DELIRIUM Approach and Management By Dr. K.S. Jacob, Professor of Psychiatry and Dr. Anju Kuruvilla, Professor of Psychiatry, Christian Medical College, Vellore. Based on a chapter in the book Psychiatric Presentations in General Practice ; Published by Byword Books, available at www.bywordbooks.in A common psychiatric presentation among hospitalized patients in a general medical and surgical setting is the patient with delirium. Delirium or an acute confusional state is a transient global disorder of cognition. It is more common among the hospitalized, the frail and elderly, postoperative patients, those admitted to intensive care units and those with compromised mental state (e.g. dementia). The condition is a medical emergency associated with increased morbidity and mortality rates. This chapter discusses the recognition and management of delirium. KEY POINTS The clinical presentation of delirium is characterized by difficulties with attention and concentration, and disorientation to time, place and person. Additional symptoms of restlessness, delusions, hallucinations, abnormal behavior and sleep disturbance can colour the picture. Delirium is commonly seen in the elderly, in patients admitted to the intensive care unit, and during the postoperative period. As all causes of delirium are medical, neurological or endocrine abnormalities, they will have to be excluded by a physical examination and laboratory investigations. The medical basis of the condition needs to be treated. Agitation and sleep disturbance are managed using small doses of antipsychotic medication. Reorienting the patient to time, place and person is part of essential management. What is the clinical picture in delirium? Delirium is characterized by a rapid onset and fluctuating course of clouding of consciousness, attention deficits, cognitive disturbances, psychomotor changes and sleep disturbance. What is the prevalence of delirium? The estimated prevalence of delirium in critical care units is as high as 80%. It is commonly seen among the hospitalized, the elderly, postoperative patients, those admitted to intensive care units and those with compromised mental state, e.g. dementia. What is the recognition rate of delirium? Many studies have documented the face that a majority of patients with delirium are not identified by physicians. What happens to patients who do not get help from physicians? The causes of delirium are always medical and neurological. The recognition of delirium and the treatment of the underlying medical cause(s) therefore improves medical outcomes and contributes to good medical practice. Failure to do so results in the prolongation of illness and longer hospital stays. Moreover, the mortality rates of patients with delirium are much higher than those CMI 13:2 59
Box 1: Causes of delirium Common reversible causes hypoxia, hypoglycaemia, hyperthermia, anticholinergic medication, and alcohol or sedative withdrawal. Other causes: Infections, Metabolic abnormalities, Structural lesions of the brain, Postoperative states, Sensory or sleep deprivation, Faecal impaction, Urinary retention Change of environment. Often particularly in the critically ill and in elderly hospitalized patients, delirium may have multiple aetiologies. Occasionally, no clear aetiology is immediately apparent. who are not delirious. Will I be able to make a clinical diagnosis of delirium? The diagnosis of delirium is based on the recognition of the clinical syndrome. Recognizing delirium is not difficult in clinical practice and can be done on the basis of a detailed history from relatives and observations from hospital and intensive care staff. Will a single protocol help in the management of different types of patients? Yes. The protocol contains all the essential steps in the management of these conditions. What are the ten steps? The ten steps in management are: 1. Recognize the clinical presentation 2. Acknowledge distress Box 2: Clinical features of delirium The clinical hallmarks are 1. decreased attention span and 2. a waxing and waning type of confusion. Major symptoms Clouding and fluctuation of consciousness, Difficulties in attention and Disorientation to time, place and person. Visual and auditory hallucinations and paranoid delusions may also be present. The patient may have associated neurological symptoms, such as dysarthria, dysphasia, tremor and asterixis. The disturbance is characterized by an acute onset of symptoms, over hours or days, and may fluctuate in severity from hour to hour with a worsening state, particularly at night. Box 3: Different clinical presentations of delirium Generally, two patterns of delirium are recognized: (i) Delirium with agitation (hyperactive): the patient is disturbed and disrupts the routine care in the hospital or intensive care unit. (ii) Quiet delirium (hypoactive). The the patient is not disruptive. These patients are often missed and physicians must attempt to routinely test people to check for delirium. 3. Elicit the patient s and the family s prespective 4. Take a focused history, carry out physical examination and laboratory investigations to rule out medical problems 5. Educate about the nature of illness and its treatment 6. Prescribe medication 7. Discuss the role of stress as cause and consequence of illness CMI 13:2 60
