates Steroids Cocaine Ethanol ASA NSAIDS Cardiac Glycosides Amphetamines Theophylline Captopril Antivirals Lithium Antibiotics And many more 39

40 EVALUATION OF DELIRIUM Obtain careful history Onset, duration, symptoms, change from baseline functioning Physical Examination Mental Status Examination Folstein Mini Mental Status Exam Medication Analysis Laboratory Data CMP, CBC, LFTs, EKG, CXR, ABGs, pulse ox, UDS, UA, blood/urine cultures, serum drug levels, B12/Folate, Thyroid panel, EEG, Brain CT/MRI, LP, ESR, heavy metal screen, ANA, HIV, RPR/VDRL 40

41 MANAGEMENT OF DELIRIUM First and foremost.treat the underlying medical cause Review and discontinue nonessential medications Monitor Vitals Regulate Sleep Prevent and Manage Behavior May need sitter Safety issues Lower the bed, clear environment of other patients, equipment, overstimulating instruments, restrain if necessary Antipsychotic for agitation Haldol, risperdal, seroquel 41

42 MANAGEMENT OF DELIRIUM Avoid Benzodiazepines/Sedative Hypnotics Unless the patient is in withdrawal from alcohol or sedative hypnotics Avoid Narcotics Unless in severe pain then avoid meperedine which can cause seizures, worsening delirium and serotonin syndrome Avoid Anticholinergic Medications Additive effect Facilitate Reality Testing Clock, calendar, orient patient repetitively, familiar cues, encourage family visits, maintain day/night lighting, maintain consistency, avoid overstimulation, repeatedly reassure patient, ensure use of hearing aids and glasses 42

43 MEDICATIONS Agitation: Haldol 1mg to 2mg IV q 2-4 hours Sedation: Seroquel 12.5 to 25mg PO q 8-12 hours Zyprexa 2.5 to 10mg IM/PO q 12 hours Ativan 1 to 2mg IV/PO/IM q 4-6 hours *In the elderly minimize the dose; use the lower end of dose regime or cut the dose in half 43

44 COMPLICATIONS OF MEDICATIONS Antipsychotics can lead to an increase in the QT interval prolongation >450msec or 25% over previous EKG, increases risk of Torsades de Pointes May lower seizure threshold Extrapyramidal side effects (IV has lower risk of EPS) 44

45 COMPLICATIONS OF MEDICATIONS Benzodiazepines Additive effect on delirium, cognitive impairment intensified Respiratory depression Use in combination with antipsychotics, do not use alone Use for alcohol and sedative hypnotic withdrawal Use benzodiazepines that are glucouronidated, bypass the liver, renal elimination, lorazepam, oxazepam, temazepam 45

46 EXTREME CASES OF DELIRIUM Extreme cases my need sedation, paralytics, and ventilation 46

47 IN SUMMARY Delirium is a common clinical syndrome Delirium is frequently missed and misdiagnosed Delirium results in increased morbidity, mortality, and costs to the health care system 47

48 QUESTION & ANSWER SESSION 48

49 SURVEY 49