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Delirium

Key points you need to remember for your practice:
• Delirium is an acute medical condition and is the most frequent form of organ dysfunction • Remember that delirium is pathological not psychological • It is very common in acutely ill patients • In delirium, the patients ability to receive, process, store and recall information is strikingly • Delirium can have serious adverse outcomes • Delirium is often the first sign of a new infection • The diagnosis of delirium can be made at the bedside Delirium:
• is a disturbance of consciousness • is an acute change in mental status • has a fluctuating course – worse at night • develops over short time, hours to days • is often recognized by impaired attention • involves disorganised thinking • is what we used to call ‘sundowner syndrome’ Risk Factors for Delirium


There are a number of different motoric types of delirium that have been identified:
Hyperactive – Patients who have hyperactive delirium are usually agitated, disoriented and
delusional and they may experience hallucinations
Hypoactive – Patients who have hypoactive delirium is characterized by quiet, confused
disoriented and apathetic behavior BUT with inattention and disorganized thinking.
Mixed – In mixed delirium the patient has a combination hypoactive & hyperactive symptoms
exhibiting all of the symptoms at different times. This makes it difficult to diagnose but is
commonly associated with daytime sedation and night time agitation,
Why does it matter that we identify Delirium?
After adjusting for age, gender, race, pre-existing comorbidity & cog impairment, ICU diagnosis
and severity of illness studies have found patient with delirium :
• 3 fold higher rate of death by 6 months • 1.6 fold increase in ICU costs (ICU LOS 8 vs 5 days) • Longer hospital stays (21 vs 11 days) • Nearly 10x rate of cognitive impairment on discharge. • 1 in 3 survivors with delirium develop permanent cognitive impairment.
Research is ongoing into what causes delirium:
• Reversible changes to cerebral oxygen and metabolism • Release of inflammatory cytokines toxic to the brain • Increased physical stressors • Sleep deprivation • Changes in levels of neurotransmitters such as decreasing levels of acetylcholine & seratonin; increased levels of dopamine & gamma aminobutyric acid (GABA)
What can we do about Delirium:
1. Early recognition is key. In ICU/CCU use ICU-CAM. On wards screen for delirium and have OT administer Mini Mental is screening is positive, 2. Once recognized we need to get into the habit of reviewing possible causes a. Review patient for changes in what we have determined to be precipitating factors b. Review chart for any preexisting issues that can be risk factors for delirium c. Review patients medications both preop and present that be implicated in delirium d. If in ICU setting maintain sedation vacation routine to get patients extubated e. Arrange patient environment to be quiet, with a regular day & night routine with special attention to optimising sleep patterns f. provide frequent reorientation with clock and calendar within view g. provisions of stimulating activities for the patients throughout the day h. early mobilization i. have family help with care, a familiar face will sometimes be calming
Drug that may be precipitate Delirium :

♦ Analgesics
♦ Antiemetics
♦ Corticosteroids
♦ Antipsychotics
♦ Hypnotic agents
Antidepressants
Antimuscarinics
♦ Anticonvulsants ♦ Cardiovascular agents -Thiopentone
♦ Miscellaneous agents
♦ Antihistamines

Pharmacological Management:
• Use an antipsychotic to treat both hypo and hyperactive delirium • Haloperidol is the preferred antipsychotic because it has fewer active metabolites, limited anticholinergic effects, less sedative and hypotensive effects and can be administered by different routes (watch for long QT) • Haloperidol IV/PO 0.5-5mg 2-3 times a day • Regular treatment for a few days may be required to treat delirium. • Reduce the dose gradually over the following few days. • Seroquil is also used in conjunction with haldol.

Source: http://ottawaheart.ca/content_documents/DeliriumColes_Notes.pdf