8. Elaborate coping strategies 9. Negotiate a treatment plan, compliance, participation and responsibility 10. Give an appointment for review. Step1. Recongnize the clinical presentation of delirium Delirium can be easily recongnized by eliciting a history of disorientation to time, place and person. Mild disorientation results in the lack of appreciation of time, while marked disorientation results in an inability to recognize people and the place. Other important features of delirium include a decreased attention span, and a waxing and waning type of confusion. There is clouding and fluctuation of consciousness. The patient could be either restless and agitated or withdrawn. Visual and auditory hallucinations and fleeting paranoid delusions may also be present. The patient may have associated neurological symptoms such as dysarthria, dyspasia, tremor and asterixis. The disturbance is classically characterized by an acute onset of symptosm, over hours or days. The disturbance may fluctuate in severity from hour to hour, with a worsening state, particularly at night. A detailed history and clinical examination are necessary to establish the clinical presentation. Psychosis (characterized) by strange beliefs, hallucination, grossly abnormal behavior), which is not associated with clouding of consciousness and disorientation, will need not be excluded. Step 2. Acknowledge distress The sudden onset of disturbance places a heavy burden on caregivers, family members and the hospital staff. Acknowledging the distress to caregivers caused by delirium is mandatory. Step 3. Elicit the patient s and the family s perspective on symptoms Providing appropriate reassurance is an important part of the medical consultation. It is most effective if based on the patient s actual concerns. Asking patients, relatives and the hospital staff what they think or fear is wrong with the patient is useful in addressing specific concerns. (The relatives often report: He has been very restless, abusive and he even hit me or He constantly accuses me of stealing his possessions.) Many of the beliefs held by the family and hospital staff my contradict the biomedical model of the illness. They may consider violence and disinhibited behaviour as a deliberate provocation rather than consider it as part of a disease process. The beliefs held by the family and the hospital staff need to be discussed for presenting alternative biomedical explanations. Step 4. Take a focused history, carry out physical examination and laboratory investigations Delirium must be distinguished from a psychotic disorder, which is not generally associated with confusion or a change in the level of consciousness. The acuteness of onset, fluctuating severity and disturbance of consciousness of delirium is helpful in distinguishing it from dementia, in which the patient is generally alert, the onset is usually gradual and does not fluctuate. The establishing of deficits in attention and concentration, the disorientation to time, place and person, and the clouding of consciousness of acute onset and short duration clinches the diagnosis. CMI 13:2 61
Box 4: Diagnostic hallmarks of delirium 1. Attention and concentration deficits 2. Disorientation to time, place and person 3. Clouding of consciousness 4. Symptoms are of acute onset, of short duration and fluctuating in severity (waxing and waning, especially worse at night) Box 5: Appropriate laboratory tests complete blood count, serum creatinine, blood sugar, renal and liver function tests serum electrolyte, urine protein and microscopy, urine analysis for proteinuria and white cells TSH Neuroimaging, EEG, ECG and pulse oxymetry are also useful. The next step will be physical and mental examination and appropriate laboratory tests to identify the medical cause (Box 1,5) which has contributed to the delirium. A brief yet systematic examination will go a long way in identifying specific causes of delirium. The extent of laboratory investigation which should be done is dependent on the clinical presentation and the patient s socioeconomic status. Basic tests may be required to identify conditions which do not have clinical signs and pathognemonic manifestations. Step 5. Educate about illness and treatment The disturbed behavior or complete apathy due to delirium and the clouding of consciousness are distressing both for the family and the hospital staff. Educating the family and caregivers about the disease status is mandatory. It becomes necessary to Box 6: Physical examination Blood pressure to rule out very high or low blood pressure Heart rate Respiratory rate Signs of dehydration Icterus to rule out jaundice Cyanosis Temperature to rule out fever Localizing signs of infection tachypnoea, signs of consolidation in lung e, signs of meningeal irritation (Neck stiffness, Kernig s sign) etc. Papilloedema A detailed mental status examination which checks for orientation to time, place and person is crucial. Attention deficits, confusion, visual and auditory hallucinations, fear and perplexity are also pointers to a diagnosis of delirium. address the family s and attending health professional s beliefs and misconceptions about the condition. Discussing the nature of the condition, the need to manage causal and risk factors, the role of medication and psychosocial treatments is necessary. Vital functions (e.g. heart rate, blood pressure, respiration, temperature, intake and output, etc.) should be regularly monitored. Fluid and nutrition should be managed. The patient s medications should be carefully reviewed; non-essential medication should be discontinued, and doses of needed medication should be kept as low as possible. Severely delirious patients who are agitated and wandering benefit from constant observation and reassurance, which may help avoid the use of physical restraints. Reorientation techniques, such as the use of calendars, clocks and family photos, may be helpful. The environment should be stable, quiet and CMI 13:2 62
