delirium-for nurse, 2014

8/12/2019 Delirium-for Nurse, 2014

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DeliriumSurat Tanprawate, MD, FRCP(T), MSc(Lond.)

Division of NeurologyChiang Mai University


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What this talk will cover Denition

Risk factors

Causes

How to identify

How to treat

How to manage


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How common? Present in 10-15% of older adult hospital admissions

Occur in:

10-30% of hospitalised older adults

More than 50% of post-operative hospitalised patients

70-80% in ICU

Up to 60% of nursing home

1 year mortality rate is 35-40%


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Arousal and awareness, the two components of consciousness in coma,vegetative state, minimally conscious state, and locked-in syndrome.

arousal = !"#$% awareness = !"#&'(


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Delirium-the criteriaDSM-IV-TR Criteria

Disturbance of consciousness with reducedability to focus, sustain, or shift attention.

A change in cognition (memory decit,disorientation, language disturbance) or thedevelopment of a perceptual disturbance(i.e. auditory or visual hallucinations) that isnot better accounted for by a preexistingdementia.


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Delirium-the criteria

DSM-IV-TR Criteria, cont.

The disturbance develops over a short time(hours to days) and uctuates during the day.

There is evidence that the disturbance is caused

by the direct physiological consequences of ageneral medical condition or substance.


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Sleep-wake cycle disruption

Insomnia

Napping

Being awake at night


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Affective lability! Mood may fluctuate widely in a very

short period of time (minutes/hours)! Anxiety/panic/fear/anger! Apathy/sadness - commonly mistaken

for depression! Euphoria (esp. if steroid-induced)


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Differential diagnosis of

delirium Dementia with Behavioral Disturbance

Psychotic Disorder (Schizophrenia)

Mood Disorder (Depression, Mania)

Catatonia

Others


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Delirium subtypes Three subtypes by clinical

1. Hyperactive: features of this type of delirium includepsychomotor agitation, increased arousal and delusion.The degree of cognitive impairment may be variable andeven minimal in some instance.

2. Hypoactive: features of this type of delirium includewithdrawal, lethargy, and reduced arousal.

3. Mixed: characteristics of both hyperactive andhypoactive delirium


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DSM IV 1994

4 major subtypes by cause

Delirium due to a general medical condition

Substance induced delirium

Delirium due to multiple etiologies

Delirium not otherwise specied

American Psychiatric Association (1994) Diagnostic and Statistical Manual ofMental Disorders (4th Ed).Washington: American Psychiatric Association.


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When do they get it? -

acute illness

dehydration infection U&E disturbance

low O2, high CO2

heart failure liver failure renal failure CVA


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Red ag cause of deliriumUrgent recognition

Wernickes

Hypoxia

Hypoglycemia

Hypertensive encephalopathy

Intracerebral hemorrhage

Meningitis/encephalitis

Poisoning/medications


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Etiologies - I WATCH DEATH

! I = Infection

! W = W ithdrawal! A = A cute Metabolic! T = T rauma! C = C NS Pathology! H = H ypoxia

! D = Deficiencies(especially vitamin)

! E = Endocrinopathies! A = A cute Vascular! T = T oxins! H = H eavy metals


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A special note onmedications

They contribute up to 40% of cases

older people have decreased renal excretion and hepaticmetabolism

drugs of concern:

antipsychotics

anti-convulsants

corticosteroids

opiates

NSAIDS


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Why do we get it? Nobody really knows

Likely chemical imbalances caused by stress/ inammation/medications or combination thereof.

Best established neurotransmitter dysfunction: reducedcholinergic activity

Increased dopamine may also play a role

Low and excessive serotonin

Low and excessive GABA

Trzepacz and Meagher 2005


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practical evaluation


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How do we treat patient

Treat risk factors and precipitants !!!!


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Delirium management Monitor VS and I/O

Ensure good oxygenation

D/C nonessential medications

Minimize opioids, benzos, etc

Repeat PE, further lab, radiologic studies if causenot yet identied


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Delirium managementBehavioral/Environmental Strategies

Reorientation, calendars, clocks

Room near nursing station

Lights on/off during day/night

Windows

Family/familiarity

Hearing aids, glasses

Avoid restraints


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Delirium management! Pharmacological Therapy

! Nothing FDA-approved

! Antipsychotics are treatment of choice for

agitation compromising care or safety

! Haloperidol best studied, widely used

!

Virtually no anticholinergic effects! Virtually no hypotensive effects

! Risk of EPS (akathisia), rare with IV route


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Delirium management! Pharmacological Therapy

! Haloperidol! EPS rare when IV route used, however, IV

route carries risk of QTc prolongation ! riskof TdP

! Risk greatest with higher doses over shorter

periods of time, in pts with QTc >450! Monitor EKG and electrolytes (K, Mg)! Monitor for akathisia


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! Antipsychotic Dosing in Elderly!

Use clinical judgment depending on severity of symptoms for starting dose:! Haloperidol

! 0.5mg mild! 1mg moderate! 2mg severe

! Assess response to initial dose and repeat as needed, monitoring foreffectiveness and adverse effects

! Day one: order prn! Day two and beyond: assess total drug needed previous day and schedule

that amount over the next day. Reassess daily continuing process untildelirium resolves.

! Once symptoms have remitted, continue effective dose for 48 hours, thenslowly taper and discontinue over 1-5 days, depending on severity andduration of delirium up to that point. Avoid abrupt discontinuation after firstday or two of mental clarity to avoid risk of rebound symptoms


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Management of delirium

! Pharmacological Therapy! Benzodiazepines

! Primarily indicated in EtOH or benzodiazepinewithdrawal delirium

! Adjunct to neuroleptics in treatment of severeagitation

! Lorazepam preferred given its reliable

absorption from po/IM/IV routes! Generally avoided as may WORSEN

delirium-- especially hepatic encephalopathy


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Non-pharmacological encourage adequate uids

glasses, hearing aids

quiet rooms, well lit

re-orientation - clocks, calendars

personal items

encourage self-care and mobility

avoid frequent stafng changes

avoid catheters, iv lines

Guard/PCA/Companion


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How do we prevent it? Identify high risk patients

Do cognitive assessment as routine

reduce bad drugs

maintain adequate analgesia

maintain U&Es, Oxygenation, etc

try not to move patients

use the same nurse if possible

familiar things - pictures from home, clothes, books


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What you should remember

about delirium Confusion with altered Concentration + Consciousness Lots of Risk factors dementia and blindness

Look for and treat underlying causes Get history from family/friends

Avoid iv lines, catheters, changing rooms

Try familiar items, companions

Remember sedatives can make it worse!


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delirium-for nurse, 2014

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