well lit. Support from a familiar nurse and the family should be encouraged. Sensory deficits should be corrected with eyeglasses and hearing aids. Step 6. Prescribe medication Treating the specifically identified causes of delirium and risk factors is necessary. The control of hypertension and diabetes mellitus, the treatment of infections (respiratory, urinary tract and central nervous system), the correction of dehydration and electrolyte imbalance, or the management of liver and kidney decompensation, when contributory to the delirium, is mandatory. Substance use will need to be managed. Medication for physical conditions which is deemed to be not absolutely necessary should be withdrawn. Antipsychotics are the medication of choice in delirium. Older neuroleptics such as haloperidol are useful, but have adverse neurological effects. Newer neuroleptics, such as risperidone, olanzapine and quetiapine, relieve the symptoms while minimizing the adverse effects. Smaller doses than used in functional psychosis are required (See Table 1). Benzodiazepines are reserved for delirium resulting from seizures withdrawal from alcohol/sedative hypnotics (see Table 1) or when unknown substances may have been ingested. These medications must be used cautiously as Table 1: Drug dosages in treatment of delirium Medication Recommended Dosage Haloperidol Risperidone Olanzapine Quetiapine 0.25-1 mg / day 0.5-1mg / day 2.5-5mg / day 25-100mg / day Lorazepam (after seizures) 1-3 mg / day Lorazepam (withdrawal from alcohol/sedative hypnotics) 2-8 mg/ day they can cause respiratory depression, especially in patients who are elderly or debilitated. Benzodiazepines are best avoided as they are addictive and could cause a paradoxical worsening of symptoms, especially in the elderly. Anticholinergic medication is also contraindicated as it may worsen the memory impairment and increase the confusion. An attempt should be made to taper the medication once the symptoms are under control. The principles in medication management in older people include starting at lower doses with much slower increases in dose. This is also necessary in patients with liver and kidney disease or dysfunction. Step 7. Discuss the role of stress especially on relatives and hospital staff The burden of delirium on the family members and hospital staff should be discussed. Educate the family regarding the aetiology and course of the problem. Providing reassurance that delirium often is temporary and is the result of a medical condition may be beneficial to both patients and their families. Suggest that family members or friends visit the patient, ideally one at a time, and provide a calm and structured environment. Psychological support will be required for relatives. Step 8. Elaborate coping strategies Providing a calm atmosphere is necessary. The use of physical restraints may be necessary for a short duration to prevent the patient from harming himself, especially if he is not cooperative with the medical management of his underlying disease. Adequate lighting, daily attempts at orientation of the patient and the use of large calendars and clocks are helpful. Unfamiliar people should be introduced and hospital and laboratory procedures explained. CMI 13:2 63
Box 1. Quiet delirium A 70-year-old man was brought to casualty with a 1-week history of fever and loss of appetite. His relatives noticed that he was not aware of his surroundings and was confused. His personal care had deteriorated. His sleep was disturbed. On examination, he was disorientated to time, place and person. Physical examination and laboratory investigations suggested pneumonia. He was started on antibiotics. A very small dose of haloperidol (0.25 mg at bedtime) was given. He recovered his mental functions with treatment. Box 2. Agitated delirium A 75-years-old woman was brought to casualty with a 2-day history of confusion and an inability to recognize relatives. She was restless and agitated. Physical examination did not reveal any abnormality. However, urine microscopy showed a high white blood cell count, suggesting a urinary tract infection. She was started on antibiotics. Tab. Risperidone, 0.25 mg twice a day, was added to control her restlessness. The dose was increased to 1 mg in divided doses. She settled down in a few days and recovered her original function. Step 9. Negotiate a treatment plan Most patients with delirium recover with adequate treatment. The identification of the underlying medical cause may require further investigation and stay in the hospital/intensive care. The course in hospital and the investigations and treatment need to be negotiated with the family. Step 10. Give a specific appointment for review Regular and daily review of the clinical status is required. Psychotropic medication can be gradually tapered after the mental status improves. A regular review of the patient s condition is mandatory for fine-tuning medication and for providing support and advice to relatives. The antipsychotic medication can be tapered and withdrawn in about 3 months. Will I be able to cure the patient s disease? The treatment of delirium usually results in good outcomes and cure in the majority of patients. Early diagnosis and appropriate management of the cause are mandatory. When should I refer a patient for specialist help? Many patients with delirium settle with the treatment of the underlying cause, antipsychotic medication and supportive measures. However, psychiatric consultation may be indicated for the management of behavioural problems, such as severe agitation or aggressive behaviour. Conclusion The recognition of delirium is crucial to managing patients in an in-patient hospital setting. Identifying specific causes and risk factors and their management are mandatory. ************************************************************* CMI 13:2 64